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Brief Table of Contents

The Concept of Holism Applied to Critical Care Nervous System 289
Nursing Practice 1 Chapter 21 Patient Assessment: Nervous System 289
Chapter 1 Critical Care Nursing Practice 1 Chapter 22 Patient Management: Nervous System 304
Chapter 2 The Patients and Familys Experience Chapter 23 Common Neurosurgical and Neurological
With Critical Illness 8 Disorders 317
Chapter 3 Patient and Family Education in Critical

Chapter 4
Care 18
Ethical and Legal Issues in Critical Care
Nursing 23 Gastrointestinal System 351
Chapter 24 Patient Assessment: Gastrointestinal
System 351
P AR T T W O Chapter 25 Common Gastrointestinal Disorders 361
Essential Interventions in Critical Care 31
Chapter 5 Relieving Pain and Providing Comfort 31
Chapter 6 End-of-Life and Palliative Care 41 P ART E IGHT
Chapter 7 Providing Nutritional Support, Fluids, Endocrine System 377
and Electrolytes 46 Chapter 26 Patient Assessment: Endocrine System 377
Chapter 8 Dysrhythmia Interpretation and Chapter 27 Common Endocrine Disorders 384
Management 62
Chapter 9 Hemodynamic Monitoring 92
Chapter 10 Airway Management and Ventilatory P ART N IN E
Support 114 Hematological and Immune Systems 399
Chapter 11 Code Management 135 Chapter 28 Patient Assessment: Hematological
and Immune Systems 399
P AR T T H R EE Chapter 29 Common Hematological and Immunological
Disorders 408
Cardiovascular System 143
Chapter 12 Patient Assessment: Cardiovascular
System 143 P ART T E N
Chapter 13 Patient Management: Cardiovascular Integumentary System 423
System 157 Chapter 30 Patient Assessment: Integumentary
Chapter 14 Common Cardiovascular Disorders 179 System 423
Chapter 31 Patient Management: Integumentary
P AR T F O U R Chapter 32
System 434
Burns 441
Respiratory System 207
Chapter 15 Patient Assessment: Respiratory
System 207 P ART E L E VE N
Chapter 16 Patient Management: Respiratory Multisystem Dysfunction 457
System 219 Chapter 33 Shock and Multisystem Organ Dysfunction
Chapter 17 Common Respiratory Disorders 227 Syndrome 457
Chapter 34 Trauma 470
Renal System 255 Index 487
Chapter 18 Patient Assessment: Renal System 255
Chapter 19 Patient Management: Renal System 263
Chapter 20 Common Renal Disorders 273

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Essentials of
Critical Care
A Holistic Approach

Patricia Gonce Morton, RN, PhD, ACNP-BC, FAAN

Professor and Associate Dean for Academic Affairs
University of Maryland School of Nursing
Acute Care Nurse Practitioner
University of Maryland Medical Center
Baltimore, Maryland

Dorrie K. Fontaine, RN, PhD, FAAN

Dean, School of Nursing, University of Virginia
Sadie Health Cabaniss Professor of Nursing
Charlottesville, Virginia

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Executive Acquisitions Editor: Elizabeth Nieginski
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Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or trans-
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Library of Congress Cataloging-in-Publication Data

Morton, Patricia Gonce, 1952-
Essentials of critical care nursing : a holistic approach / Patricia Gonce Morton, Dorrie K. Fontaine.
p. ; cm.
Related work: Critical care nursing / [edited by] Patricia Gonce Morton, Dorrie K. Fontaine. 9th ed. c2009.
Includes bibliographical references and index.
ISBN 978-1-60913-693-2
I. Fontaine, Dorrie K. II. Critical care nursing. III. Title.
[DNLM: 1. Critical Care. 2. Holistic Nursingmethods. WY 154]

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

Morton_FM.indd iv 2/4/2012 3:51:08 PM

T o the students and the nurses who will learn from this book.
May you provide holistic, patient-centered care to all critically ill
patients and their families.
Never lose site of the difference you make in their lives.

Trish and Dorrie

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Clinical Consultant

Kendra Menzies Kent, RN, MS, CCRN, CNRN

ICU Staff Nurse
St. Marys Hospital
West Palm Beach, Florida


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Thank You
The authors and Lippincott Williams & Wilkins extend a special,
heartfelt thank you to the contributors of the ninth edition of Critical
Care Nursing: A Holistic Approach whose work served as the basis for
the content in this book.

Susan E. Anderson, RN, MSN Donna Charlebois, RN, MSN, ACNP-CS
Senior Quality Assurance Specialist Lung Transplant Coordinator
United States Army Graduate Program University of Virginia
in Anesthesia Nursing Charlottesville, Virginia
Fort Sam Houston, Texas
JoAnn Coleman, RN, DNP, ACNP, AOCN
Sue Apple, RN, PhD Acute Care Nurse Practitioner and Coordinator
Assistant Professor Gastrointestinal Surgical Oncology
Department of Professional Nursing John Hopkins Hospital
School of Nursing and Health Studies Baltimore, Maryland
Georgetown University
Washington, District of Columbia Vicki J. Coombs, RN, PhD, FAHA
Senior Vice President
Carla A. Aresco, RN, MS, CRNP Spectrum Clinical Research, Inc.
Nurse Practitioner, Shock Trauma Towson, Maryland
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center Joan M. Davenport, RN, PhD
Baltimore, Maryland Assistant Professor and Vice-Chair
Department of Organizational Systems
Mona N. Bahouth, MSN, CRNP, MD and Adult Health
Neurology Resident University of Maryland School of Nursing
Johns Hopkins Hospital Baltimore, Maryland
Baltimore, Maryland
Marla J. De Jong, RN, PhD, CCNS, Colonel
Kathryn S. Bizek, MSN, ACNS-BC, CCRN Dean
Nurse Practitioner, Cardiac Electrophysiology United States Air Force School of Aerospace
Henry Ford Heart and Vascular Institute Medicine
Henry Ford Health System Wright-Patterson Air Force Base, Ohio
Detroit, Michigan
Nancy Kern Feeley, RN, MS, CRNP, CNN
Kay Blum, PhD, CRNP Nephrology Adult Nurse Practitioner
Nurse Practitioner and Assistant Professor The Johns Hopkins University
University of Maryland Medical System Baltimore, Maryland
University of Maryland School of Nursing
Baltimore, Maryland Charles Fisher, RN, MSN, CCRN, ACNP-BC
Acute Care Nurse Practitioner Medical ICU
Eileen M. Bohan, RN, BSN, CNRN University of Virginia Health System
Senior Program Coordinator Charlottesville, Virginia
The Johns Hopkins University
Baltimore, Maryland Barbara Fitzsimmons, RN, MS, CNRN
Nurse Educator
Garrett K. Chan, PhD, APRN, FAEN, FPCN Department of Neuroscience Nursing
Lead Advanced Practice Nurse The Johns Hopkins Hospital
Stanford Hospitals and Clinics Baltimore, Maryland
Stanford, California

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x Contributors

Conrad Gordon, RN, MS, ACNP Karen L. Johnson, RN, PhD

Assistant Professor Director of Nursing, Research, and Evidence-Based
Department of Organizational Systems Practice
and Adult Health University of Maryland Medical Center
University of Maryland School of Nursing Baltimore, Maryland
Baltimore, Maryland
Dennis W. Jones, RN, MS, CFRN
Christine Grady, RN, PhD Critical Care Flight Nurse
Head, Section on Human Subjects Research Johns Hopkins Hospital
Department of Bioethics Baltimore, Maryland
Clinical Center
National Institutes of Health Kimmith M. Jones, RN, DNP, CCNS
Bethesda, Maryland Advanced Practice Nurse
Critical Care and Emergency Center
Debby Greenlaw, MS, CCRN, ACNP Sinai Hospital of Baltimore
Acute Care Nurse Practitioner Baltimore, Maryland
Hospitalist Group, Providence Hospital
Columbia, South Carolina Roberta Kaplow, RN, PhD, AOCNS,
Kathy A. Hausman, RN, C, PhD Clinical Nurse Specialist
Chair, Department of Nursing Emory University Hospital
Baltimore City Community College Atlanta, Georgia
Baltimore, Maryland
Jane Kapustin, PhD, CRNP
Jan M. Headley, RN, BS Associate Professor of Nursing
Director, Clinical Marketing and Professional Assistant Dean for Masters and DNP Programs
Education University of Maryland School of Nursing
Edwards Lifesciences LLC Adult Nurse Practitioner, Joslin Diabetes Center
Irvine, California University of Maryland Medical Center
Baltimore, Maryland
Janie Heath, PhD, APRN-BC, FAAN
Associate Dean Academic Affairs Susan N. Luchka, RN, MSN, CCRN, ET
University of Virginia School of Nursing Director of Clinical Education
Charlottesville, Virginia Memorial Hospital
York, Pennsylvania
Kiersten N. Henry, MS, APRN-BC, CCNS,
CCRN-CMC Christine N. Lynch, RN, MS, CCRN, CRNP
Cardiovascular Nurse Practitioner Acute Care Nurse Practitioner, Surgical
Montgomery General Hospital Critical Care
Olney, Maryland Union Memorial Hospital
Baltimore, Maryland
Gennell D. Hilton, PhD, CRNP, CCNS, CCRN
Nurse Practitioner, Trauma Services Cathleen R. Maiolatesi, RN, MS
San Francisco General Hospital Advanced Practice Nurse
San Francisco, California The Johns Hopkins Hospital
Faculty, Life Sciences Department Baltimore, Maryland
Santa Rosa Junior College
Santa Rosa, California Sandra W. McLeskey, RN, PhD
Dorene M. Holcombe, RN, MS, ACNP, CCRN University of Maryland School of Nursing
Nephrology Acute Care Nurse Practitioner Baltimore, Maryland
Johns Hopkins University School of Medicine
Baltimore, Maryland Alexander R. McMullen III, RN, JD, MBA, BSN
Christina Hurlock-Chorostecki, PhD(c), McMullen and Drury
NP-Adult Towson, Maryland
Nurse Practitioner
St. Josephs Health Care Patricia C. McMullen, PhD, JD, CRNP
London, Ontario, Canada Associate Provost for Academic Administration
The Catholic University of America
Washington, District of Columbia

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Contributors xi

Paul K. Merrel, RN, MSN, CCNS Michael V. Relf, RN, PhD, CNE, ACNS-BC,
Advanced Practice Nurse 2-CNS, Adult AACRN, FAAN
Critical Care Associate Professor and Assistant Dean for
University of Virginia Health System Undergraduate Education
Charlottesville, Virginia Duke University School of Nursing
Durham, North Carolina
Sandra A. Mitchell, PhD, ARNP, AOCN
Senior Research Nurse, Clinical Center Kenneth J. Rempher, RN, PhD, MBA, CCRN
National Institute of Health Assistant Vice President Patient Care Services
Bethesda, Maryland Sinai Hospital of Baltimore
Baltimore, Maryland
Nancy Munro, RN, MN, CCRN, ANCP
Acute Care Nurse Practitioner Valerie K. Sabol, PhD, ACNP-BC, GNP-BC,
Critical Care Medicine Department CCNS
National Institutes of Health Specialty Director
Bethesda, Maryland Acute Care Nurse Practitioner (ACNP)/Critical Care
Clinical Instructor Clinical Nurse Specialist (CCNS) Masters Tracks
University of Maryland School of Nursing Duke University School of Nursing
Baltimore, Maryland Durham, North Carolina

