High-Acuity Nursing - pearsonhighered.com€¦ · Portfolio Management Assistant: ... The authors...

High-Acuity NursingSeventh Edition

Kathleen Dorman Wagner, EdD, MSN, RNFaculty Emerita, University of Kentucky College of NursingLexington, Kentucky

Melanie G. Hardin-Pierce, DNP, RN, APRN, ACNP-BCAssociate Professor of Nursing, University of Kentucky College of NursingLexington, Kentucky

Darlene Welsh, PhD, MSN, RNAssociate Professor of Nursing, University of Kentucky College of NursingLexington, Kentucky

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Library of Congress Cataloging-in-Publication Data

Names: Wagner, Kathleen Dorman, author. | Hardin-Pierce, Melanie G., author. | Welsh, Darlene, author.Title: High-acuity nursing / Kathleen Dorman Wagner EdD, MSN, RN, Faculty Emerita, University of Kentucky College of Nursing, Lexington, Kentucky, Melanie G. Hardin-Pierce, DNP, RN, APRN, ACNP-BC, University of Kentucky College of Nursing, Lexington, Kentucky, Darlene Welsh, PhD, MSN, RN, University of Kentucky College of Nursing, Lexington, Kentucky.Description: Seventh edition. | Boston : Pearson, [2018] | Revision of: High- acuity nursing / Kathleen Dorman Wagner, Melanie Hardin-Pierce, Darlene Welsh. | Includes

bibliographical references and index.Identifiers: LCCN 2017025338| ISBN 9780134459295 | ISBN 0134459296Subjects: LCSH: Intensive care nursing.Classification: LCC RT120.I5 K53 2018 | DDC 616.02/8—dc23 LC record available at https://lccn.loc.gov/2017025338

ISBN-10: 0-13-445929-6ISBN-13: 978-0-13-445929-5

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About the Authors

Kathleen Wagner, EdD, MSN, RN, is now faculty emerita, having recently retired from the University of Kentucky Col-lege of Nursing after many years of teaching pathophysiology, pathopharmacology, and high-acuity nursing to under-graduate nursing students. She was also the educational consultant for the Undergraduate Nursing Program at the University of Kentucky. She has a doctorate in instructional systems design and continues to work on a team developing Web-based clinical simulations for nursing students.

Melanie Hardin-Pierce, DNP, RN, APRN, ACNP-BC, is a tenured associate professor in the University of Kentucky Col-lege of Nursing, where she has over 30 years of experience as a critical care nurse and has taught high-acuity nursing to undergraduate and graduate nursing students. She currently teaches in the Doctor of Nursing Practice program and is the Coordinator of the Adult Geriatric Acute Care Nurse Practitioner DNP Option. In addition to teaching, she has been active in curriculum development in both baccalaureate and graduate nursing programs. She earned her Doctor of Nursing Prac-tice degree at the University of Kentucky, having studied oral health in mechanically ventilated patients. She is a board-certified acute care nurse practitioner who practices as a critical care intensivist in the Veterans Health Administration Medical Center, Cooper Drive Division, Lexington. She is active in research of critically ill, mechanically ventilated patients; evidence-based practice; and interdisciplinary collaboration.

Darlene Welsh, PhD, MSN, RN, is Associate Professor, BSN Program Director, and Assistant Dean of Undergraduate Fac-ulty Affairs at the University of Kentucky College of Nursing. Dr. Welsh earned a PhD in Educational Psychology and an MS in Nursing from the University of Kentucky. Her experiences in the care of critically ill patients include direct patient care, the conduct of research, and supervision of undergraduate and graduate students. Her research interests center on the provision of dietary instruction for patients with heart failure and interprofessional education for clinicians.

iii


We extend a heartfelt thanks to our contributors and reviewers, who gave their time, effort, and expertise to the development and writing of

this new edition of our book.

ContributorsJill Arzouman, DNP, RN, ACNS, BC, CMSRNDirector of Professional PracticeBanner University Medical CenterTucson, ArizonaChapter 1, High-Acuity NursingChapter 2, Holistic Care of the Patient and Family

Susan K. Bohnenkamp, MS, RN, ACNS-BC, CCMClinical Nurse SpecialistBanner University Medical CenterTucson, ArizonaChapter 30, Alterations in White Blood Cell Function and Oncologic Emergencies

Pamela Branson, MSN, RNClinical Nurse SpecialistUniversity of KentuckyLexington, KentuckyChapter 23, Alterations in Liver Function (with Melanie Hardin-Pierce)Chapter 34, Determinants and Assessment of Oxygenation (with Melanie Hardin-Pierce)

Elizabeth Burckardt, DNP, ACNPDepartment of Pulmonary and Critical Care MedicineUniversity of LouisvilleLouisville, KentuckyChapter 38, Multiple Organ Dysfunction Syndrome (with Melanie Hardin-Pierce and Kathleen Dorman Wagner)

Heather L. Carlisle, PhD, DNP, RN-BC, FNP-BC, AGACNP-BC, CHPNClinical Assistant ProfessorUniversity of Arizona College of NursingTucson, ArizonaChapter 3: Palliative and End-of-life Care

Jennifer Cowley, MSN, RNSenior LecturerUniversity of Kentucky College of NursingLexington, KentuckyChapter 25, Determinants and Assessment of Fluid and Electrolyte BalanceChapter 26, Alterations in Fluid and Electrolyte Balance

Alexandra Dampier, DNP, APRN, NP-C, NRCMEInstructorUniversity of Kentucky College of NursingLexington, KentuckyChapter 29, Alterations in Red Blood Cell Function and Hemostasis (with Angela Hensley)

Margaret M. Ecklund, MS, RN, CCRN-K, ACNP-BCClinical Nurse SpecialistLegacy HealthPortland, OregonChapter 6, Nutrition SupportChapter 7, Mechanical Ventilation

Nancy R. Eksterowicz, MSN, RNBC, APN2Clinical Nurse, Pain Resource NurseUniversity of Virginia HospitalCharlottesville, VirginiaChapter 5, Acute Pain Management

Julianne M. Evers, DNP, RN, CCRNICU IntensivistNorton HealthCareLouisville, KentuckyInstructorUniversity of Kentucky College of NursingLexington, KentuckyChapter 37, Shock States (with Melanie Hardin-Pierce)

Stephanie Fugate, MSN, ARNP, ACNP-BCInstructorUniversity of Kentucky College of NursingLexington, KentuckyChapter 27, Alterations in Kidney Function

Thank You

v


vi Thank You

Sarah E. Lester, DNP, APRN, FNP-C, CNRNNeurosciences Clinical Nurse SpecialistUniversity of KentuckyLexington, KentuckyChapter 16, Determinants and Assessment of Cerebral FunctionChapter 19, Traumatic Brain Injury

Theresa Loan, APRN, PhD, FNP-BCProfessorDepartment of Baccalaureate and Graduate NursingEastern Kentucky UniversityRichmond, KentuckyChapter 13, Determinants and Assessment of Cardiac Function

Samantha Mancuso, DNP, RN, APRN, AG-ACNP-BC, CCRNUniversity of Kentucky Medical CenterLexington, KentuckyChapter 31, Determinants and Assessment of Nutrition and Metabolic FunctionChapter 32, Metabolic Responses to Stress (with Melanie Hardin-Pierce)

Angela C. Muzzy, RN, MSN, CCRN, CNS-BCClinical Nurse SpecialistTucson Medical CenterTucson, ArizonaChapter 9, Basic Cardiac Rhythm Monitoring

Grace Nolde-Lopez, RN, MS, ANP-BCCraig HospitalEnglewood, ColoradoChapter 20, Acute Spinal Cord Injury

Gail L. Priestley, RN, MS, CCRNClinical Nurse SpecialistThe University of Arizona Health NetworkTucson, ArizonaChapter 12, Alterations in Pulmonary Function

Yvonne Rice, DNP, RN, APRN, AGACNP-BC, FNP-CInstructorLead APP Trauma and Acute Care SurgeryUniversity of KentuckyLexington, KentuckyChapter 35, Multiple Trauma

Kathleen Dorman Wagner, EdD, MSN, RNFaculty EmeritaUniversity of Kentucky College of NursingLexington, KentuckyChapter 33, Diabetic CrisesChapter 38, Multiple System Dysfunction (with Elizabeth Burckardt and Melanie Hardin-Pierce)