Angela C. Muzzy, RN, MSN, CCRN, CNS Brenda K. Shelton, RN, MS, CCRN, AOCN
Clinical Nurse Specialist/CVICU Critical Care Clinical Nurse Specialist
University Medical Center The Sidney Kimmel Comprehensive Cancer Center
Tucson, Arizona at Johns Hopkins
Baltimore, Maryland
Colleen Krebs Norton, RN, PhD, CCRN
Associate Professor and Director of the Jo Ann Hoffman Sikora, RN, MS, CRNP
Baccalaureate Nursing Program Nurse Practitioner, Division of Cardiac Surgery
Georgetown University School of Nursing and University of Maryland Medical Systems
Health Studies Baltimore, Maryland
Washington, District of Columbia
Kara Adams Snyder, RN, MS, CCRN, CCNS
Dulce Obias-Manno, RN, BSN, MHSA, CCDS, Clinical Nurse Specialist, Surgical Trauma
CEPS, FHRS Critical Care
Nurse Coordinator, Cardiac Arrhythmia Center/ University Medical Center
Device Clinic Tucson, Arizona
Medstar/Washington Hospital Center
Washington, District of Columbia Debbi S. Spencer, RN, MS
Chief Nurse, Joint Trauma System
Mary O. Palazzo, RN, MS United States Army Institute of Surgical Research
Director of Cardiothoracic Surgery, Heart Institute Fort Sam Houston, Texas
St. Joseph Medical Center
Towson, Maryland Allison G. Steele, MSN, BSN, CRNP
Nurse Practitioner
Suzanne Prevost, RN, PhD, COI University Physicians Inc.
Associate Dean for Practice and Community University of Maryland Department of Medicine
Engagement Division of Gastroenterology and Hepatology
University of Kentucky College of Nursing Baltimore, Maryland
Lexington, Kentucky
Louis R. Stout, RN, MS, CEN
Kim Reck, RN, MSN, CRNP Lieutenant Colonel, United States Army
Clinical Program Manager, CRNP Nurse Corps
Division of Cardiology United States Army Medical Department
University of Maryland Medical Center Fort Lewis, Washington
Baltimore, Maryland
Sidenia S. Tribble, RN, MSN, APRN-BC, CCRN
Kathryn P. Reese, RN, BSN, Major Acute Care Nurse Practitioner
Element Chief, Cardiac Intensive Care Unit Page Memorial Hospital
Wilford Hall Medical Center Luray, Virginia
Lackland Air Force Base, Texas

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xii Contributors

Terry Tucker, RN, MS, CCRN, CEN Janet Armstead Wulf, RN, MS, CNL, CHPN
Critical Care Clinical Nurse Specialist Staff Nurse
Maryland General Hospital Union Memorial Hospital
Baltimore, Maryland Baltimore, Maryland

Mary van Soeren, RN, PhD Karen L. Yarbrough, MS, CRNP

Director Acute Care Nurse Practitioner
Canadian Health Care Innovations Director, Stroke Programs
Guelph, Ontario, Canada Stroke and Neurocritical Care
University of Maryland Medical Center
Kathryn T. VonRueden, RN, MS, FCCM Baltimore, Maryland
Associate Professor, Trauma, Critical Care
Department of Organizational Systems Elizabeth Zink, RN, MS, CCRN, CNRN
and Adult Health Clinical Nurse Specialist
University of Maryland School of Nursing Neurosciences Critical Care Unit
Clinical Nurse Specialist, Trauma Resuscitation Unit The Johns Hopkins Hospital
R Adams Cowley Shock Trauma Center Baltimore, Maryland
University of Maryland Medical Center
Baltimore, Maryland

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Jane Baltimore, MSN Julie C. Chew, RN, PhD

Clinical Nurse Specialist Faculty
Harborview Medical Center Mohave Community College
Seattle, Washington Colorado City, Arizona

Susan Barnason, PhD, MSN, BSN, MA Patricia Connick, RegN, CNCC(c)

Associate Professor Faculty Health Sciences Nursing Department
University of Nebraska Medical Center College of Georgian College of Applied Arts & Technology,
Nursing Barrie Campus
Lincoln, Nebraska Durham College, Oshawa Campus
Bracebridge, Ontario, Canada
Mali M. Bartges, RN, MSN
Associate Professor L. Angelise Davis, RN, DSN, MN, AHNP
Northampton Community College Associate Professor, Baccalaureate Nursing
Bethlehem, Pennsylvania Program
Mary Black School of Nursing, University of South
Deborah Becker, PhD, ACNP, BC, CCNS Carolina Upstate
Practice Assistant Professor of Nursing Spartanburg, South Carolina
University of Pennsylvania School of Nursing
Philadelphia, Pennsylvania Jack E. Dean, MSN, BSN, BS
Cynthia Gurdak Berry, RN, DNP UPMC Shadyside Hospital School of Nursing
Assistant Professor Pittsburgh, Pennsylvania
Ida V. Moffett School of Nursing, Samford University
Birmingham, Alabama Daniel Defeo, MSN, MA
West Virginia University School of Nursing
Mary Spitak Bilitski, RN, MSN, CVN South Morgantown, West Virginia
Instructor of Nursing
The Washington Hospital School of Nursing Theresa Delahoyde, RN, EdD
Washington, Pennsylvania Associate Professor of Nursing
BryanLGH College of Health Sciences
Kathleen Buck, BSN Lincoln, Nebraska
Huntington University Hazel Downing, RN, EdD, MN
Huntington, Indiana Assistant Professor of Nursing
Hawaii Pacic University
Sharon Burke, MSN, APRN, CCRN, BCEN Kanehoe, Hawaii
Thomas Jefferson University Kathleen Evanina, RN, PhDc, CRNP-BC
Philadelphia, Pennsylvania Professor
Marywood University
Doris Cavlovich, RN, MSN, CCRN Scranton, Pennsylvania
Nursing Instructor II
St. Margaret School of Nursing Shelley Gerbrandt, RN, BSN, CCN(C)
Pittsburgh, Pennsylvania Facilitator, Basic Critical Care Program Casual
Sask Institute of Applied Science and Technology
Regina, Saskatchewan


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xiv Reviewers

Kelly Goebel, DNP, ACNP-BC, CCRN Karen S. March, RN, PhD, MSN, CCRN,
Associate Professor ACNS-BC
Nova Southeastern University Associate Professor of Nursing
Fort Myers, Florida York College of Pennsylvania
York, Pennsylvania
Linda M. Graham, MSN
Assistant Professor Leigh W. Moore, RN, MSN, CNOR, CNE
Department of Nursing Associate Professor of Nursing
Thomas More College Southside Virginia Community College
Crestview Hills, Kentucky Alberta, Virginia

Margaret Gramas, RN, MSN Teresa Newby, RN, MSN

Nursing Instructor Nursing Department Chair
Morton College Crown College
Cicero, Illinois St. Bonifacius, Minnesota

Cam A. Hamilton, RN, MSN Crystal OConnell-Schauerte, MscN, BscB

Instructor Nursing Professor
Auburn University at Montgomery Algonquin College
Montgomery, Alabama Ottawa, Ontario, Canada

Trina R. Hill RN, MAEd, BScN Jeanne M. Papa, MSN, MBE, CRNP
Faculty Full-time Faculty
Saskatchewan Institute of Applied Science and Neumann University
Technology (SIAST) Aston, Pennsylvania
Regina, Saskatchewan
Patricia Perry, RN, MSN, BSN
Glenda Susan Jones, RN, MSN, CNS, CCRN Nursing Instructor
Assistant Professor of Nursing Galveston College
Jefferson College of Health Science Galveston, Texas
Roanoke, Virginia
Carrie Pucino, RN, MS,CCRN
Catherine B. Kaesberg, MSN, BSN Nursing Faculty
Instructional Assistant Professor York College of Pennsylvania
Faculty York, Pennsylvania
Illinois State University
Normal, Illinois Carol Anne Purvis, RN, EdD, MSN, MEd, BSN
Associate Professor of Nursing
Heather Kendall, RN, MSN, CCRN-CMC-CSC Gordon College
Assistant Professor Barnseville, Georgia
Missouri Western State University
St. Joseph, Missouri Stephanie A. Reagan, MSN, CNS
Associate Professor of Nursing
Tonia Kennedy, RN, MSN, CCRN Malone University
Director of Generic Program and Assistant Canton, Ohio
Professor of Nursing
Liberty University Mary Runde, RN, MN-APN
Lynchburg, Virginia Online Teacher, Critical Care
Durham College
Anita J.K. Langston, MSN, ANP-BC, CCRN, Oshawa, Ontario
Clinical Associate Professor Nancy Sarpy, RN, MS
University of Memphis Assistant Professor of Nursing
Memphis, Tennessee Loma Linda University School of Nursing
Loma Linda, California
Janice Garrison Lanham, RN, MS, CCRN,
CNS, FNP Heidi H. Schmoll, MSN-Ed, BSN, ADN, AA, AS
Nursing Faculty/Lecturer Simulation Nurse Educator
School of Nursing, Clemson University Medical University of South Carolina
Clemson, South Carolina Charleston, South Carolina

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Reviewers xv

Susan Schroeder, RN, MSN Donna Talty, RN, MSN, FNP-BC, CNE
Assistant Professor of Nursing Professor of Nursing
Marian University School of Nursing Oakton Community College
Indianapolis, Indiana Des Plaines, Illinois

Deborah J. Schwytzer, MS, BSN, BS Stephanie B. Turner, RN, EdD, MSN

Associate Professor of Nursing Nursing Faculty
University of Cincinnati College of Nursing Wallace State Community College
Cincinnati, Ohio Hanceville, Alabama

Joanne Farley Serembus, RN, EdD, CCRN, Ronald S. Ulberg, RN, MSN, CCRN
CNE Assistant Teaching Professor
Associate Professor Brigham Young University
Drexel University Provo, Utah
College of Nursing and Health Professions
Philadelphia, Pennsylvania Judy Voss, RN, MSN
Eileen Shackell, RN, MSN, CNCC(c) The University of Texas Pan American
Faculty Edinburg, Texas
British Columbia Institute of Technology
Burnaby, British Columbia, Canada Sally A. Weiss, RN, EdD, MSN, CNE, ANEF
Associate Chair Nursing Department/Professor
Lora R. Shelton, RN, DNP, FNP-BC Nova Southeastern University
Instructor Miami, Florida
Ida V. Moffett School of Nursing, Samford
University Rachel Wilburn, RN, MSN, BSN
Birmingham, Alabama Assistant Professor
McNeese State University College of Nursing
Susan Shirato, RN, DNP, CCRN Lake Charles, Louisiana
Nursing Instructor
Jefferson School of Nursing, Thomas Jefferson Phyllis D. Wille, RN, MS, FNP-C
University Nursing Faculty
Philadelphia, Pennsylvania Danville Area Community College
Danville, Illinois
Lisa B. Soontupe, RN, EdD
Associate Professor Jacqueline C. Zalumas, RN, PhD, FNP-BC
Nova Southeastern University Professor of Nursing
Fort Lauderdale, Florida Georgia Baptist College of Nursing, Mercer
Amy K. Stoker, RN MSN, CCRN Atlanta, Georgia
Faculty Coordinator N304 Complex Health Nursing
UPMC Shadyside School of Nursing
Pittsburgh, Pennsylvania

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I n the United States, changes in healthcare

delivery and the changing healthcare needs of the
population are leading to an increased demand Essentials of Critical Care Nursing: A Holistic
for nurses who are educated to provide care for Approach is organized into 11 parts:
critically ill patients. Todays critically ill patient is
liable to be older and more critically ill than ever Part 1: The four chapters that make up Part 1
before, thus increasing the demand for nurses with introduce the reader to the concept of holistic care,
the skills to handle complex, life-threatening condi- as it applies in critical care practice. In Chapter 1,
tions. Nurses who are educated to provide critical the reader is introduced to issues of particular perti-
care are highly sought after now, and will be for the nence to critical care nursing practice, including the
foreseeable future. benets of certication, the importance of evidence-
Essentials of Critical Care Nursing: A Holistic based practice, and how a healthy work environ-
Approach, the newest member of the family of books ment contributes to the well-being of the nurse and
that started in 1973 with the rst edition of Critical facilitates the optimal care of patients and families.
Care Nursing: A Holistic Approach, has been created Chapter 2 reviews the psychosocial effects of critical
as an introduction to the specialty of critical care illness on the patient and the family, and describes
nursing and focuses on entry-level information a the nurses role in guiding the patient and family
novice would need to care for critically ill patients. through the crisis. Chapter 3 emphasizes the role of
Like the classic parent text (now in its 10th edition), the nurse in providing patient and family education
Essentials of Critical Care Nursing remains true to in critical care. In Chapter 4, legal and ethical issues
our commitment to excellence by providing stu- in critical care practice are explored.
dents with the most up-to-date information needed Part 2: The seven chapters that comprise Part
to care for critically ill patients and their families, 2 address essential concepts and interventions
with a strong emphasis on holistic care. The patient that pertain to the care of the critically ill patient.
is the center of the healthcare teams efforts, and all Chapter 5 focuses on strategies for relieving pain
interventions must be based on an understanding of and promoting comfort, and Chapter 6 concen-
the patients psychosocial, as well as physical, needs. trates on the topics of end-of-life and palliative
For todays critical care nurse, knowledge of dis- care. Chapter 7 addresses the assessment of nutri-
ease processes and competence in using high-tech tion and uid and electrolyte balance and describes
equipment in the care of critically ill patients is not associated nursing interventions. Chapter 8 explores
enough. Todays critical care nurse must also include dysrhythmia interpretation and the management
the family in all aspects of care and demonstrate of patients with dysrhythmias. Chapter 9 reviews
caring behaviors that address the human aspect of hemodynamic monitoring. Chapter 10 concentrates
suffering. on airway management and ventilatory support. The
Essentials of Critical Care Nursing: A Holistic unit concludes with Chapter 11, which addresses the
Approach provides a solid, focused introduction to management of a patient in cardiopulmonary arrest.
the discipline of critical care nursing. In writing the Parts 3 through 10: Parts 3 through 10 take a
text, we assumed a basic knowledge of medical body systems approach to presenting disorders most
surgical nursing, anatomy and physiology, patho- commonly seen in critical care. Each part is struc-
physiology, and assessment. However, these areas tured so that general assessment techniques and
are reviewed as needed within the context of specic management modalities that pertain to the organ
discussions, focusing specically on the needs of the system under discussion are presented rst, followed
patient in a critical care setting. A strong emphasis by a discussion of specic disorders of that organ
on what the novice nurse needs to know and do in system that often necessitate admission to the criti-
caring for critically ill patients and their families is cal care unit. By covering assessment and manage-
maintained throughout the book. ment modalities in some detail initially, we provide


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xviii Preface

the student with foundational knowledge and avoid to gain insight into the patients current critical
the repetition of information that can occur when health problem. (QSEN competencies: patient-
the same assessment technique or management centered care)
modality is used in the assessment or management Case Studies. Each chapter concludes with a case
of multiple disorders. study followed by a series of critical thinking ques-
Part 11: The nal part of the text, Part 11, focuses tions designed to guide the students knowledge to
on multisystemic disorders, including shock, multi- practical application.
system organ dysfunction syndrome (MODS), and
Ancillary Package
To further facilitate teaching and learning, a care-
The features of Essentials of Critical Care Nursing: A fully designed ancillary package is available.
Holistic Approach have been designed to assist read-
ers with practice as well as learning. Many of the
features support the quality and safety pre-licensure Resources for Instructors
competencies put forth by the Quality and Safety
Education for Nurses (QSEN) initiative, which Tools to assist instructors with teaching the course
seeks to develop the knowledge, skills, and attitudes are available upon adoption of this text on
(KSAs) necessary to continuously improve the qual- as well as on an Instructors Resource DVD-ROM for
ity and safety of the healthcare system. Key quality instructors who prefer that method of delivery.
and safety competencies that are supported by the A Test Generator includes a bank of over 600
features in this text include patient-centered care, questions to aid in the creation of quizzes and tests
teamwork and collaboration, evidence-based prac- for assessing students mastery of the material.
tice, quality improvement, and safety. An Image Bank contains illustrations and photo-
Evidence-Based Practice Highlights. These graphs from the book in formats suitable for print
boxes present current evidence-based recom- or digital use.
mendations related to key nursing interventions. PowerPoint Presentations for each chapter facil-
(QSEN competencies: evidence-based practice, itate the development of slide shows and handouts,
quality improvement) providing an easy way to integrate the textbook
Collaborative Care Guides. These boxes describe with the students classroom experience.
how the healthcare team works together to man- Case Study Questions and Discussion Points.
age a patients illness and minimize complications. Discussion points for the case studies that appear
The information is presented in a tabular format, in the text are provided to facilitate small group
with outcomes in the rst column and interven- discussions about the clinical scenarios presented
tions in the second. (QSEN competencies: patient- in the cases.
centered care, teamwork and collaboration) Guided Lecture Notes guide instructors through
Red Flag Notes. These notes highlight clinically the chapters, objective by objective, and provide
important information, such as signs and symp- corresponding PowerPoint slide numbers.
toms of developing complications or life-threat- Sample Syllabi provide guidance for structuring
ening conditions, and actions the nurse should the critical care course.
take to ensure safe care. (QSEN competencies: A QSEN Pre-Licensure KSA Competencies
safety) Map identies content in the textbook that sup-
The Older Patient Notes. These notes, appearing ports QSENs pre-licensure KSA competencies of
within the ow of the text, highlight information patient-centered care, teamwork and collabora-
related to assessing and caring for older patients tion, evidence-based practice, quality improve-
in the critical care setting. (QSEN competencies: ment, safety, and informatics.
patient-centered care) Strategies for Effective Teaching provide tips
Drug Therapy Tables. These tables summarize for preparing the course, meeting students needs,
information related to the safe administration and and helping students to succeed.
monitoring of drug therapy. (QSEN competencies: Instructors are also given access to all of the stu-
safety) dent resources.
Diagnostic Tests Tables. These tables summa-
rize information about key diagnostic tests, with a
focus on the key information the nurse should be
aware of with regard to preparing a patient for a
Resources for Students
diagnostic test and caring for the patient during or An exciting set of free resources is available to help
after the test. (QSEN competencies: safety) students master the material. These materials are
Health History Boxes. These boxes summarize accessible on with the access code printed
aspects of the history that are important to explore in the front of the textbook.

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Preface xix

An E-Book on provides access to the 100 commonly prescribed drugs in a quick-review

books full text and images online. format.
Journal Articles offer access to current research A Spanish-English Audio Glossary provides
related to chapter content. helpful words and phrases for communicating
Internet Resources provide links to Web sites of with Spanish-speaking patients.
interest that support the topics discussed in the text.
It is with great pleasure that we introduce these
Learning Objectives are supplied for each chap-
resourcesthe textbook and the ancillary package
ter in the book, to guide teaching and learning.
to you. It is our intent that these resources will pro-
Chapter Review Questions provide an easy way
vide a solid introduction to, and foundation for, the
for students to check their understanding of chap-
discipline of critical care nursing. We hope that we
ter content.
have succeeded in that goal, and we welcome feed-
Answers to Chapter Review Questions with ratio-
back from our readers.
nales are also accessible to students to allow self-
assessment of their mastery of the chapter content.
Concepts in Action Animations bring physio-
Patricia Gonce Morton, RN, PhD, ACNP-BC, FAAN
logic and pathophysiologic concepts to life.
Dorrie K. Fontaine, RN, PhD, FAAN
Monographs of 100 Commonly Prescribed Drugs
Kendra Menzies Kent, RN, MS, CCRN, CNRN
provide up-to-date, detailed drug information for

Morton_FM.indd xix 2/4/2012 3:51:13 PM

Morton_FM.indd xx 2/4/2012 3:51:13 PM

T his book was made possible through the dedi-

cation and hard work of many people. First, we would
Melanie Cann, Director, Product Development, for
her editorial insight and direction, and Helen Kogut,
like to thank Kendra Menzies Kent, RN, MS, CCRN, Senior Product Manager, for the masterful job she
CNRN, who served as a content expert and reviewer did of coordinating the efforts of authors, content
for the entire book. Kendra helped us immeasurably experts, editors, and vendors to make this essentials
with reducing, refocusing, reorganizing, and updat- text a reality. We would also like to acknowledge Matt
ing information to create this new textbook. Our pub- Skalka, Product Manager at Words & Numbers, for
lisher, Lippincott Williams & Wilkins, demonstrated his work on behalf of the project. Finally, we must
the same commitment to producing an excellent express our appreciation to Elizabeth Nieginski,
essentials text that they have shown through all edi- Executive Editor, for her encouragement and sup-
tions of the parent text. We especially want to thank port throughout the development of the textbook.