Melanie Hardin-Pierce, DNP, RN, APRN, ACNP-BCAssociate Professor of NursingUniversity of Kentucky College of NursingLexington, KentuckyChapter 17, Mentation and Sensory Motor Complications of Acute IllnessChapter 21, Determinants and Assessment of Gastrointestinal FunctionChapter 22, Alterations in Gastrointestinal FunctionChapter 23, Alterations in Liver Function (with Pamela Branson)Chapter 32, Metabolic Responses to Stress (with Samantha Mancuso)Chapter 34, Determinants and Assessment of Oxygenation (with Pamela Branson)Chapter 37, Shock States (with Julianne Evers)Chapter 38, Multiple Organ Dysfunction Syndrome (with Elizabeth Burckardt and Kathleen Dorman Wagner)

Angela B. Hensley, DNP, APRN, FNP-BCInstructorUniversity of Kentucky College of NursingLexington, KentuckyChapter 29, Alterations in Red Blood Cell Function and Hemostasis (with Alexandria Dampier)

Dea J. Kent, DNP, RN, NP-C, CWOCNDirector, Nursing Home Oversight & ConsultingCommunity Healthcare NetworkFishers, IndianaChapter 10, Complex Wound ManagementChapter 36, Acute Burn Injury

Maureen E. Krenzer, MS, RN, ACNS-BCClinical Nurse SpecialistChair, Pain Resource Nurse CommitteeRochester General HospitalRochester, New YorkChapter 24, Alterations in Pancreatic Function

Helen W. Lach, PhD, RN, CNL, FGSA, FAANProfessorSaint Louis University School of NursingSt. Louis, MissouriChapter 4, The Older Adult High-Acuity Patient (with Kristine L’Ecuyer)

Kristine M. L’Ecuyer, PhD, RN, CNLCoordinator, Accelerated Master’s of Science in NursingSaint Louis University School of NursingSt. Louis, MissouriChapter 4, The Older Adult High-Acuity Patient (with Helen W. Lach)

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Thank You vii

Deola Hardy, MSN, RNRN FacultyBaton Rouge General School of NursingBaton Rouge, Louisiana

Laura Logan, MSN, RN, CCRNNursing FacultyCritical Care Clinical InstructorStephen F. Austin State UniversityNacogdoches, Texas

Peter Miskin, DHSc, MScN, RN, PHN, CMSRNNursing InstructorDe Anza CollegeCupertino, CaliforniaAdjunct Assistant ProfessorSamuel Merritt UniversityOakland, California

Diane Mulbrook, MA, BSAssistant Professor of NursingMount Mercy UniversityCedar Rapids, Iowa

Bridget Nichols, RN, MSN, CCRNNurse EducatorThe University of South DakotaSioux Falls, South DakotaAvera Heart HospitalSioux Falls, South Dakota

Joan E. Niederriter, PhD, MSN, CMSRN, RN-BCAssociate ProfessorCleveland State UniversityCleveland, Ohio

Jan Paauwe-Weust, DNP, RNAssistant Professor in NursingIndiana State University School of NursingTerre Haute, Indiana

Joan Palladino, EdD, RNProfessor, Chair of the Department of NursingWestern Connecticut State UniversityDanbury, Connecticut

Jill Price, PhD, MSN, RNDean, RNBSN Online OptionChamberlain College of NursingDowners Grove, Illinois

Darlene Welsh, PhD, MSN, RNAssociate Professor of NursingUniversity of Kentucky College of NursingLexington, KentuckyChapter 8, Basic Hemodynamic MonitoringChapter 14, Alterations in Cardiac FunctionChapter 15, Alterations in Myocardial Tissue PerfusionChapter 18, Acute Stroke InjuryChapter 28, Determinants and Assessment of Hematologic FunctionChapter 39, Solid Organ and Hematopoietic Stem Cell Transplantation

Maria D. Willey, DNP, APRN, NP-C, FNP-BC, AGACNP-BCBrooke Army Medical CenterSan Antonio, TexasChapter 11, Determinants and Assessment of Pulmonary Function

Accuracy ReviewerRachel Kinder, PhD, RNAssociate ProfessorWestern Kentucky UniversityBowling Green, KY

ReviewersMelissa A. Bathish, PhD, RN, CPNP-PCResearch Area Specialist/Lecturer/Student Resolutions OfficerUniversity of Michigan School of NursingAnn Arbor, Michigan

Maureen J. Dunn, RN, MSNNursing InstructorPennsylvania State UniversitySharon, Pennsylvania

Antoinette France, MSNed, CCRN, RNSalt Lake Community CollegeWest Jordan, Utah

Sarah Gabua, DNP, RN, CNEFull-time FacultyAspen UniversityDenver, Colorado


viii Thank You

Kerrie Young, RN, MSN, CCRNNursing InstructorAmarillo CollegeAmarillo, Texas

Kristiann T. Williams, DNP, APRN, FNP-CAssociate ProfessorWeber State UniversityOgden, Utah

Maurita Wisniewski, MSN, RN, CCRNOhio Valley HospitalMcKees Rocks, Pennsylvania


When the first edition of High-Acuity Nursing was published in 1992, the term high acuity was largely confined to leveling patient acuity for

determining hospital staffing needs rather than being applied to a type of nursing care or education. Since that time, the meaning of the term has been evolving to increas-ingly represent a distinct category of nursing that denotes care of complex patients outside of the critical care setting. For the purposes of this textbook, we continue to define high acuity in a way that is consistent with our original intent—that it represents a level of patient problems beyond uncomplicated acute illness on a health–illness continuum.

The high-acuity nurse cares for complex patients with unpredictable outcomes across care settings (to include critical care). Today, high-acuity patients are found in many healthcare settings, from high-skill, long-term-care facili-ties to critical care units. The patient population is older and faces an increased number of health issues upon enter-ing the healthcare system. Hospitalized patients are being discharged earlier, often in a poorer state of health. In the home health setting, nurses provide care to patients with mechanical ventilators, central venous catheter lines, IV antibiotic therapy, and complicated injuries. Whereas criti-cal care units are considered specialty areas within the hos-pital walls, much of the knowledge required to work within those specialties is generalist in nature. It is this generalist knowledge base that is needed by all nurses who work with patients experiencing complex care problems to ensure competent and safe nursing practice.

New to This EditionThe seventh edition of the book has been revised based on feedback from faculty and students.

• All chapters have been updated, and many have been reorganized and expanded.

• A new chapter focusing on palliative care and end-of-life issues has been added.

• New features that address Quality and Safety and Genetic Considerations have been added where appropriate.

• Posttest items have been revised to reflect changes in content and are written using NCLEX style.

• Emerging Evidence features have been updated.

Purpose of the TextThe High-Acuity Nursing text delivers critical information focusing on the adult patient, using learner-focused, active learning principles, with concise language and a user-friendly format. The book’s design breaks down complex information into small, discrete chunks to assist learners in mastering the material. Self-testing is provided through-out the text, with short section quizzes and chapter post-tests. All answers to the section review quizzes are provided to give learners immediate feedback on their command of section content before proceeding to the next chapter section.

The chapters in this book focus on the relationship between pathophysiology and the nursing process with the following goals in mind:

• To revisit and translate critical pathophysiological concepts pertaining to the high-acuity adult patient in a clinically applicable manner

• To examine the interrelationships among physiological concepts

• To enhance clinical decision-making skills

• To provide immediate feedback to the learner regarding assimilation of concepts and principles

• To provide self-paced learning

Ultimately, the goal is for the learner to be able to approach patient care conceptually, so that care is provided with a strong underlying understanding of its rationale.

This book is appropriate for use in multiple educa-tional settings, including for undergraduate nursing stu-dents, novice nurses, novice critical care nurses, and home health nurses. It also serves as a review book for the expe-rienced nurse wanting updated information about high-acuity nursing for continuing education purposes. Hospital staff development departments will find it useful as sup-plemental or required reading for nursing staff or for high-acuity or critical care classes.

Organization of the TextThe book is divided into ten parts: Introduction to High-Acuity Nursing, Therapeutic Support of the High-Acuity Patient, Pulmonary, Cardiovascular, Neurologic, Gastro-intestinal, Fluid and Electrolytes, Hematologic, Nutrition and Metabolism, and Multisystem Dysfunction.

Preface

ix


x Preface

SummaryThis text focuses on major problems and therapies fre-quently encountered in high-acuity patients. It is not designed as a comprehensive textbook of adult medical–surgical or critical care nursing. The book’s format reduces the learner’s sense of being overwhelmed by complex information. Learners are more apt to feel in command of the concepts, giving them the confidence to proceed to more complex concepts.

The seventh edition of High-Acuity Nursing has main-tained the overall look and feel of the previous editions, with some valuable changes. Although the seventh edition has been updated and is offered in eText format as well as print, we have not compromised our interactive approach. The ultimate goal of this book continues to be to enhance the preparation of nurses for practice in today’s healthcare settings.

AcknowledgmentsWith any publication, several years of sweat and tears go into its development. To our Executive Portfolio Manager, Pam Fuller, and our Development Editor, Pam Lappies, thank you so much for your patience, diligence, sense of humor, and work ethic—the book would have never made it to fruition without your hard work and guidance. It has been a true pleasure to work with you! To our Content Pro-ducer, Bianca Sepulveda, our Portfolio Management Assis-tant, Erin Sullivan, and our Project Manager at Aptara, Sudip Sinha, thank you all for your efforts and hard work. We would also like to warmly acknowledge the wonderful work of our Accuracy Reviewer, Dr. Rachel Kinder, PhD, RN, whose meticulous scrutiny of the information in the book chapters made our work much easier and significantly enhanced the quality and accuracy of the book. Warm thanks goes to Dr. Kathy Wagner for her mentorship and unwavering support in this “book business” and for invit-ing Darlene and Melanie to be part of High-Acuity Nursing.

Finally, our warm thanks also to our Chapter Review item writer, Pamela Fowler, who significantly added to the value of the tests.

In memory of a colleague, mentor, and friend, Pam Kidd, RN, PhD, ARNP, CEN, who died too soon and with Kathy coedited High-Acuity Nursing from its inception, we say her passion for teaching, warmth, and wit are deeply missed.

Kathleen Dorman Wagner

Melanie G. Hardin-Pierce

Darlene Welsh

Part One: Introduction to High-Acuity Nursing is composed of four introductory chapters with topics that apply across high-acuity problems, including an introduc-tion to high-acuity nursing and the care of high-acuity patients, and important considerations when caring for the high-acuity older adult. Part Two: Therapeutic Support of the High-Acuity Patient is composed of six chapters that focus on supportive interventions, including pain manage-ment, nutrition support, mechanical ventilation, hemody-namic monitoring, basic cardiac rhythm monitoring, and complex wound management. Parts Three through Ten cover topics that represent the more common complex health problems, assessments, and treatments associated with high-acuity adult patients.

All chapters contain Learning Outcomes, Section Review questions, and Chapter Review questions. Most chapters include Clinical Reasoning Checkpoint exercises. Each chapter is divided into small sections that cover one facet of the chapter’s topic (e.g., pathophysiology or nurs-ing management), and each section ends with a short self-assessment review quiz. Key words are bolded throughout the chapters to indicate glossary terms defined in the text-book’s Glossary. Parts Three through Ten are composed of two different types of chapters: Determinants and Assess-ment chapters and Alterations chapters.

DETERMINANTS AND ASSESSMENT CHAPTERS Each part begins with an overview of normal concepts that pro-vide a solid foundation for understanding the diseases being presented. Normal anatomy and physiology are reviewed, and relevant diagnostic tests and assessments are profiled. The therapeutic support and disease-focused (Alterations) chapters draw heavily on the normal con-cepts, diagnostic tests, and assessments covered in their corresponding Determinants and Assessment chapters.

ALTERATIONS CHAPTERS Following each Determi-nants and Assessment chapter is a series of organ- or con-cept-specific chapters that focus on a single topic area. The majority of Alterations chapters are based on body systems (e.g., Chapter 12, Alterations in Pulmonary Function) and include the pathophysiology, assessments, diagnostic test-ing, and collaborative management of disorders com-monly seen in high-acuity adult patients. Several Alterations chapters focus on complications of high-acuity illness, such as multiple organ dysfunction syndrome and sensory motor complications of acute illness. The patho-physiologic basis of disease is emphasized in this text-book, based on the belief that strong foundational knowledge about the basis of disease improves learner understanding of the associated disease manifestations and rationales for treatment.


About the Authors iii

Thank You v

Preface ix

Part One Introduction to High-Acuity Nursing

1 High-Acuity Nursing 1

Section One: High-Acuity Environment 1Historical Perspective 1Determining the Level of Care Needed 1Levels of Intensive Care Units 2Profile of the High-Acuity Nurse 4

Section Two: Resource Allocation 4Nurse Staffing 4Decreasing Resources, Increasing Care Needs 5

Section Three: Use of Technology in High-Acuity Environments 7

Patient Depersonalization 7Overload and Overreliance Issues 7Finding a Balance 8

Section Four: Healthy Practice Environment 8Healthy Practice Environment 8Stress, Burnout, and Compassion Fatigue 9Coping with Stress, Burnout, and Compassion Fatigue 9

Section Five: Ensuring Patient Safety in High-Acuity Environments 10

The Culture 10Patient Safety 10Technology and Patient Safety 11Other Factors Contributing to Patient Safety 12Clinical Reasoning Checkpoint 12References 14

2 Holistic Care of the Patient and Family 16

Section One: Impact of Acute Illness on Patient and Family 16

Kübler-Ross’s Stages of Grief 16Nursing Considerations 17

Section Two: Coping with Acute Illness 18Complementary and Alternative Therapies 18

Section Three: Patient- and Family-centered Care 20Educational Needs of Patients and Families 20Visitation Policies 21

Section Four: Cultural Diversity 23Cultural Competence 23Developing Cultural Competence 24

Section Five: Environmental Stressors 24Sensory Perceptual Alterations 25Interventions to Decrease Sensory Perceptual Alterations 25Clinical Reasoning Checkpoint 26References 28

3 Palliative and End-of-life Care 30

Section One: Palliative Care 30What Is Palliative Care? 31Palliative Care in High-Acuity Settings 31

Section Two: Communication and Decision Making 32Establishing Goals of Care 32Family-centered Care 33End-of-life Decision Making 33

Section Three: Pain and Symptom Management 36Pain Assessment and Management 36Management of Non-pain Symptoms 37

Section Four: Withdrawal of Life-sustaining Treatment 39

Process of Withdrawal 39Brain Death and Organ Donation 40After the Death 40Bereavement 41

Section Five: Professional Issues 41Moral Distress 41Caring for the Caregiver 42Barriers to End-of-life Care in High-Acuity Settings 42Clinical Reasoning Checkpoint 44References 45

4 The Older Adult High-Acuity Patient 49

Section One: Introduction to the Aging Patient 49The Older Adult Patient 49Characteristics of the Older Adult Population 50

Section Two: Neurologic and Neurosensory Systems Changes 51

Neurologic System 51Neurosensory Systems 52

Section Three: Cardiovascular and Pulmonary Systems Changes 53

Cardiovascular System 53Pulmonary System 55

Contents

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xii Contents

Section Three: Pain Assessment 87Pain History 87Unidimensional and Multidimensional Pain Assessment 87Assessment of Pain in the Adult with Altered Communication Status 89Pain and Vital Sign Changes 89

Section Four: Management of Acute Pain 92Pharmacologic Pain Management 92Nonpharmacologic Interventions 96

Section Five: Issues in Inadequate Treatment of Acute Pain 98

Definitions 98Reasons for Opioid Undertreatment of Pain 98Nursing Approach in Acute Pain Management 99

Section Six: Monitoring for Opioid-induced Respiratory Depression 101

Assessment 101Nursing Interventions 102

Section Seven: Pain Management in Special Patient Populations 104

Pharmacology and Aging 104Patients with Concurrent Medical Disorders 104Management of the Tolerant Patient with Superimposed Acute Pain 104The Known Active or Recovering Substance Abuser as Patient 105Major Considerations in Pain Management 106

Section Eight: Procedural Sedation or Analgesia 108Purpose of Moderate Sedation or Analgesia 108Nursing Management of the Patient Undergoing Procedural Sedation 108Drugs Used for Moderate Sedation 109Possible Complications of Moderate Sedation 111Clinical Reasoning Checkpoint 111References 113

6 Nutrition Support 116

Section One: Nutritional Alterations in Specific Disease States 116

Hepatic Failure 116

Lung Failure 117Kidney Failure 118Obesity 120Burns 120Traumatic Brain Injury 120

Section Two: Enteral Nutrition 121Criteria for Selection of Enteral Nutrition 122Benefits of Enteral Nutrition 122Common Contraindications for Enteral Nutrition 122Types of Enteral Feedings 123Feeding Tube Placement 125