Morton_FM.indd xxi 2/4/2012 3:51:13 PM

Morton_FM.indd xxii 2/4/2012 3:51:14 PM

The Concept of Holism Applied to Critical Care Nursing Practice 1
Chapter 1 Critical Care Nursing Practice 1
Chapter 2 The Patients and Familys Experience With Critical Illness 8
Chapter 3 Patient and Family Education in Critical Care 18
Chapter 4 Ethical and Legal Issues in Critical Care Nursing 23

Essential Interventions in Critical Care 31
Chapter 5 Relieving Pain and Providing Comfort 31
Chapter 6 End-of-Life and Palliative Care 41
Chapter 7 Providing Nutritional Support, Fluids, and Electrolytes 46
Chapter 8 Dysrhythmia Interpretation and Management 62
Chapter 9 Hemodynamic Monitoring 92


Morton_FM.indd xxiii 2/4/2012 3:51:14 PM

xxiv Contents


Chapter 10 Airway Management and Ventilatory Support 114
Chapter 11 Code Management 135

Cardiovascular System 143
Chapter 12 Patient Assessment: Cardiovascular System 143
Chapter 13 Patient Management: Cardiovascular System 157
Chapter 14 Common Cardiovascular Disorders 179

Respiratory System 207
Chapter 15 Patient Assessment: Respiratory System 207
Chapter 16 Patient Management: Respiratory System 219
Chapter 17 Common Respiratory Disorders 227

Renal System 255
Chapter 18 Patient Assessment: Renal System 255

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Contents xxv

Chapter 19 Patient Management: Renal System 263

Chapter 20 Common Renal Disorders 273

Nervous System 289
Chapter 21 Patient Assessment: Nervous System 289
Chapter 22 Patient Management: Nervous System 304
Chapter 23 Common Neurosurgical and Neurological Disorders 317

Gastrointestinal System 351
Chapter 24 Patient Assessment: Gastrointestinal System 351
Chapter 25 Common Gastrointestinal Disorders 361

Endocrine System 377
Chapter 26 Patient Assessment: Endocrine System 377
Chapter 27 Common Endocrine Disorders 384

Hematological and Immune Systems 399
Chapter 28 Patient Assessment: Hematological and Immune Systems 399
Chapter 29 Common Hematological and Immunological Disorders 408

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xxvi Contents


Integumentary System 423
Chapter 30 Patient Assessment: Integumentary System 423
Chapter 31 Patient Management: Integumentary System 434
Chapter 32 Burns 441

Multisystem Dysfunction 457
Chapter 33 Shock and Multisystem Organ Dysfunction Syndrome 457
Chapter 34 Trauma 470

Index 487

Morton_FM.indd xxvi 2/4/2012 3:51:15 PM

The Concept of Holism
Applied to Critical Care
Nursing Practice
Critical Care Nursing Practice

Based on the content in this chapter, the reader should be able to:
1 Describe the value of certification in critical care nursing.
2 Describe the value of evidence-based practice (EBP) in caring for critically ill
3 List the six standards for a healthy work environment and describe how the
work environment can affect patient outcomes and employee well-being.
4 Describe the critical care nurses role in promoting a healthy work environment.
5 Explain the underlying premises of the synergy model.

C ritical care nurses routinely care for patients

with complex, life-threatening conditions. In addi-
seeking to provide interventions that are based on
current evidence, working to create and promote
tion to managing the physiological alterations a healthy work environment (HWE), and working
brought on by critical illness, critical care nurses to cultivate core nursing competencies (eg, clinical
must also manage the accompanying psychosocial judgment, advocacy, collaboration) are strategies
challenges and ethical conicts that often arise in the the critical care nurse can use to achieve this goal.
critical care setting. While operating within a highly
technological environment, critical care nurses are
charged with providing compassionate, patient- and Value of Certification
family-focused care.
The overreaching professional goal for the critical Specialty certication by the American Association
care nurse is to promote optimal outcomes for the of Critical-Care Nurses (AACN) promotes excel-
patients and families who are being cared for in the lence in the critical care nursing profession by
complex setting of the critical care unit. Becoming helping nurses achieve and maintain an up-to-date
certied in the discipline of critical care nursing, knowledge base and allowing nurses to voluntarily

Morton_Chap01.indd 1 2/4/2012 9:23:40 AM

2 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

demonstrate their breadth and depth of knowledge of evidence into practice can be a long process. Common
the discipline of critical care nursing.1 Certication barriers to implementation are summarized in
has value for patients and families, employers, and Box 1-1. Strategies for promoting the incorporation
nurses themselves: of evidence into clinical practice include
Value to the patient and family. Certication Use of protocols, clinical pathways, and algorithms4
validates to patients and families that the nurses Increasing clinicians awareness of available
caring for them have demonstrated experience resources (eg, databases such as PubMed, CINAHL,
and knowledge that exceeds that which is assessed and MEDLINE; Web sites such as UpToDate, which
in entry-level licensure examinations.1 Experience offers real-time evidence-based recommendations
and knowledge enable nurses to recognize and for patient care, and the Cochrane Library, a source
respond to clinical situations more quickly, and of high-quality, independent evidence to inform
research has shown that nurses who have had healthcare decision making; and professional nurs-
their knowledge validated through a certication ing organizations, such as the AACN, which pub-
examination make decisions with greater con- lishes research-based Practice Alerts)
dence, promoting optimal outcomes.1 In addition, Creating an organizational culture that supports
nurses who are certied in a specialty have dem- EBP (eg, identifying EBP champions, incorporat-
onstrated commitment to continual learning, an ing EBP activities into nurses roles, allocating
attribute that is needed to care for patients with time and money to the process, promoting multi-
complex multisystem problems. disciplinary collaboration among researchers and
Value to employers. Certication validates to practitioners)4
employers that the nurse is committed to the disci-
pline and has the knowledge and experience to work
efciently to promote optimal patient outcomes. It Healthy Work Environments
has been suggested that organizations that support
and recognize the value of certication may expe- A healthy work environment (HWE) optimizes pro-
rience decreased turnover and improved retention fessional collaboration and nursing practice (thus
rates.1 In addition, employing nurses who have facilitating quality clinical outcomes) and promotes
achieved certication demonstrates to the public (ie, employee satisfaction. In 2001, in light of data indi-
healthcare consumers) and to credentialing organi- cating that harmful healthcare working environ-
zations (eg, the Joint Commission, the American ments exist nationwide and that these environments
Nurses Credentialing Center) that the facility has result in medical errors, poor healthcare delivery,
recruited and retained knowledge-validated nurses.1 and dissatisfaction among healthcare providers, the
Value to nurses. Certication provides nurses with AACN helped develop the HWE initiative. The HWE
a sense of professional pride and achievement, and initiative focuses on barriers to patient safety and
the condence that comes with certication may employee satisfaction and identies six essential
give the nurse a competitive edge when seeking a standards for promoting a HWE: skilled communi-
promotion or new career opportunities. In addition, cation, true collaboration, effective decision mak-
certied nurses can anticipate increased recogni- ing, appropriate stafng, meaningful recognition,
tion from peers and employers. Certication may and authentic leadership (Box 1-2).
have monetary benets as well. For example, some
employers recognize certication with a salary dif-
ferential, and one of the worlds largest insurance
Skilled Communication
brokers offers a discount on malpractice premiums Skilled communication is essential to prevent errors
to nurses who are certied in critical care.1 as well as to recruit and retain healthcare providers.
Almost 70% of sentinel events reported to the Joint
Commission in 2005 were related to communica-
Evidence-Based Practice in Critical tion issues.5 AACN partnered with VitalSmarts (a
Care Nursing
BOX 1-1 Barriers to Evidence-Based Practice
Evidence-based practice (EBP) is the use of the best (EBP)
available research data from well-designed studies
coupled with experiential knowledge and character- Lack of knowledge
istics, values, and patient preferences in clinical prac- Lack of research skills, resources, or both
tice to support clinical decision making.2 The use of Lack of organizational support and management
research ndings in clinical practice is essential to commitment
promote optimal outcomes and to ensure that nurs- Lack of time
ing practice is effective.3 Practice based on intuition Lack of incentive to change behavior
or information that does not have a scientic basis Lack of condence in personal ability to change
is not in the best interest of patients and families. practice
Although knowledge regarding effectual nurs- Lack of authority to change practice
ing interventions continues to increase, transfer of

Morton_Chap01.indd 2 2/4/2012 9:23:42 AM

Critical Care Nursing Practice C H A P T E R 1 3

BOX 1-2 Critical Elements of the Six Essential Standards of a Healthy Work Environment

Standard 1: Skilled Communication Every team member contributes to the achievement

Nurses must be as procient in communication skills as of common goals by giving power and respect to each
they are in clinical skills. persons voice, integrating individual differences,
The healthcare organization provides team members resolving competing interests, and safeguarding the
with support for and access to education programs essential contribution each must make in order to
that develop critical communication skills including achieve optimal outcomes.
self-awareness, inquiry/dialogue, conict manage- Every team member acts with a high level of personal
ment, negotiation, advocacy, and listening. integrity.
Skilled communicators focus on nding solutions and Team members master skilled communication, an
achieving desirable outcomes. essential element of true collaboration.
Skilled communicators seek to protect and advance Each team member demonstrates competence appro-
collaborative relationships among colleagues. priate to his or her role and responsibilities.
Skilled communicators invite and hear all relevant Nurse managers and medical directors are equal part-
perspectives. ners in modeling and fostering true collaboration.
Skilled communicators call on goodwill and mutual Standard 3: Effective Decision Making
respect to build consensus and arrive at common Nurses must be valued and committed partners in
understanding. making policy, directing and evaluating clinical care,
Skilled communicators demonstrate congruence and leading organizational operations.
between words and actions, holding others account-
The healthcare organization provides team members
able for doing the same.
with support for and access to ongoing education and
The healthcare organization establishes zero-tolerance
development programs focusing on strategies that
policies and enforces them to address and eliminate
ensure collaborative decision making. Program con-
abuse and disrespectful behavior in the workplace.
tent includes mutual goal setting, negotiation, facili-
The healthcare organization establishes formal structures
tation, conict management, systems thinking, and
and processes that ensure effective information sharing
performance improvement.
among patients, families, and the healthcare team.
The healthcare organization clearly articulates organi-
Skilled communicators have access to appropriate com-
zational values, and team members incorporate these
munication technologies and are procient in their use.
values when making decisions.
The healthcare organization establishes systems that
The healthcare organization has operational struc-
require individuals and teams to formally evaluate the
tures in place that ensure the perspectives of patients
impact of communication on clinical, nancial, and
and their families are incorporated into every decision
work environment outcomes.
affecting patient care.
The healthcare organization includes communica-
Individual team members share accountability for
tion as a criterion in its formal performance appraisal
effective decision making by acquiring necessary skills,
system, and team members demonstrate skilled com-
mastering relevant content, assessing situations accu-
munication to qualify for professional advancement.
rately, sharing fact-based information, communicating
Standard 2: True Collaboration professional opinions clearly, and inquiring actively.
Nurses must be relentless in pursuing and fostering The healthcare organization establishes systems, such
true collaboration. as structured forums involving all departments and
The healthcare organization provides team members healthcare disciplines, to facilitate data-driven decisions.
with support for and access to education programs The healthcare organization establishes deliberate
that develop collaboration skills. decision-making processes that ensure respect for the
The healthcare organization creates, uses, and rights of every individual, incorporate all key perspec-
evaluates processes that dene each team members tives, and designate clear accountability.
accountability for collaboration and how unwilling- The healthcare organization has fair and effective
ness to collaborate will be addressed. processes in place at all levels to objectively evaluate
The healthcare organization creates, uses, and evalu- the results of decisions, including delayed decisions
ates operational structures that ensure the decision- and indecision.
making authority of nurses is acknowledged and Standard 4: Appropriate Staffing
incorporated as the norm. Stafng must ensure the effective match between patient
The healthcare organization ensures unrestricted needs and nurse competencies.
access to structured forums, such as ethics commit-
The healthcare organization has stafng policies in
tees, and makes available the time needed to resolve
place that are solidly grounded in ethical principles
disputes among all critical participants, including
and support the professional obligation of nurses to
patients, families, and the healthcare team.
provide high-quality care.
Every team member embraces true collaboration as
an ongoing process and invests in its development to
ensure a sustained culture of collaboration.
(continued on page 4)