Section Four: Integumentary and Musculoskeletal Systems Changes 56

Integumentary System 56Musculoskeletal System 57

Section Five: Gastrointestinal and Genitourinary Systems Changes 58

Gastrointestinal System 58Genitourinary System 60

Section Six: Endocrine and Immune System Changes 61

Endocrine System 61Immune System 62

Section Seven: Cognitive Conditions Impacting Hospitalization 64

Dementia 64Depression 65Delirium 65

Section Eight: Factors Impacting Hospitalization 66Falls 66Pain 66Pharmacotherapy 66

Section Nine: Geriatric Assessment Tools for the High-Acuity Nurse 70

Assessment of Mental Status 70Geriatric Depression Scale 70Skin Assessment 70Falls and Mobility Assessment 71Pain Assessment 71Laboratory Data Assessment 71

Section Ten: High-Risk Injuries and Complications of Trauma 73

Traumatic Injury: An Overview 73Syncopal Episodes 73Specific Types of Traumatic Injury 74

Section Eleven: Special Considerations—A Culture of Caring and End-of-life Care 75

A Culture of Caring for Older Adults 75End-of-life Care 76Clinical Reasoning Checkpoint 77References 79

Part Two Therapeutic Support of the High-Acuity Patient

5 Acute Pain Management 82

Section One: The Multifaceted Nature of Pain 82A Working Definition of Acute Pain 82A Multifaceted Model of Pain 83

Section Two: Acute Pain in the High-Acuity Patient 85Potential Sources of Pain 85Types of Acute Pain 85The Effects of Stress and Pain on the Body 86

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Contents xiii

Section Eight: Care of the Patient Requiring Mechanical Ventilation 158

Nursing Management of Physiologic Needs 158Impaired Gas Exchange 160Ineffective Breathing Pattern 160Alteration in Cardiac Output 161Nursing Management of Psychosocial Needs 161

Section Nine: Weaning the Patient from the Mechanical Ventilator 163

Readiness for Weaning 163The Weaning Process: Duration 163The Weaning Process: Methods 164Special Considerations for Older Adults 166Postextubation Follow-up 166Terminal Weaning 166Clinical Reasoning Checkpoint 167References 169

8 Basic Hemodynamic Monitoring 171

Section One: Introduction to Hemodynamic Parameters 171Hemodynamics 172Cardiac Output and Cardiac Index 172Heart Rate 173

Section Two: Noninvasive and Minimally Invasive Hemodynamic Technologies 174

Noninvasive Technologies 174Minimally Invasive Hemodynamic Technologies 175

Section Three: Introduction to Pulmonary Artery Catheters 179

Purpose of PA Catheters 179Required Provider Competencies 179Interpretation of Data 180Standard PA Catheter Construction and Components 180Hemodynamic Monitoring Equipment 181Special Pulmonary Artery Catheters 181Care of Central Venous Catheters 182

Section Four: Pulmonary Artery Catheter Insertion and Measurements 183

Catheter Insertion and Management 183PA Catheter Measurements 185

Section Five: Right Atrial and Ventricular Pressures 186Right Atrial Pressure 186Right Ventricular Pressure 189

Section Six: Pulmonary Artery and Pulmonary Artery Wedge Pressures 190

Pulmonary Artery Pressure 190Pulmonary Artery Wedge Pressure 191

Section Seven: Vascular Resistance and Stroke Work 193Systemic Vascular Resistance 193Pulmonary Vascular Resistance 194Stroke Volume 194Ventricular Stroke Work 194Clinical Reasoning Checkpoint 195References 196

Gastric Versus Postpyloric Feeding 125Complications of Enteral Nutrition 125Supportive Drug Therapy 125

Section Three: Total Parenteral Nutrition 128Delivery of Parenteral Nutrition 129Complications of Total Parenteral Nutrition 130

Section Four: Refeeding Considerations 132Clinical Reasoning Checkpoint 134References 135

7 Mechanical Ventilation 137

Section One: Determining the Need for Ventilatory Support 137

Acute Ventilatory Failure 138Hypoxemic Respiratory Failure 138Pulmonary Mechanics 138Special Considerations 138

Section Two: Required Equipment for Mechanical Ventilation 139

Initial Equipment Necessary for Establishment of a Patent Airway 139

Section Three: Types of Mechanical Ventilators 143Negative Pressure Ventilators 143Positive Pressure Ventilators 143

Section Four: Commonly Monitored Ventilator Settings 144

Tidal Volume 145Fraction of Inspired Oxygen (FiO2) 145Respiratory Rate 146Positive End-expiratory Pressure 146Ventilation Modes 146Peak Inspiratory Pressure or Peak Airway Pressure 148Alarms 148High-pressure Alarm 148Initial Ventilator Settings 148

Section Five: Noninvasive Alternatives to Mechanical Ventilation 149

Noninvasive Intermittent Positive Pressure Ventilation 149Continuous Positive Airway Pressure 151Complications of NIPPV 152Nursing Considerations 152

Section Six: Major Complications of Mechanical Ventilation 153

Cardiovascular Complications 153Pulmonary Complications 154Neurovascular Complications 155Renal Complications 155Gastrointestinal Complications 156

Section Seven: Artificial Airway Complications 156Nasal or Oral Damage 156Cuff Trauma 157Tracheostomy Tubes 157


xiv Contents

Clinical Reasoning Checkpoint 249References 251

10 Complex Wound Management 253

Section One: Anatomy and Physiology of the Skin and Effects of Wounds 253

Normal Skin Anatomy 253Wounds: A Disruption of Skin Functions 254

Section Two: Wound Physiology 255Phases of Wound Repair 255Classifications of Wound Closure 257

Section Three: Factors That Affect Wound Healing 258Oxygenation and Tissue Perfusion 258Nutrition 259Age 259Diabetes Mellitus 260Medications 260Obesity 260Topical Therapy 260

Section Four: Clinical Assessment of Wound Healing 261Wound Assessment 261Inspection 261Assessment of Tissue Perfusion and Oxygenation Status 263Assessment of Immunologic Status 264Assessment of Nutritional Status 264

Section Five: Principles of Wound Management 265Wound Cleansing 265Debridement 265Dressings 266Negative Pressure Wound Therapy 266

Section Six: Wound Infections: Etiology, Diagnosis, and Treatment 269

Predisposing Factors for Wound Infection 269Diagnosis and Treatment of Wound Infection 269Prevention of Wound Infections 270

Section Seven: Necrotizing Soft-tissue Infections 271Necrotizing Fasciitis 271Fournier Gangrene 275Nursing Care 276

Section Eight: Enterocutaneous Fistulas 276Risk Factors 276Clinical Presentation 277Collaborative Management 277

Section Nine: Pressure Ulcers 278Etiology of Pressure Ulcers 278Risk Factors for Pressure Ulcer Development 278Predicting Risk for Pressure Ulcers 279Pressure Ulcer Staging 280Collaborative Management of Pressure Ulcers 280Nursing Management 282Clinical Reasoning Checkpoint 283References 286

9 Basic Cardiac Rhythm Monitoring 198

Section One: Cellular Membrane Permeability 198Resting Cardiac Cell 198Active Cardiac Cell—Action Potential 199

Section Two: Cardiac Conduction and the Electrocardiogram 201

Electrical Conduction of the Heart 201The Electrocardiogram 201Cardiac Monitoring Systems 203Nursing Care of a Patient Who Requires Cardiac Monitoring 205

Section Three: Basic Interpretation Guidelines 206ECG Graph Paper 206Eight Steps of ECG Interpretation 206Clinical Significance 208

Section Four: Risk Factors for Development of Dysrhythmias 210

Electrolyte Abnormalities 210Fluid Volume Abnormalities 212Hypoxemia 212Altered Body Temperature 212

Section Five: Sinus Dysrhythmias 212Sinus Bradycardia 212

Section Six: Atrial Dysrhythmias 215Premature Atrial Contractions 216Supraventricular Tachycardia 216Atrial Flutter 216Atrial Fibrillation 217

Section Seven: Junctional Dysrhythmias 221

Section Eight: Ventricular Dysrhythmias 223Premature Ventricular Contractions 223Ventricular Tachycardia 226Ventricular Fibrillation 227Asystole 228

Section Nine: Conduction Abnormalities 231First-degree Atrioventricular Block 231Second-degree Atrioventricular Block 231Third-degree (Complete) Atrioventricular Block 233Bundle Branch Block 233

Section Ten: Pharmacologic and Countershock Interventions and Nursing Implications 236

Antidysrhythmic Agents 236Countershock 238Defibrillation 240

Section Eleven: Electrical Therapy 241Pacemakers 241Pacemaker Sensing 244Pacemaker Settings and Modes 244Pacemaker Troubleshooting 246Pacemaker Classification 246Implantable Cardioverter-defibrillator 247Electrical Therapy Nursing Considerations 247


Contents xv

Section Two: Acute Respiratory Failure 326Respiratory Insufficiency and Failure 326Management of the Patient with Acute Respiratory Failure 328

Section Three: Acute Respiratory Distress Syndrome 328Etiologic Factors 328Diagnosis 329Pathogenesis 329Clinical Presentation 330Collaborative Management of the ARDS Patient 332Prognosis 337

Section Four: Pulmonary Embolism 338Types and Causes of Emboli 338Predisposing Factors of Venous Thromboembolism 339Pathophysiology of Pulmonary Embolism 340Signs and Symptoms of Pulmonary Embolism 340Diagnosis 340Management of Pulmonary Embolism 342

Section Five: Acute Respiratory Infections 343Pneumonia 343Aspiration Pneumonitis and Aspiration Pneumonia 345Viral Pneumonias 346

Section Six: Thoracic Surgery and Chest Tubes 348Pneumonectomy 348Thoracic Incisions 348Postthoracic Surgery Management 348Chest Drainage Management 349

Section Seven: The Standard Respiratory Plan of Care 355Breathing Pattern and Ventilation 355Impaired Oxygenation and Ventilation 356Ineffective Ability to Clear Airway Secretions 356Clinical Reasoning Checkpoint 357References 359

Part Four Cardiovascular

13 Determinants and Assessment of Cardiac Function 365

Section One: Review of the Cardiopulmonary System 365Cardiopulmonary Circuits 365Blood Vessels 366

Section Two: Review of Heart Anatomy 368Heart Chambers 368Heart Wall Layers 368Structure and Function of Heart Valves 370Cardiac Cycle 370Mycocardial Tissue Perfusion 371Anatomy of the Coronary Arteries 371

Section Three: Determinants of Cardiac Output 372Determinants of Cardiac Output 372Afterload 374Contractility 374

Part Three Pulmonary

11 Determinants and Assessment of Pulmonary Function 289

Section One: Mechanics of Breathing—Ventilation 289The Conducting Airways 289Ventilation 290Effects of Aging on Ventilation 292

Section Two: Pulmonary Gas Exchange—Respiration and Diffusion 292

Diffusion 292Oxyhemoglobin Dissociation Curve 294The Effects of Aging on Diffusion 295

Section Three: Pulmonary Gas Exchange—Perfusion 295Cardiac Output 296Gravity 296Ventilation–perfusion Relationship 296Pulmonary Shunt 298Pulmonary Vascular Resistance 300

Section Four: Acid–base Physiology and Disturbances 301

Acid–base Physiology 301Maintaining Acid–base Balance: Buffer Systems and Compensation 302Respiratory Acid–base Disturbances 303Metabolic Acid–base Disturbances 304

Section Five: Arterial Blood Gases 305Determinants of Oxygenation Status 305Arterial Blood Gas 306

Section Six: Focused Respiratory Nursing History and Assessment 309

Nursing History 309Common Complaints Associated with Pulmonary Disorders 310Focused Respiratory Assessment 311

Section Seven: Pulmonary Function Evaluation 313Pulmonary Function Tests 313Bedside Pulmonary Function Measurements 314Forced Expiratory Volumes 314

Section Eight: Noninvasive and Invasive Monitoring of Gas Exchange 315

Pulse Oximetry 315Capnography 315Invasive Blood Gas Monitoring 317Clinical Reasoning Checkpoint 318References 319

12 Alterations in Pulmonary Function 321

Section One: Review of Restrictive and Obstructive Pulmonary Disorders 321

Restrictive Pulmonary Disorders 321Obstructive Pulmonary Disorders 322


xvi Contents

Section Two: Etiologic Factors for Coronary Artery Disease 420

Nonmodifiable Risk Factors 420Modifiable Risk Factors 421Collaborative Management of Risk Factor Reduction 421

Section Three: Clinical Presentation of Impaired Myocardial Tissue Perfusion 423

Subjective Data 423Objective Data: Physical Assessment 424

Section Four: Diagnostic Tests for Alterations in Myocardial Tissue Perfusion 425

Electrocardiogram 425Exercise Stress Test 427Myocardial Perfusion Imaging 427

Section Five: Impaired Myocardial Tissue Perfusion: Acute Coronary Syndromes 428

Diagnosis of Acute Coronary Syndromes 428Initial Collaborative Management 429Pharmaceutical Management 429

Section Six: Collaborative Interventions to Restore Myocardial Tissue Perfusion 431

Reperfusion 431Thrombolytic Therapy 431Percutaneous Coronary Intervention 432Coronary Artery Bypass Surgery 435Critical Reasoning Checkpoint 439References 440

Part Five Neurologic

16 Determinants and Assessment of Cerebral Function 443

Section One: Selective Neurological Anatomy and Physiology 443

The Central Nervous System 443The Peripheral Nervous System 446Cerebral Arterial Circulation 447Cerebral Venous Circulation 448Cerebral Oxygenation 448

Section Two: Intracranial and Cerebral Perfusion Pressures 449

Intracranial Pressure 449Cerebral Perfusion Pressure 450

Section Three: Assessment of Cerebral Tissue Perfusion 451Level of Consciousness 451In-depth Clinical Assessment 453Intracranial Pressure Monitoring 457Cerebral Oxygenation Monitoring 459

Section Four: Diagnostic Procedures 460Computed Tomography Scanning 460Magnetic Resonance Imaging 460

Section Four: Review of Blood Pressure 376Arterial Blood Pressure 376Venous Blood Pressure 376Regulation of Arterial Blood Pressure 377

Section Five: Assessment of Cardiac Function 378Patient History 378Nursing Physical Assessment 379Diagnostic Laboratory Tests 381Assessment of Specific Components of Cardiac Output 382

Section Six: Cardiac Diagnostic Procedures 383Noninvasive Procedures 383Invasive Diagnostic Procedures 384Clinical Reasoning Checkpoint 388References 389

14 Alterations in Cardiac Function 391

Section One: Valvular Heart Disease 391Valve Stenosis 391Valvular Regurgitation 393Infective Endocarditis 394Assessment and Diagnosis of Valvular Disorders 395Collaborative Management 396Nursing Management 396

Section Two: Heart Failure 397Clinical Manifestations and Classification 397Pathophysiology 398Assessment and Diagnosis 398Collaborative Management 399Nursing Management 401Cardiogenic Shock 402Hospital Discharge 402

Section Three: Hypertension 403Assessment and Diagnosis 404Collaborative Management 404Nursing Management 404

Section Four: Hypertensive Crises 406Risk Factors for Development of Crises 406Pathophysiology 406Types of Hypertensive Crises 406

Section Five: Aortic Aneurysm 408Aneurysms 408Aortic Aneurysm Emergencies 411Nursing Considerations 413Clinical Reasoning Checkpoint 413References 415

15 Alterations in Myocardial Tissue Perfusion 418

Section One: Pathophysiology of Atherosclerosis and Coronary Artery Disease 418

Atherosclerosis and Coronary Artery Disease 420


Contents xvii

Altered Nutrition 503Urinary Elimination 504Alterations in Skin Integrity 504Unilateral Neglect 505Ineffective Verbal Communication 505Inadequate Coping 506Other Sensory and Motor Deficits 506Clinical Reasoning Checkpoint 509References 511

19 Traumatic Brain Injury 513

Section One: Mechanisms of Brain Injury and Skull Fractures 513

Mechanisms of Injury 514Skull Fractures 515

Section Two: Decreased Intracranial Adaptive Capacity 518Increase in Brain Volume 518Cerebral Blood Volume 518Cerebrospinal Fluid 519

Section Three: Focal and Diffuse Brain Injuries 520Focal Brain Injuries 520Diffuse Brain Injuries 521

Section Four: Assessment and Diagnosis 522Assessment 522Initial Diagnostic Tests and Procedures 524

Section Five: Collaborative Management of Traumatic Brain Injury 525

Approach to Cerebral Tissue Perfusion Management 525Leveled Approach to Intracranial Pressure Management 527

Section Six: Nursing Management 530Interventions to Reduce Secondary Injury Following TBI 530Interventions to Manage ICP 530Interventions to Provide a Safe and Protective Environment 532

Section Seven: Complications Associated with Increased Intracranial Pressure 533

Neurogenic (Central) Diabetes Insipidus 533Syndrome of Inappropriate Antidiuresis Hormone 534Cerebral Salt Wasting 534Seizure Activity 534Brain Herniation 535Brain Death 536Clinical Reasoning Checkpoint 536References 538