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4 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

BOX 1-2 Critical Elements of the Six Essential Standards of a Healthy Work Environment (continued)

Nurses participate in all organizational phases of the The healthcare organization regularly and compre-
stafng process from education and planninginclud- hensively evaluates its recognition system, ensuring
ing matching nurses competencies with patients effective programs that help to move the organization
assessed needsthrough evaluation. toward a sustainable culture of excellence that values
The healthcare organization has formal processes in meaningful recognition.
place to evaluate the effect of stafng decisions on
Standard 6: Authentic Leadership
patient and system outcomes. This evaluation includes
Nurse leaders must fully embrace the imperative of a
analysis of when patient needs and nurse competen-
healthy work environment (HWE), authentically live it,
cies are mismatched and how often contingency plans
and engage others in its achievement.
are implemented.
The healthcare organization has a system in place that The healthcare organization provides support for and
facilitates team members use of stafng and out- access to educational programs to ensure that nurse
comes data to develop more effective stafng models. leaders develop and enhance knowledge and abilities
The healthcare organization provides support services in skilled communication, effective decision making,
at every level of activity to ensure nurses can optimally true collaboration, meaningful recognition, and ensur-
focus on the priorities and requirements of patient ing resources to achieve appropriate stafng.
and family care. Nurse leaders demonstrate an understanding of the
The healthcare organization adopts technologies that requirements and dynamics at the point of care and
increase the effectiveness of nursing care delivery. within this context successfully translate the vision of
Nurses are engaged in the selection, adaptation, and a HWE.
evaluation of these technologies. Nurse leaders excel at generating visible enthusiasm
for achieving the standards that create and sustain
Standard 5: Meaningful Recognition HWEs.
Nurses must be recognized and must recognize oth- Nurse leaders lead the design of systems necessary to
ers for the value each brings to the work of the effectively implement and sustain standards for HWEs.
organization. The healthcare organization ensures that nurse leaders
The healthcare organization has a comprehensive are appropriately positioned in their pivotal role in cre-
system in place that includes formal processes and ating and sustaining HWEs. This includes participation
structured forums that ensure a sustainable focus in key decision-making forums, access to essential infor-
on recognizing all team members for their contri- mation, and the authority to make necessary decisions.
butions and the value they bring to the work of the The healthcare organization facilitates the efforts of
organization. nurse leaders to create and sustain a HWE by pro-
The healthcare organization establishes a systematic viding the necessary time and nancial and human
process for all team members to learn about the facil- resources.
itys recognition system and how to participate by The healthcare organization provides a formal comen-
recognizing the contributions of colleagues and the toring program for all nurse leaders. Nurse leaders
value they bring to the organization. actively engage in the comentoring program.
The healthcare organizations recognition system Nurse leaders role-model skilled communication, true
reaches from the bedside to the board table, ensuring collaboration, effective decision making, meaningful
individuals receive recognition consistent with their recognition, and authentic leadership.
personal denition of meaning, fulllment, develop- The healthcare organization includes the leadership
ment, and advancement at every stage of their profes- contribution to creating and sustaining a HWE as a
sional career. criterion in each nurse leaders performance appraisal.
The healthcare organizations recognition system Nurse leaders must demonstrate sustained leadership
includes processes that validate that recognition is in creating and sustaining a HWE to achieve profes-
meaningful to those being acknowledged. sional advancement.
Team members understand that everyone is respon- Nurse leaders and team members mutually and objec-
sible for playing an active role in the organizations tively evaluate the impact of leadership processes and
recognition program and meaningfully recognizing decisions on the organizations progress toward creat-
contributions. ing and sustaining a HWE.


company that provides corporate training and orga- physicians, and administrators in urban, rural, and
nizational performance solutions) to conduct a study suburban hospitals nationwide.6 Overwhelming
of conversations that do not occur in hospitals, to the data indicated that poor communication and col-
detriment of patient safety and provider well-being. laboration were prevalent among healthcare provid-
The Silence Kills study used focus groups, inter- ers. The study concluded that healthcare providers
views, workplace observation, and surveys of nurses, repeatedly observe errors, breaking of rules, and

Morton_Chap01.indd 4 2/4/2012 9:23:42 AM

Critical Care Nursing Practice C H A P T E R 1 5

dangerous levels of incompetence, yet rather than assigned to a unit on a given shift. However, appro-
speak up, they consider leaving their respective units priate stafng must also consider the competencies
because of their concerns. The ability to communi- of the staff assigned in relation to the needs of the
cate effectively and assertively and manage conict patient and family during that shift. When the needs
is essential for advocating for oneself and others, and of patients and families are matched with the com-
fosters a positive workplace environment character- petencies of the assigned nurse, optimal outcomes
ized by an atmosphere of respect and collaboration. may be achieved. The ability to monitor patient
health status, perform therapeutic interventions,
True Collaboration integrate patient care to avoid healthcare gaps, and
promote optimal patient outcomes is compromised
Collaboration is a multifaceted concept, which has when the number of nurses is inadequate, or when
been dened as working together to accomplish a nurses lack the required competencies.
common goal. One researcher has identied collab-
oration as both a process (blending different points
of view to better comprehend a difcult issue) and
Meaningful Recognition
an outcome (the integration of solutions contrib- Employee recognition can have a signicant
uted by more than one person).7 This researcher effect on job satisfaction, and can help to retain
has identied 10 lessons in collaboration: (1) know high-performing nurses and ensure an adequate
thyself; (2) learn to value and manage diversity; (3) workforce in the future. Effective recognition pro-
develop constructive conict resolution skills; (4) grams enhance the nurses sense of accomplishment
create winwin situations; (5) master interpersonal and validate the nurses contributions to quality
and process skills; (6) recognize that collabora- healthcare. The recognition may be modest in scale
tion is a journey; (7) leverage all multidisciplinary but must represent genuine caring and apprecia-
forums; (8) appreciate that collaboration can occur tion. In addition to monetary rewards when pos-
spontaneously; (9) balance autonomy and unity in sible, recognition can take the form of verbal or
collaborative relationships; and (10) remember that written praise, appreciation, and acknowledgment
collaboration is not required for all decisions.7 Other of excellent performance.11,12 Researchers have also
investigators have suggested that collaboration is suggested that to recruit and retain staff, employers
dened through ve concepts: sharing, partnership, need to recognize staff expectations (eg, the desire
power, interdependency, and process.8 to lead balanced lives, receive opportunities for per-
Results of several studies have supported a high sonal and professional growth, or make a meaning-
correlation between nursephysician collaboration ful contribution to the world through work).
and positive patient outcomes and a decreased inci-
dence of medication errors.9 However, a number
of barriers exist that preclude true collaboration
Authentic Leadership
in healthcare organizations, including variations Nursing leaders play an essential role in creating a
in how collaboration is conceptualized; the lack healthcare environment that is conducive to pro-
of time for communication; the complexity of the moting quality patient outcomes and employee well-
skills required to facilitate collaboration; and issues being.13 Attributes of an authentic leader that are
related to autonomy, power, and role confusion.10 essential for establishing and maintaining a HWE
include genuineness, trustworthiness, reliability,
Effective Decision Making compassion, and believability.14 An effective leader
seeks to (1) balance the tension between production
Because the healthcare environment mandates that and efciency; (2) create and sustain trust through-
nurses be accountable for their practice, they must out the organization; (3) actively manage the process
be able to participate in effective decision mak- of change; (4) involve workers in decision making
ing. A high degree of responsibility and autonomy pertaining to work design and work ow; and (5)
is necessary. An environment that consistently and use knowledge management to establish the organi-
successfully encourages nurses to participate in zation as a learning organization.14
decision making promotes quality patient outcomes
and improved employee satisfaction.
The Synergy Model
Appropriate Staffing The synergy model, developed by the AACN, has
There is a signicant relationship between inad- served as the foundation for certied practice since
equate nurse stafng and adverse patient events. the late 1990s.15 It is the conceptual model for under-
According to the Joint Commission, based on data- graduate and graduate curricula and has been used
base records from 1995 to 2004, stafng levels were in a variety of clinical settings as the basis for job
a root cause of nearly a quarter of the sentinel descriptions, performance appraisals, and career
events that resulted in death, injury, or permanent advancement.16
loss of function.5 Adequacy of stafng has tradition- The underlying premises of the synergy model
ally been based primarily on the number of staff are (1) patients characteristics are of concern to

Morton_Chap01.indd 5 2/4/2012 9:23:42 AM

6 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

g ini
nin ca
ar Participation





Vulnerability Making Stability


Clinical Inquiry

Moral Agenc
Predictability PATIENT/ Resiliency










o Care tic
sp es
Re Co
ng llab
inki orat
Systems Th ion

Characteristics of Patients, Clinical Units, and Systems of Concern to Nurses

Participation in decision makingextent to which patient/family engages in decision making
Stabilitythe ability to maintain a steady-state equilibrium
Resiliencythe capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the
ability to bounce back quickly after an insult
Complexitythe intricate entanglement of two or more systems (e.g., body, family, therapies)
Participation in careextent to which patient/family engages in aspects of care
Resource availability extent of resources (e.g., technical, fiscal, personal, psychological, and social) the
patient/family/community bring to the situation
Predictabilitythe ability to expect a certain course of events or course of illness
Vulnerabilitysusceptibility to actual or potential stressors that may adversely affect patient outcomes

Nurse Competencies of Concern to Patients, Clinical Units, and Systems

Clinical judgmentclinical reasoning which includes clinical decision making, critical thinking, and a global grasp of
the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential
knowledge and evidence-based guidelines
Advocacy and moral agencyworking on anothers behalf and representing the concerns of the patient/family and
nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and
outside the clinical setting.
Caring practicesnursing activities that create a compassionate, supportive, and therapeutic environment for patients
and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering; includes, but is not
limited to, vigilance, engagement, and responsiveness of caregivers, including family and healthcare personnel.
Collaborationworking with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages
each persons contributions toward achieving optimal/realistic patient/family goals; involves intradisciplinary and
interdisciplinary work with colleagues and community
Systems thinking body of knowledge and tools that allow the nurse to manage whatever environmental and system
resources exist for the patient/family and staff, within or across healthcare and non-healthcare systems
Response to diversitythe sensitivity to recognize, appreciate, and incorporate differences into the provision of care;
differences may include, but are not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle,
socioeconomic status, age, and values
Clinical inquiry (innovator/evaluator)the ongoing process of questioning and evaluating practice and providing
informed practice; creating practice changes through research utilization and experiential learning
Facilitator of learningthe ability to facilitate learning for patients/families, nursing staff, other members of the healthcare
team, and community; includes both formal and informal facilitation of learning

F I G U R E 1 - 1 The synergy model. Synergy results when the needs and characteristics of a patient, clinical
unit, or system (blue) are matched with a nurses competencies (green)

nurses; (2) nurses competencies are important to the basis of the model (Fig. 1-1). Patient/unit/system
patients; (3) patients characteristics drive nurses characteristics range depending on the situation and
competencies; and (4) when patients characteristics are expressed as level 1, 3, or 5, with 1 being low
and nurses competencies match and synergize, out- and 5 being high. Similarly, nurse competencies
comes for the patient are optimal.15 Eight character- range depending on the nurses level of expertise,
istics (of patients, units, or systems) and eight nurse and are expressed as level 1, 3, or 5, with 1 being
competencies that constitute nursing practice form competent and 5 being expert.