20 Acute Spinal Cord Injury 540

Section One: Spinal Cord Anatomy and Physiology 540Vertebral Column 540Spinal Cord 540Spinal Cord Neuronal Function 541

Positron Emission and Single Photon Emission Computed Tomography 460Transcranial Doppler 460Evoked Potentials 461Electroencephalography 461Cerebral Angiography 461Magnetic Resonance Angiography 462Lumbar Puncture 462References 463

17 Mentation and Sensory Motor Complications of Acute Illness 465

Section One: Decreased Level of Consciousness, Abnormal Mentation, and Anxiety 465

Alterations in Mentation 465Agitation or Anxiety and Insomnia 466

Section Two: Delirium and Coma 467Delirium 467Coma 470

Section Three: Disorders of Movement 474Critical Illness Polyneuropathy and Myopathy 474Neuromuscular Blockade – Induced Paralysis 475

Section Four: Seizure Complications in High-Acuity Patients 477

Causes 478Classification 478Management of Acute Onset Seizures 478Status Epilepticus 479Nursing Considerations 480Clinical Reasoning Checkpoint 482References 483

18 Acute Stroke Injury 486

Section One: Definition and Classifications of Strokes 486

Major Classifications of Stroke 486

Section Two: Pathophysiology of Stroke 489

Section Three: Risk Factors for Stroke 491Modifiable Risk Factors 491Nonmodifiable Risk Factors 491

Section Four: Assessment and Diagnosis of Stroke 492

Assessment 492Determining Diagnosis and Recovery 493

Section Five: Acute Stroke Management 496Medical Management of Strokes 496Invasive Procedure and Surgical Management of Strokes 497Nursing Management 498

Section Six: Hospital Management and Secondary Prevention in the Acute Phase 502

Peripheral Tissue Perfusion 502Compromised Physical Mobility 502


xviii Contents

Diagnostic and Laboratory Tests of the GI System 585Additional Pancreatic Diagnostic Studies 586Laboratory Assessment for Acute GI Bleeding, PUD, and Intestinal Obstruction 588

Section Six: Nursing Assessment 589Focused Nursing Database 589Abdominal Assessment 589Clinical Reasoning Checkpoint 591References 592

22 Alterations in Gastrointestinal Function 593

Section One: Incidence and Clinical Manifestations of Acute GI Bleeding 593

Incidence and Mortality 593Etiology and General Manifestations of Upper GI Bleeding 594Etiology and General Manifestations of Lower GI Bleeding 594Clinical Manifestations of Upper and Lower GI Bleeding 594

Section Two: Acute Upper GI Bleeding Due to Peptic Ulcer Disease 595

Risk Factors 595Classification of Ulcers 596Common Clinical Manifestations 597Diagnosis and Treatment 597

Section Three: Acute Upper GI Bleeding Due to Non-ulcer Etiologies 600

Stress-related Mucosal Disease 600Acute Erosive or Hemorrhagic Gastritis 600Esophageal and Gastric Varices 601Mallory-Weiss Tears 601Arteriovenous Malformation 601

Section Four: Acute Lower GI Bleeding 601Diverticular Bleeding 602Inflammatory Bowel Disease 602Neoplasms and Polyps 603Arteriovenous Malformations 603Ischemic Bowel Disease 603

Section Five: Management of Acute Gastrointestinal Bleeding 604

Initial Assessment 604Resuscitation 604Definitive Diagnosis 605Treatments 606Treatments of Specific GI Bleeding Problems 606Management of Shock 606Related Nursing Diagnoses 607

Section Six: Acute Intestinal Obstruction 609Types of Acute Intestinal Obstruction 609Large-bowel Obstruction 609Clinical Findings in Intestinal Obstruction 610Treatment 610

Section Two: Spinal Cord Injury 542Spinal Cord Injury Etiologies 542Spinal Cord Injury Classification 543Mechanisms of Injury 545

Section Three: Diagnosis and Assessment of Spinal Cord Injury 547

Diagnostic Testing 547Physical Assessment 548

Section Four: Stabilization and Management of Spinal Cord Injury in the Acute Care Phase 551

Surgical Stabilization 551Manual Stabilization 552Steroid Therapy 552

Section Five: High-Acuity Nursing Care of the Patient with a Spinal Cord Injury 554

Alteration in Oxygenation and Ventilation from Problems with Gas Exchange and Abnormal Breathing Patterns 554Cardiac Dysfunction 555Impaired Bladder and Bowel Function 556Ineffective Temperature Regulation 557Malnutrition 557Inability to Care for Self 557Preventing Complications 558Clinical Reasoning Checkpoint 565References 566

Part Six Gastrointestinal

21 Determinants and Assessment of Gastrointestinal Function 570

Section One: The Gastrointestinal Tract 570Anatomic Structures 570Physiologic Functions 572Blood Supply 574Innervation 575

Section Two: Gut Defenses 576Nonimmunologic Defense Mechanisms 576Immunologic Defense Mechanisms 576Mechanisms that Maintain Mucosal Integrity 576

Section Three: The Liver 577Anatomic Structures 577Physiologic Functions 578Splanchnic Circulation 579Innervation 580Laboratory Assessment 580

Section Four: The Exocrine Pancreas 582Anatomic Structures 582Physiologic Functions 583Blood Supply 584Innervation 584Laboratory Assessment 584

Section Five: Diagnostic Tests 585


Contents xix

Section Three: Nursing Assessment of the Patient with Acute Pancreatitis 642

Assessment of Pain 642Focused History and Assessment 643

Section Four: Complications of Acute Pancreatitis 644Local Complications 645Systemic Complications 645

Section Five: Medical Management 646Supportive Therapy 646Curative Therapy 648

Section Six: Nursing Care of the Patient with Acute Pancreatitis 649


Part Seven Fluid and Electrolytes

25 Determinants and Assessment of Fluid and Electrolyte Balance 656

Section One: Body Fluid Composition and Distribution 656

Fluid Compartments 656Movement of Fluids 657

Section Two: Regulation of Fluid Balance 659Hypothalamus Regulation of Fluid Balance 659Endocrine Regulation 660

Section Three: Assessment of Fluid Balance 661History 661Vital Signs 662Physical Assessment 662Hemodynamic Monitoring 664Urine Assessment 664Laboratory Assessment 665

Section Four: Electrolytes 667Sodium 667Chloride 667Calcium 667Potassium 668Magnesium 668Phosphorus/Phosphate 668

Section Five: Assessment of Electrolyte Balance 669Physical Assessment 669Laboratory Testing 670Clinical Reasoning Checkpoint 671References 672

26 Alterations in Fluid and Electrolyte Balance 673

Section One: Fluid Volume Deficit 673Etiology 673Clinical Manifestations 674

Section Seven: Intra-abdominal Hypertension and Abdominal Compartment Syndrome 611

IAH/ACS Continuum 611IAH/ACS Etiology 611Multisystem Effects of Intra-abdominal Hypertension 612Measurement of Intra-abdominal Pressure 612Treatment of IAH/ACS 613Complications of ACS 614Nursing Implications 614Clinical Reasoning Checkpoint 615References 617

23 Alterations in Liver Function 619

Section One: Introduction to Acute Liver Failure 619Defining Acute Liver Failure 619Causes of Acute Liver Failure 619Pathophysiologic Basis of Acute Liver Failure 621

Section Two: Diagnosis and Treatment Strategies 621Diagnosis of Acute Liver Failure 621Specific Treatment Strategies Based on Diagnosis 622

Section Three: Complications and Treatment Strategies 623Hepatic Encephalopathy 623Cerebral Edema 624Coagulopathy 625Hypoglycemia and Electrolyte Abnormalities 626Infection 626Cardiopulmonary Abnormalities 626Acute Kidney Injury 626

Section Four: The High-Acuity Patient with Chronic Liver Disease 627

Hepatic Encephalopathy 627Esophageal Variceal Bleeding 628Ascites 628Additional Complications 630

Section Five: Nursing Considerations 630General Goals 630The Focused Nursing Database and History 630The Focused Nursing Assessment 631The Nursing Care Plan 631Clinical Reasoning Checkpoint 633References 634

24 Alterations in Pancreatic Function 636

Section One: Pathophysiologic Basis of Acute Pancreatitis 636

Etiologies 637Pathophysiology 637

Section Two: Diagnosing Acute Pancreatitis 639Laboratory Assessment of Acute Pancreatitis 639Diagnostic Tests 640Predicting the Severity of an Episode of Acute Pancreatitis 642


xx Contents

Pathophysiology of Chronic Kidney Disease 710Diagnostic Features of Chronic Kidney Disease 711Manifestations of Chronic Kidney Disease 711Medical Treatment 713Nursing Considerations 714Clinical Reasoning Checkpoint 714References 716

Part Eight Hematologic

28 Determinants and Assessment of Hematologic Function 719

Section One: Review of Anatomy and Physiology 719Composition of Blood 719Formation of Blood Cells 719Organs and Tissues of the Immune System 722

Section Two: Erythrocytes—the Cellular Component of Oxygen Transport 723

Erythropoiesis 723Hemoglobin 724

Section Three: Innate (Natural) Immunity 725Innate (Natural) Immunity 725Major Cells of Innate Immunity 725Complement System 727

Section Four: Adaptive (Acquired) Immunity 728Humoral Immunity 728Primary and Secondary Response 728Cell-Mediated Immunity 729

Section Five: Antigens and the Antigen–Antibody Response 730

Antigens 730Antigen–Antibody Responsiveness 731Antigen Entry Site 732

Section Six: Hemostasis 733Platelets: The Cell Component of Hemostasis 733Coagulation 734

Section Seven: Assessment of Hematologic Function 736Evaluation of Erythrocytes 736Evaluation of Leukocytes 737Evaluation of Hemostasis 738Evaluation of Bone Marrow 739Clinical Reasoning Checkpoint 740References 742

29 Alterations in Red Blood Cell Function and Hemostasis 743

Section One: Acute Anemias 743Types of Acute Anemias 743Clinical Manifestations of Anemia 747

Section Two: Sickle Cell Disease—A Disorder of Abnormal RBCs 749

Medical Treatment 674Nursing Considerations 675

Section Two: Fluid Volume Excess 676Etiology 676Clinical Manifestations 676Medical Treatment 676Nursing Considerations 677

Section Three: Sodium Imbalances 678Hyponatremia 678Hypernatremia 679

Section Four: Calcium Imbalances 680Hypocalcemia 680Hypercalcemia 681

Section Five: Potassium Imbalances 682Hypokalemia 682Hyperkalemia 684

Section Six: Magnesium Imbalances 685Hypomagnesemia 685Hypermagnesemia 686

Section Seven: Phosphorus and Phosphate Imbalances 687

Hypophosphatemia 687Hyperphosphatemia 688Clinical Reasoning Checkpoint 689References 691

27 Alterations in Kidney Function 692

Section One: Pathophysiology of Acute Kidney Injury 692

Acute Kidney Injury 692Types of Acute Kidney Injury 693

Section Two: Diagnosis and Assessment of Acute Kidney Injury 696

Diagnostic Considerations 696Assessment Considerations 697Urine Output: A Measure of Renal Function 697

Section Three: Medical Treatment 700Treatment of Fluid Overload 701Treatment of Metabolic Imbalance (Catabolism) 701Treatment of Electrolyte/Acid–Base Imbalance 701Treatment of Infection 702

Section Four: Renal Replacement Therapy 703Determining the Need for Renal Replacement Therapy 703Types of Renal Replacement Therapy 703

Section Five: Nursing Care of the Patient with Acute Kidney Injury 707

Managing Fluid Overload 707Managing Catabolic Processes 708Managing Electrolyte and Acid–Base Imbalances 708Infection 709

Section Six: Chronic Kidney Failure in the High-Acuity Patient 710


Contents xxi

Section Five: Oncological Emergencies 783Tumor-related Emergencies 783Therapy-related Emergencies 785Other Oncologic Treatment Emergencies 786Nursing Implications 786

Section Six: HIV Disease—A Disorder of Immunodeficiency 787

Epidemiology and Transmission 787Pathophysiology 788Progression of HIV Infection 788Clinical Manifestations 789Diagnosis of HIV 789Prognosis and Management 790Nursing Implications 791

Section Seven: Aging, Malnutrition, Stress, Trauma, and the Immune System 792

Aging 792Malnutrition 792Stress and Trauma 792Nursing Implications 793

Section Eight: Care of the Immunocompromised Patient 793

Focused Assessment 793Immunocompetence Assessment 794Collaborative Management 794Independent Nursing Interventions 794Clinical Reasoning Checkpoint 796References 798

Part Nine Nutrition and Metabolism

31 Determinants and Assessment of Nutrition and Metabolic Function 800

Section One: Metabolism 800Anabolism and Catabolism 800Aerobic and Anaerobic Metabolism 801Energy 802

Section Two: Nutrition: The Source of Energy 803Carbohydrates 803Proteins 803Lipids 804

Section Three: Endocrine Influence on Metabolism 805Endocrine Glands and Hormones 805Physiologic Response to Stress 806

Section Four: Focused Nutritional History and Physical Assessment 809

Medical and Nutritional History 809Anthropometric Measurements 810

Section Five: Laboratory Assessment of Endocrine and Nutritional and Metabolic Status 811

Albumin 811Prealbumin 812

Epidemiology 750Pathophysiology of Sickle Hemoglobin 750Clinical Manifestations and Complications 751

Section Three: Polycythemia: A Disorder of Excessive RBCs 754

Primary Polycythemia (Polycythemia Vera) 754Secondary Polycythemia 755

Section Four: Thrombocytopenia: A Problem of Hemostasis 756

Underlying Processes 756Clinical Findings 757Diagnosis and Treatment 758Nursing Considerations 758

Section Five: Disseminated Intravascular Coagulation: A Problem of Hemostasis 759

The Coagulation Cascade and DIC 759Clinical Findings of DIC 760Laboratory Studies 760Treatment 760Nursing Considerations 761

Section Six: Nursing Assessment of the Patient with Problems of Erythrocytes or Platelets 761

The Focused Nursing Assessment 761Nursing Considerations 762Clinical Reasoning Checkpoint 763References 764

30 Alterations in White Blood Cell Function and Oncologic Emergencies 767

Section One: Neutropenia 767Underlying Causes 768Clinical Manifestations 768Management 769

Section Two: Disorders of Hyperactive Immune Response: Hypersensitivity 770

Type I (Allergic) Hypersensitivity Response 770Type II (Cytotoxic) Hypersensitivity Response 772Type III (Immune Complex-mediated) Hypersensitivity Response 773Type IV (Delayed) Hypersensitivity Response 774Drug-induced Hypersensitivity Reactions 775Management of Hypersensitivity Responses 775

Section Three: Disorders of Hyperactivity Immune Response: Autoimmunity 777

Systemic Lupus Erythematosus 778

Section Four: Acute Leukemia 780Types of Acute Leukemia 781Clinical Manifestations 781Cell Expansion and Infiltration 781Diagnosis and Prognosis 782Management 782Nursing Implications 782


xxii Contents

Section Four: Hyperglycemic Crisis—Hyperglycemic Hyperosmolar State 852

Patient Profile and Precipitating Factors 852Pathophysiologic Basis of HHS 852Clinical Presentation 852

Section Five: Management of Hyperglycemic Crises 853Collaborative Interventions 853

Section Six: Insulin Therapy During Crises 856Continuous Low-dose Intravenous Insulin Infusion 857Sliding-scale Insulin Administration 857Intensive Insulin Therapy 857

Section Seven: Acute Care Implications of Chronic Complications 858

Diabetic Peripheral Neuropathies 858Microvascular Disease 858Macrovascular Disease 859Increased Risk of Infection 860Clinical Reasoning Checkpoint 860References 862

Part Ten Multisystem Dysfunction

34 Determinants and Assessment of Oxygenation 864

Section One: Introduction to Oxygenation 864

Section Two: Pulmonary Gas Exchange 866Components of Pulmonary Gas Exchange 866Assessment of Pulmonary Gas Exchange 867

Section Three: Oxygen Delivery 869Components of Oxygen Delivery 869Assessment of Oxygen Delivery 870

Section Four: Oxygen Consumption 871Aerobic Metabolism 871Anaerobic Metabolism 872Oxygen Extraction 872Factors That Alter Oxygen Consumption 873Assessment of Oxygen Consumption 874Clinical Reasoning Checkpoint 876References 877

35 Multiple Trauma 879

Section One: Overview of the Injured Patient 879Categories of Kinetic Injury 880Risk Factors for Traumatic Injury 880Severity of Injury, Mortality, and Payer Source 881Age, Gender, Mechanism of Injury, and Geography 881

Section Two: Mechanism of Injury: Blunt Trauma 881Forces Associated with Blunt Trauma 882Injuries Associated with Blunt Trauma 882