Morton_Chap01.indd 6 2/4/2012 9:23:42 AM

Critical Care Nursing Practice C H A P T E R 1 7

The synergy model is used to evaluate the rela- References

tionship between clinical practice and outcomes.
Patient-derived outcomes may include functional 1. Kaplow R: The value of certication. AACN Adv Crit Care
2(1):2532, 2011
change, behavioral change, trust, satisfaction, com- 2. Melnyk BM, Fineout-Overholt E: Evidence-Based Practice
fort, and quality of life. Nurse-derived outcomes in Nursing and Healthcare: A Guide to Best Practice.
may include physiological changes, absence of com- Philadelphia, PA: Lippincott Williams & Wilkins, 2010
plications, and the extent to which care or treatment 3. Stafleno B, McKinney C: Evidence based nursing. Nurs
Manag 42(6):1014, 2011
objectives are attained. Healthcare systemderived 4. Schulman C: Strategies for starting a successful evidence
outcomes may include reduced recidivism, reduced based nursing program. AACN Adv Crit Care 19(3):301311,
costs, and enhanced resource utilization. 2008
5. Joint Commission on Accreditation of Healthcare
Organizations. Retrieved June 15, 2006, from http://www.
6. Maxeld D, Grenny J, McMillan R, et al.: Silence kills: The
CASE STUDY seven crucial conversations for healthcare. Retrieved from
M rs. C., an 82-year-old woman, is brought by 7. Gardner DB: Ten lessons in collaboration. Online J Issues
Nurs 10(1):2, 2005
ambulance to the emergency room because she is
8. DAmour D, Ferrada-Videla M, San Martin Rodriguez L,
experiencing left-sided weakness and difficulty with et al.: The conceptual basis for interprofessional collabora-
speech. Mrs. C., an insulin-dependent diabetic who tion: Core concepts and theoretical frameworks. J Interprof
had an acute myocardial infarction 2 years ago, Care 19(suppl 1):116131, 2005
lives at home alone but is checked on frequently by 9. LaValley D: Physician-Nurse collaboration and patient
family members. Mrs. C. has limited financial sup- safety. Forum 26(2), 2008
10. Schmalenberg C, Kramer M: Clinical units with the healthi-
port. Today, her granddaughter stopped by to check est work environments. Crit Care Nurse 28:6567, 2008
on her and called 911 when she noticed that Mrs. 11. Kramer M, Maguire P, Brewer B: Clinical nurses in Magbet
C. was having trouble speaking. hospitals conrm productive healthy unit work environ-
In the emergency room, the healthcare team ments. J Nurs Management 19(1):517, 2011
12. Briggs L, Schriner C: Recognition and support for todays
assessed Mrs. C.s neurological status using the preceptor. J Contin Educ Nurs 41(7):317322, 2010
National Institutes of Health (NIH) stroke scale. CT 13. Mastal M, Joshi M, Schulke K: Nursing leadership:
studies were negative for hemorrhagic stroke. She Championing quality and patient safety in boardroom. Nurs
was admitted to the critical care unit for ischemic Econ 25(6):323330, 2007
stroke. 14. Shirey MR: Authentic leaders creating healthy work envi-
ronments for nursing practice. Am J Crit Care 15(4):256
The critical care nurse performed a bedside 267, 2006
swallow evaluation prior to administering oral medi- 15. American Association of Critical-Care Nurses Certication
cation. Based on this evaluation, the nurse decided Corporation: The AACN Synergy Model for Patient Care.
to obtain a speech therapy consult to perform a Retrieved June 15, 2006, from cert-
more comprehensive swallow examination. The 16. Reed KD, Cline M, Kerfoot KM: Implementation of the
oral medication was held until the evaluation could synergy model in critical care. In Kaplow R, Hardin SR
be performed. Mrs. C.s son arrived at the hospital (eds): Critical Care Nursing: Synergy for Optimal Outcomes.
to visit his mother; although he came during non- Sudbury, MA: Jones & Bartlett, 2007
visiting hours, the nurse allowed him to visit with
his mother, and provided him with a pamphlet that
provided information regarding the critical care unit Want to know more? A wide variety of resources to enhance your learn-
environment, what to expect, and visitation hours. ing and understanding of this chapter are available on . Visit
Because Mrs. C. is currently unable to make her to access chapter review
own healthcare decisions, her son provided the questions and more!
hospital with a copy of his mothers power of attor-
ney for healthcare, which identified him as the pri-
mary decision maker.
1. Which patient characteristics are concerns for
Mrs. C.?
2. By performing the swallow evaluation and obtain-
ing a speech therapy consult, the critical care
nurse demonstrated which nurse competencies?
3. Allowing Mrs. C.s son to visit even though his
visit did not coincide with standard visiting hours
demonstrates which nurse competencies?

Morton_Chap01.indd 7 2/4/2012 9:23:42 AM

The Patients and Familys

2 Experience With Critical Illness

Based on the content in this chapter, the reader should be able to:
1 Explain the effects of prolonged stress and anxiety and describe measures
the nurse can take to minimize the amount of stress and anxiety patients and
family members experience.
2 Describe the critical care nurses role in assisting the family through the crisis.
3 Describe strategies to promote sleep in critically ill patients.
4 Discuss alternatives to the use of physical restraints in the critical care unit.

The patients experience in a critical care unit

has lasting meaning for the patient and fam-
perceive admission to critical care as a sign of
impending death, based on their own past experi-
ily. Often, it is the caring and emotional support ences or the experiences of others. In addition,
given by the nurse that is remembered and val- the near-constant noise (eg, from equipment and
ued. A number of authors have sought to study alarms), bright lights, and lack of privacy in the crit-
and describe patients experiences related to their ical care unit are intimidating and stress inducing.
stay in a critical care unit. Research has found that The body responds to these stressors by activating
although many patients recall negative experiences, the hypothalamic pituitaryadrenal axis. The resul-
they also recall neutral and positive experiences. tant increase in catecholamine, glucocorticoid, and
Negative experiences were related to fear, anxiety, mineralocorticoid levels leads to a cascade of physi-
sleep disturbance, cognitive impairment, and pain ological responses known as the stress response
or discomfort. Positive experiences were related (Fig. 2-1). In critically ill patients, prolonged activa-
to feelings of being safe and secure and were often tion of the stress response can lead to immunosup-
attributed to the care provided by nurses, speci- pression, hypoperfusion, tissue hypoxia, and other
cally nurses technical competence and effective physiologic effects that impair healing and jeopar-
interpersonal skills.1 The need to feel safe and the dize recovery.
need for information were predominant themes in Anxiety, pain, and fear can initiate or perpetu-
other research studies as well.1 ate the stress response. Anxiety is an emotional
state of apprehension in response to a real or per-
ceived threat that is associated with motor tension,
Managing Stress and Anxiety increased sympathetic activity, and hypervigilance.
Feelings of helplessness, loss of control, loss of
Patients admitted to the critical care unit are sub- function or self-esteem, and isolation can produce
ject to multiple physical, psychological, and envi- anxiety, as can a fear of dying. Left untreated or
ronmental stressors, as are their family members. undertreated, anxiety can contribute to the morbid-
For example, patients and their families frequently ity and mortality of critically ill patients.

Morton_Chap02.indd 8 2/4/2012 2:21:23 PM

The Patients and Familys Experience With Critical Illness C H A P T E R 2 9

(neural stimuli) possible behaviors/responses

anxiety, fear
increased mental activity
cognitive appraisal dyspnea
of the stressor hyperventilation
CRF gastric irritation
muscle tension
activates agitation
nervous system


direct effects
on target


H plasma costisol
adrenal gland and aldosterone

effects contribute to:

kidney elevated blood pressure

decreased urinary output


h ri increased serum glucose
plasma norepinephrine
and epinephrine

effects contribute to:

F I G U R E 2 - 1 The stress response. Prolonged stress has increased heart rate
far-reaching physiological effects that hinder the bodys elevated blood pressure
ability to heal. CRF, corticotropin releasing factor; ACTH, dilated pupils
adrenocorticotropic hormone. angina, palpitations

RED FLAG! It is important to assess patients because they are unable to feel safe and secure.
and family members for anxiety. The top five A trusting relationship between the nurse and
physiological and behavioral indicators of anxiety patient can make a difference in the patients recov-
are agitated behavior, increased blood pressure, ery or facilitating a dignied death. Displaying a
increased heart rate, verbalization of anxiety, and condent, caring attitude; demonstrating techni-
restlessness.2 cal competence; and developing effective commu-
nication techniques are strategies that help the
Management of stress and anxiety entails elimi- nurse to foster trusting relationships with both
nating or minimizing the stressors. For the critically patients and family members.
ill patient, providing supportive care (eg, nutrition, Providing information. Anxiety can be greatly
oxygenation, pain management, sedatives, and anx- relieved with simple explanations. Critically ill
iolytics) is indicated.3 Mindbody strategies that patients and their family members need to know
may be employed to lessen stress and anxiety are what is happening at the moment, what will
summarized in Box 2-1. Often, the way the nurse happen to the patient in the near future, how
interacts with the patient and family can have a sig- the patient is doing, and what they can expect.
nicant impact on the amount of stress and anxiety Many patients also need frequent explanations
they experience. Positive actions the nurse can take of what happened to them. These explanations
to minimize stress and anxiety include reorient them, sort out sequences of events, and
Fostering trust. When patients or family mem- help them distinguish real events from dreams or
bers mistrust caregivers, they are more anxious hallucinations.

Morton_Chap02.indd 9 2/4/2012 2:21:25 PM

10 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

BOX 2-1 MindBody Techniques for Lessening Anxiety and Stress

Presencing and reassurance. Presencing, or just progresses in this way, tensing and releasing the
being there, can alleviate distress and anxiety. Nurses muscles in a systematic manner throughout the body.
practice presencing by adopting a caring attitude, pay- Deep breathing. People who are acutely anxious
ing attention to the persons needs, and actively listen- tend to hold their breath. Diaphragmatic (abdominal)
ing. Reassurance can be provided verbally or through breathing may be useful as both a distraction and a
caring touch. Verbal reassurance is most appropriate coping mechanism. To practice diaphragmatic breath-
for people who are expressing unrealistic or exagger- ing, the person places a hand on the abdomen, inhales
ated fears. It is not valuable when it prevents a person deeply through the nose, holds the breath briey, and
from expressing emotions or sties the need for fur- exhales through pursed lips.
ther dialogue. Music therapy. Music therapy can reduce anxiety,
Reframing dialogue. Highly anxious people tend to provide distraction, and promote relaxation, rest, and
give themselves messages that perpetuate their anxi- sleep. It has also been shown to be effective for relax-
ety. For example, a patient may be thinking things ing mechanically ventilated patients. Usually, music
such as, I cant stand it in here. Ive got to get out. sessions are 20 to 90 minutes long, once or twice daily.
The nurse encourages the person to share his or her Most people prefer music that is familiar to them.
internal dialogue, and then helps the person replace Humor. Laughter releases endorphins (the bodys
the negative thoughts with constructive, reassuring natural pain relievers) into the bloodstream, and can
ones (eg, Ive been in tough situations before, and relieve tension and anxiety and relax muscles. The use
Im capable of making it through this one!). A simi- of humor, spontaneous or planned, can help reduce
lar method can be applied to external dialogues. By procedural anxiety and provide distraction. The nurse
speaking accurately about the situation to others, the takes cues from the person regarding the appropriate
persons own misconceptions about the situation will use of humor.
be improved. Massage. Nurses have traditionally used efeurage
Cognitive reappraisal. This technique asks the per- (slow, rhythmic strokes from distal to proximal areas
son to identify a particular stressor and then reframe of long muscles such as those of the back or extremi-
his or her perception of the stressor in a more posi- ties) to promote patient comfort. Massage can be
tive light so that the stimulus is no longer viewed as combined with the use of scented oils or lotions (eg,
threatening. lavender to promote relaxation). Not all patients are
Guided imagery. Guided imagery is a way of purpose- good candidates for massage. For example, massage
fully diverting or focusing a persons thoughts. Guided is not appropriate for patients who are hemodynami-
imagery can be used to promote relaxation through cally unstable.
mental escape. The nurse encourages the person to Therapeutic touch. In therapeutic touch, the practi-
imagine being in a very pleasant place or taking part in tioners hands move over a patient in a systematic way
a very pleasant experience. The nurse instructs the per- to rebalance the patients energy elds. Therapeutic
son to focus and linger on the sensations that are expe- touch as a complementary therapy has been used suc-
rienced, prompting with questions if necessary (eg, cessfully in acute care settings to decrease anxiety and
What colors do you see? What do you hear? How promote a sense of well-being.
does the air smell?). Guided imagery can also be used Meridian therapy. Meridian therapy, which originates
to mentally prepare to meet a challenge (eg, relearning from traditional Chinese medicine, refers to therapies
how to walk) successfully. When applied in this way, that involve an acupoint (eg, acupuncture, acupres-
the nurse teaches the person to visualize herself mov- sure, the activation of specic sites with electrical
ing through the task and successfully completing it. stimulation and low-intensity laser).
Relaxation training. In progressive relaxation, the Pet (animal-assisted) therapy. Interacting with ani-
person is directed to nd a comfortable position and mals can provide physical benets (eg, lowered blood
then to take several deep breaths and let them out pressure), as well as emotional ones (eg, increased
slowly. Next, the person is asked to clench a st or curl self-esteem). Some facilities allow pets to visits
the toes as tightly as possible, to hold the position for their owners. Other facilities participate in formal
a few seconds, and then to let go while focusing on programs wherein volunteer ownerdog teams visit
the sensations of the releasing muscles. The person patients in the critical care unit.

Ensuring privacy. Ensuring privacy while sensi- members to a quiet room away from the general
tive or condential information is being exchanged waiting area to afford privacy when discussing
can markedly reduce the anxiety of a patient or specic patient information.
family member. Healthcare providers are not Allowing control. Nursing measures that rein-
always mindful of their surroundings when dis- force a persons sense of control help increase
cussing condential details of a patients case. The autonomy and reduce the overpowering sense of
nurse can direct healthcare providers and family loss of control that can increase anxiety and stress.

Morton_Chap02.indd 10 2/4/2012 2:21:26 PM

The Patients and Familys Experience With Critical Illness C H A P T E R 2 11

The nurse can help the patient and family exert Frequently, the period of illness extends well
more control over the environment by providing beyond the initial crisis phase and creates additional
order and predictability in routines; using antici- burdens for the patient and the family. The patient
patory guidance; allowing the patient and fam- may experience a slow and unpredictable course with
ily to make choices whenever possible; involving periods of organ compromise or failure. Recovery is
the patient and family in decision making; and measured in small changes that occur over days and
explaining procedures thoroughly, including why weeks. Over time, it may become increasingly dif-
the procedure is needed. cult for the family to obtain information and patient
status reports from the healthcare team. Often, phy-
sician schedules are unpredictable and physician
Assisting the Family Through visits may not coincide with family member avail-
ability. With protracted critical illness, many fami-
the Crisis lies struggle to keep the lines of communication
open to the extended family, creating opportunities
A critical illness is a sudden, unexpected, and stress- for conict and misinformation. Throughout the
ful occurrence for both the patient and the family patients illness, it is vitally important for the critical
that threatens the equilibrium of the family unit. care nurse to maintain a link with the family.
During the acute crisis, family members often expe-
rience stress, disorganization, and feelings of help- RED FLAG! The time the critical care nurse can
lessness that make it difcult for them to mobilize spend with the family is often limited because of
appropriate coping resources.2 The critical care the crucial physiological and psychosocial needs of
nurse plays a key role in assisting the family through the patient. Therefore, it is important to make every
this stress response and helping them to adapt to the interaction with the family as useful and therapeutic
critical care environment. When caring for the fam- as possible.
ily, the nurse seeks to (1) provide a human, caring
presence; (2) acknowledge multiple perceptions; (3)
respect diversity; and (4) value each person within Identifying and Meeting Family Needs
the context of the family. Nursing assessment of the family seeks to identify
The way a family reacts to a crisis is difcult to the familys strengths as well as the problems they
categorize because reactions depend on the different are facing. The nursing assessment is comprehen-
coping styles, personalities, and stress management sive, exploring family members physiological, psy-
techniques of the family. However, the following chological, and spiritual responses to crisis, as well
generalizations usually hold true: as social, environmental, cultural, and economic
Whether people emerge stronger or weaker as a factors that inuence the family. The family history
result of a crisis is based not so much on their provides insight into the familys past experience
character, as on the quality of help they receive with critical illness, and is helpful for identifying
during the crisis. family roles and relationships. Identifying a formal
People are more open to suggestions and help or informal leader of the family facilitates decision
during an actual crisis. making and communication about legal matters (eg,
With the onset of a crisis, old memories of past obtaining consent, withdrawing life support).
crises may be evoked. If maladaptive behavior was Numerous assessment tools, such as the Critical
used to deal with previous situations, the same Care Family Needs Inventory (CCFNI), are available
type of behavior may be repeated in the face of to aid the nurse in determining the needs and prob-
a new crisis. If adaptive behavior was used, the lems the family faces. Nursing research using these
impact of the crisis may be lessened. tools reveals a great deal of consistency in what
The primary way to survive a crisis is to be aware needs are important to family members (Box 2-2).
of it. Nursing interventions that help to address the needs
of a family in crisis are given in Box 2-3. An approach
The nurses initial interaction with family members to assisting the family with problem-solving is given
is extremely important because it helps establish a in Box 2-4.
foundation of trust and respect between the nurse Some families will benet from a referral to
and family. Taking a few minutes to learn the names another objective professional with experience in
of family members and their relationship to the critical illness and its impact on the family (eg, a
patient signies respect and begins to build a thera- mental health clinical specialist, a social worker,
peutic and trusting relationship. The primary goal a psychologist, or a chaplain). Many critical care
of the nurse is to assist the family as they deal with units have such resources available on a 24-hour,
the crisis phase of this illness by providing con- on-call basis to ensure prompt interventions. The
sistent and accurate information about the condi- nurse can best encourage the family to accept help
tion of their loved one. Research has demonstrated from others by acknowledging the difculty and
that up-to-date information is the highest priority complexity of the problem and providing contact
for family members who are coping with critical information for several professionals who will be
illness.3 able to assist.

Morton_Chap02.indd 11 2/4/2012 2:21:26 PM

12 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

BOX 2-2 Commonly Identified Needs of BOX 2-4 Assisting the Family in Crisis With
Family Members in Crisis Problem-Solving

The need to feel satised with the care given 1. Identify the problem. Families in crisis are often
The need for courteous caregivers who show an overwhelmed and immobilized by acute stress and
interest in how the family is doing anxiety. Helping the family to articulate the immedi-
The need to receive information about the patient ate problem reduces anxiety by giving family mem-
at least once a day, and assurance that someone will bers a clearer understanding of what is happening,
call the family with any changes and facilitates the planning of goal-directed activities.
The need to see the patient frequently and be in close 2. Identify available support systems. Asking fam-
proximity to the patient ily members to identify the person to whom they
The need for honest information about the patients usually turn when they are upset, and encouraging
condition, including information about the patients them to seek assistance from that person now, helps
prognosis direct the family back to the normal mechanisms
The need to have understandable explanations of for handling stressful issues. Few families are truly
why things are being done without resources; rather, they only have failed to
The need to have physical needs met (eg, a comfort- recognize and call on them.
able place to wait with easy access to refreshments 3. Focus on feelings. During the difcult days of the
and bathroom facilities) critical illness, the family may become dependent on
The need to have emotional needs met (eg, the need the judgment of professionals. It is important that
to feel that there is hope, the need to share negative the nurse acknowledges the familys feelings and rec-
feelings) ognizes the complexity of the problem, while empha-
sizing the responsibility each member of the family
has for his or her feelings, actions, and decisions.
The nurse encourages family members to reect on
Facilitating Visitation their feelings and practices by using active listening.
Policies regarding visiting hours should be evalu- 4. Identify steps. Once the problem has been dened
ated periodically. Family presence at the bedside and the family begins goal-directed activities, the
has been shown to decrease patient and family anxi- nurse may help further by asking the family members
ety, and can have a positive effect on the patients to identify the steps that they must take to achieve
physiological parameters (eg, intracranial pressure) those goals. For example, sometimes the nurse must
as well. Novel approaches to visitation (eg, chil- help family members recognize that returning home
dren accompanied by an adult, animals as part of to rest is an important step for maintaining their own
health and ability to help the patient.