Section Three: Mechanism of Injury: Penetrating Trauma 883

Forces Associated with Penetrating Trauma 883

Transferrin 812Nitrogen Balance 812Vitamin and Mineral Assays 813Total Lymphocyte Count 813Anergy Screen 813

Section Six: Physiologic Studies of Nutrition and Metabolic Status 814

Oxygen Consumption and Energy Expenditure 814Oxygen Extraction 815Harris–Benedict Equation 815Clinical Reasoning Checkpoint 817References 818

32 Metabolic Response to Stress 820

Section One: Introduction to Responses to Stress in Acute and Critical Illness 820

Neuro-endocrine Stress Response 820The Metabolic Stress Response 822

Section Two: Acute Adrenal Insufficiency During Critical Illness 824

Types of Adrenal Insufficiency 824Signs and Symptoms of Adrenal Insufficiency 824Evaluation of Adrenal Insufficiency 825Diagnostic Criteria for Adrenal Insufficiency 825Treatment 825

Section Three: Thyroid Dysfunction During Critical Illness 827

Thyroid Hormones 827Primary Hyperthyroidism and Hypothyroidism 827Nonthyroid Illness Syndrome 829

Section Four: Hyperglycemic Syndromes in the High-Acuity Patient 833

Hyperglycemia, Hypoglycemia, Glycemic Variability, and Patient Outcomes: The Evidence 833Prevention of Insulin-induced Hypoglycemia 835Hyperglycemic Syndromes: Collaborative Management 835Critical Reasoning Checkpoint 836References 838

33 Diabetic Crises 841

Section One: Review of Diabetes Mellitus and Insulin Deficit 841

Types of Diabetes Mellitus 842Effects of Insulin Deficit 842

Section Two: Hypoglycemic Crisis 844Clinical Diagnosis and Presentation 844Other Determinants of Hypoglycemic Symptoms 845Collaborative Interventions 846

Section Three: Hyperglycemic Crisis—Diabetic Ketoacidosis 849

Patient Profile and Precipitating Factors 849Pathophysiologic Basis of DKA 850

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Contents xxiii

Section Four: Resuscitative Phase—Neurologic and Psychologic Effects 916

Neurologic Effects 916Anxiety and Psychiatric Issues 917

Section Five: Resuscitative Phase—Metabolic and Renal Effects 917

Metabolic Effects 917Renal Effects 918

Section Six: Burn Wound Healing 919Initial Wound Care 920Acute Rehabilitative Phase Wound Management 920

Section Seven: Acute Rehabilitative Phase— Psychosocial Needs and Physical Mobility 925

Psychosocial Needs 925Physical Mobility 925

Section Eight: Overview of Long-term Rehabilitative Phase 926


37 Shock States 932

Section One: Introduction to Shock States 932Physiologic Response to Shock 933

Section Two: Assessment of Shock States 935Traditional Parameters 935Objective Parameters of Shock 935Emerging Technologies 936

Section Three: General Management of Shock States 937

Interventions to Optimize Oxygen Delivery 937Interventions to Decrease Oxygen Consumption 938Nursing Considerations 939

Section Four: Vasoactive Pharmacotherapy in Shock Treatment 940

Vasopressors 940Inotropes 941Vasodilators 941Vasoactive Agents: Nursing Implications 943

Section Five: Cardiogenic Shock 944Pathophysiology 944Clinical Manifestations and Diagnosis 945Management 945

Section Six: Hypovolemic Shock 947Pathophysiology 947Clinical Manifestations 947Treatment 948

Section Seven: Distributive Shock—Septic 949Introduction to Distributive Shock 949Pathophysiologic Basis of Septic Shock 949Clinical Manifestations 950Treatment 950

Section Eight: Distributive Shock—Neurogenic and Anaphylactic 951

Low- to Medium-energy Missiles 883High-energy Missiles 884Secondary Missiles 884Injuries Associated with Penetrating Trauma 884

Section Four: Mechanism of Injury: Patterns and Mediators of Injury Response 885

Mechanisms of Injury and Injury Patterns 885Factors Affecting the Response to Injury 885

Section Five: Primary and Secondary Surveys 888The Primary Survey 888The Secondary Survey 891

Section Six: Trauma Resuscitation 892Trimodal Distribution of Trauma Deaths 892Trauma Resuscitation 893End Points of Resuscitation 894

Section Seven: Management of Selected Injuries 895Chest Injuries 895Pulmonary Injuries 896Cardiac Injuries 897Abdominal Injuries 897Pelvic Injuries 898

Section Eight: Complications of Traumatic Injury 899

Risks for Complications 899Metabolic Response to Injury: Risk for Undernutrition 899Venous Thromboembolism 900Sepsis 900Acute Respiratory Distress Syndrome 900Disseminated Intravascular Coagulation 900Acute Kidney Injury (AKI) 901Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome 901Nursing Assessment and Diagnosis 901Psychosocial Nursing Considerations 901Clinical Reasoning Checkpoint 902References 903

36 Acute Burn Injury 906

Section One: Mechanisms of Burn Injury 906Thermal Burns 907Chemical Burns 907Electrical Burns 907Radiation and Extreme Cold Burns 908

Section Two: Burn Wound Classification and Burn Center Transfer 908

Burn Classification 909Burn Center Transfer 910

Section Three: Resuscitative Phase—Cardiovascular and Pulmonary Effects 912

Cardiovascular Effects of Burn Injury 912Peripheral Vascular Effects of Burn Injury 913Pulmonary Effects of Burn Injury 914


xxiv Contents

Types of Donors 977Legal Aspects of Donation and Transplantation 978

Section Three: Determination of Death 979Definition of Death 979Determination of Death 979Clinical Diagnosis of Brain Death 980

Section Four: Donor Management 981Donor Management 981

Section Five: Organ Procurement 983Referral to the Organ Procurement Organization 983Determination of Patient’s Suitability for Organ Donation 983Obtaining Consent 984Donor Testing 984The Organ Recovery Process 984

The Organ Recipient 985

Section Six: Immunologic Considerations 985Donor–Recipient Compatibility Testing 985

Section Seven: Determination of Transplant Need 986Evaluation of the Transplant Recipient 986

Section Eight: Posttransplantation Complications 988Technical Complications 988Graft Rejection 989Immunosuppressant-related Complications 989

Section Nine: Immunosuppressant Therapy 991Calcineurin Inhibitors 991Glucocorticoids 992Cytotoxic Agents 992Antibodies (Monoclonal and Polyclonal) 992Nursing Considerations 994

Section Ten: Hematopoietic Stem Cell Transplantation 995Types of HSCT 995Sources of Hematopoietic Stem Cells 995Transplanting Procedure 995Post-HSCT Complications 996Management of the Immediate Post-allogeneic HSCT Patient 997

Section Eleven: Kidney Transplantation: An Overview 998Major Indications for Renal Transplantation 998Preparation of the Recipient 998Postoperative Management 998Clinical Reasoning Checkpoint 1000References 1002

Glossary 1004

Abbreviations 1019

Index 1029

Neurogenic Shock 951Anaphylactic Shock 953

Section Nine: Obstructive Shock States 954Pulmonary Embolism 954Tension Pneumothorax 954Cardiac Tamponade 955Clinical Reasoning Checkpoint 956References 957

38 Multiple Organ Dysfunction Syndrome 961

Section One: Inflammatory Response and Endothelium 961

Review of the Inflammatory Response 961Endothelium 962

Section Two: Systemic Inflammatory Response Syndrome 964

Etiology and Risk Factors 964Clinical Manifestations 965The SIRS–MODS Connection 965

Section Three: Multiple Organ Dysfunction Syndrome 966Pathophysiologic Considerations 966Risk Factors 967

Section Four: Sequential Organ Involvement and Failure 967

Assessing the Severity of Organ Dysfunction 967Sequential Organ Injury 968

Section Five: Management of MODS 969Prevent SIRS and Sepsis 969Detect Early SIRS, Sepsis, and MODS 969Implement a Treatment Plan 969Clinical Reasoning Checkpoint 971References 973

39 Solid Organ and Hematopoietic Stem Cell Transplantation 975

Section One: Brief History of Organ Transplantation 9751910 to 1930: The Beginnings 9751930 to 1950: In Search of Long-term Success 9761950 to 1960: The Isograft and Immunosuppressant Discovery Years 9761961 to 1979: The Expansion Years 9761980 to the Present 976

The Organ Donor 977

Section Two: Graft, Immunologic, and Legal Considerations 977

Types of Grafts 977


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