BOX 2-3 Nursing Interventions for Care of the

Family in Crisis an animal-assisted therapy program) have also been
shown to have positive effects on patients, including
Convey feelings of hope and condence in the
increased feelings of happiness and calmness and
familys ability to deal with the situation.
reduced feelings of loneliness.4 These ndings sup-
Try to perceive the feelings that the crisis evokes in
port the need for less restrictive and individualized
the family.
visiting policies for patients and families.
Demonstrate concern about the patient and family
The nurse prepares family members for the ini-
and a willingness to help.
tial visit to the unit by providing explanations of
Speak openly to the patient and the family about the
the functions of monitors, IV drips, ventilators, and
critical illness.
other equipment, as well as the meaning of alarms,
Discuss all issues as they relate to the patient speci-
before and during the visit. The nurse also introduces
cally, avoiding generalizations.
the family to the members of the healthcare team
Be realistic and honest about the situation, taking
involved in the patients care, providing names, titles,
care not to give false reassurance.
and an explanation of responsibilities. Encouraging
Ensure that the family receives information about all
family members to provide direct care to the patient
signicant changes in the patients condition.
(eg, assistance with grooming, eating, or hygiene),
Mitigate feelings of powerlessness and hopelessness by
if they are interested, can help decrease anxiety and
involving families in decision making and patient care.
provide the family with some sense of control.
Advocate for the adjustment of visiting hours to
accommodate the needs of the family.
Locate space near the unit where the family can be Managing Family Presence During Invasive
alone and have privacy. Procedures and Resuscitation Efforts
Recognize the patients and familys spirituality, and sug-
gest the assistance of a spiritual advisor if there is a need. Although controversial, family presence dur-
ing invasive procedures and resuscitation efforts

Morton_Chap02.indd 12 2/4/2012 2:21:26 PM

The Patients and Familys Experience With Critical Illness C H A P T E R 2 13

is becoming more common. In light of current

research, it has demonstrated positive benets for BOX 2-5 The Nurses Role Before and After
the Family Conference
family members. When family members were inter-
viewed, 97.5% believed that family presence was a Before the Conference
right, 100% said they would repeat family presence Explain the medical equipment and therapies that
in the same situation again, 95% believed that their are being used in the care of the patient to the family.
presence helped the patient, even if the patient was Tell the family what to expect during their confer-
unconscious, and 95% said it helped them real- ence with the healthcare team members.
ize the seriousness of the patients condition.5 In Talk with the family about their spiritual or religious
the event of the patients death, family members needs and take actions to address unmet spiritual or
have reported that being present during resusci- religious needs.
tation efforts was helpful during the bereavement Talk with the family about specic cultural needs
process.3 and take actions to address unmet cultural needs.
However, many healthcare providers are uncom- Talk with the family about what the patient values in life.
fortable with family presence during resuscitation Talk with the family about the patients illness and
efforts, due to concerns about litigation, making treatment.
a mistake, or that caring for family members may Talk with the family about their feelings.
take time and attention away from the patient. Reminisce with the family about the patient.
The American Association of Critical-Care Nurses Tell the family it is all right to talk to and touch their
(AACN) recommends that each facility establish pol- loved one.
icies and procedures for handling family presence Discuss with the family what the patient might have
during resuscitation.6 Every effort must be made to wanted if he or she were able to participate in the
have a knowledgeable person present to explain to treatment decision-making process.
the family what measures are being implemented Locate a private place or room for the family to talk
and the rationale. Protocols must also be in place to among themselves.
escort family members from the room if the health-
care team cannot perform resuscitative measures After the Conference
effectively. Talk with the family about how the conference went.
Talk with any other healthcare team members
who were present at the conference about how the
conference went.
Facilitating Family Conferences Ask the family if they had any questions following
As a patient and family advocate, the nurse pro- the conference.
vides accurate information and shares the plan of Talk with the family about their feelings.
care with the family. The nurse may arrange for a Talk with the family about any disagreement among
family conference to provide a forum for health- the family concerning the plan of care.
care providers and family members to share infor- Talk with the family about changes in the patients
mation in an organized way. During the family plan of care as a result of the conference.
conference, the healthcare team provides infor- Support the decisions the family made during the
mation about the condition of the patient and the conference.
patients prognosis and reviews recommendations Reassure the family that the patient will be kept
for care. Family conferences facilitate open com- comfortable.
munication and are often useful for dispelling Tell the family it is all right to talk to and touch their
misinformation and misconceptions about the loved one.
patients progress. Family conferences also serve Locate a private place or room for the family to talk
as a forum for exploring how family members may among themselves.
wish to participate in determining treatment goals
for the patient.5 From Curtis JR, Patrick DL, Shannon SE, et al.: The family con-
ference as a focus to improve communication about end-of-life
Consensus among providers is an important care in the intensive care unit: Opportunities for improvement.
step before presenting treatment options and Crit Care Med 29(2 suppl):N26N33, 2001.
recommendations.3 Providing conicting informa-
tion creates confusion for everyone involved and
may lead families to request nonbenecial inter- RED FLAG! The nurse should have the patients
ventions. Box 2-5 describes the nurses role before permission before giving confidential medical
and after the family conference5 and Box 2-6 information to family members. If that is not possible
describes how to facilitate communication during because of the patients condition, the patients
a family conference. Encouraging the family to be next of kin should be identified as the person who
active participants during the family conference may receive confidential information. The names of
increases their level of satisfaction and improves those family members approved to receive medical
the quality of communication among providers information about the patient should be recorded in
and families.7 the patients medical record.8

Morton_Chap02.indd 13 2/4/2012 2:21:26 PM

14 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

BOX 2-6 Facilitating Communication During a Family Conference

Before the Conference Support the familys decision.

Review previous knowledge of the patient and family. Do not discourage all hope; consider redirecting
Review previous knowledge of the familys attitudes hope toward a comfortable death with dignity if
and reactions. appropriate.
Review your knowledge of the diseaseprognosis, Avoid the temptation to give too much medical detail.
treatment options. Make it clear that withholding life-sustaining treat-
Examine your own personal feelings, attitudes, biases, ment is not withholding caring.
and grieving. Make explicit what care will be provided including
Plan the specics of location and setting: a quiet, symptom management, where the care will be deliv-
private place. ered, and the familys access to the patient.
Discuss with the family in advance about who will be If life-sustaining treatments will be withheld or with-
present. drawn, discuss what the patients death might be like.
Use repetition to show that you understand what the
During the Conference
patient or family is saying.
Introduce everyone present.
Acknowledge strong emotions and use reection to
If appropriate, set the tone in a nonthreatening way:
encourage patients or families to talk about these
This is a conversation we have with all families
Discuss the goals of the specic conference.
Tolerate silence.
Find out what the family understands.
Review what has happened and what is happening to At the Conclusion of the Conference
the patient. Achieve common understanding of the disease and
Discuss prognosis frankly in a way that is meaningful treatment issues.
to the family. Make a recommendation about treatment.
Acknowledge uncertainty in the prognosis. Ask if there are any questions.
Review the principle of substituted judgment: What Review the follow-up plan and make sure the family
would the patient want? knows how to reach you for questions.

From Curtis JR, Patrick DL, Shannon SE, et al.: The family conference as a focus to improve commu-
nication about end-of-life care in the intensive care unit: Opportunities for improvement. Crit Care Med
29(2 suppl):N26N33, 2001.

Practicing Cultural Sensitivity connectedness with the universe at large. Spirituality

is intrinsically related to a persons beliefs and val-
Culturally competent nursing care is dened as ues, and for some people, it has a religious compo-
being sensitive to issues related to culture, race, nent. The nurse assesses the patients and familys
gender, sexual orientation, social class, and eco- spiritual belief systems and assists the patient and
nomic situation.3 In addition, culturally competent family in recognizing and drawing on the values
nursing considers the family structure and gender and beliefs they already hold. Critical illness may
role as it relates to the patient. Health and illness
beliefs are deeply rooted in culture. How a patient or
family member responds to the diagnosis or a pro-
posed treatment may be strongly inuenced by his BOX 2-7 Key Pieces of Information to Obtain
or her values and culture. During initial assessment, as Part of the Cultural Assessment
the critical care nurse obtains several key pieces of
information regarding the patients cultural beliefs Place of birth
(Box 2-7). Astuteness and sensitivity on the part of Length of time in this country
 Does the patient live in an ethnic community?
the critical care nurse are required to ensure that
 Who are the patients major support people?
the highly technologic, illness-focused critical care
environment does not clash with the patients and Primary and secondary languages (speaking and
familys cultural beliefs and values. Because individ- reading ability)
ual responses and values may vary within the same Religious practices
culture, the nurse takes care to recognize the patient Health and illness beliefs and practices
and family members as individuals within the cul- Communication practices (verbal and nonverbal)
tural context. How decisions are made in the context of the patient
and family

Supporting Spirituality Adapted from Lipson JG: Culturally competent nursing care. In
Lipson JG, Dibble SL, Mainarik PA (eds): Culture and Nursing
Spirituality speaks to the manner by which a person Care: A Pocket Guide. San Francisco, UCSF Nursing Press, 2005,
seeks meaning in his or her life, and experiences pp 16.

Morton_Chap02.indd 14 2/4/2012 2:21:27 PM

The Patients and Familys Experience With Critical Illness C H A P T E R 2 15

deepen or challenge existing spirituality. During

these times, it may be useful to call on a spiritual or
BOX 2-8 Nursing Interventions for Promoting
religious leader, hospital chaplain, or pastoral care
representative to help the patient and family make Ensure the patient is comfortable (eg, manage
meaningful use of the critical illness experience. pain, use pillows to ensure a comfortable
Schedule care and procedures (eg, labs, x-rays) to
Preparing the Patient and Family for disrupt sleep as little as possible.
Discharge Try to orient the patient to normal sleepwake cycles
as much as possible. Provide large clocks and calen-
As the patients condition improves and plans for dars, and dim the lights at bedtime.
transfer to a lower acuity area are discussed with Make an effort to control noise, especially during the
the healthcare team, the critical care nurse must evening hours: decrease noise from televisions and
prepare the patient and family for the eventual dis- talking, post signs to alert others to the need to be
charge from the unit. This milestone in recovery is quiet (eg, Patient Sleeping).
typically viewed by the patient and family in one of Ensure privacy by closing the door and pulling the
two ways. If the patient and family believe that the curtains (if possible).
patients condition has improved sufciently and Institute a bedtime routine (eg, brushing teeth,
that the intensity of critical care is no longer nec- washing face). As part of the bedtime routine,
essary, then this step is viewed in a positive light. consider providing a 5-minute massage.
However, if they believe that the depth of nursing At bedtime, provide information to lower anxiety.
support and level of monitoring on a lower acu- Review the day together, remind the patient of prog-
ity unit are inadequate to meet the needs of the ress made toward recovery, and explain what to
patient, there may be resistance to the transfer pro- expect for the next day.
cess. Providing information about the new units Employ anxiety-reducing strategies (eg, relaxation
routine, stafng patterns, and visiting hours before techniques, guided imagery, music therapy).
making the transfer can help mitigate some of the
negative feelings and anxiety associated with the
Once the transfer has been made, it is important
that the receiving nurse further assist the patient The nurse assesses the amount and quality of
and family with adjusting to the new routine. The the patients sleep, and intervenes to facilitate rest
nurse begins by acknowledging the normal anxi- and sleep (Box 2-8). The patients own report of
ety that accompanies the transfer process, and sleep quality is the best measure of sleep adequacy.
emphasizes that the transition is a positive stage A visual analog scale is recommended to evaluate
in the recovery process. The nurse also reassures sleep quality in select patients at high risk for sleep
the patient and family that even though the inten- disruption owing to an extended stay on the critical
sity of treatment has changed, staff members are care unit.9 Some situations (eg, mechanical ventila-
trained to anticipate the patients needs and will tion) make a self-report of sleep quality difcult to
respond appropriately to changes in the patients obtain. If a self-report is unobtainable, systematic
status. Once the patients and familys initial anxiety observation has been shown to be somewhat valid
diminishes, the nurse can begin to set new self-care and reliable.9
goals and expectations based on assessment of the
Using Restraints in Critical Care
Promoting Rest and Sleep for the Physical restraints must occasionally be used for
patients in critical care to prevent potentially seri-
Critically Ill Patient ous disruptions in therapy resulting from acciden-
tal dislodgment of endotracheal tubes, IV lines,
Sleep deprivation is common in critically ill patients, and other invasive therapies; to prevent falls; and
due to environmental factors, anxiety, pain, medi- to manage disruptive behavior. However, the use
cation side effects, and therapeutic interventions of restraints can increase agitation and puts the
that disrupt sleep. Secretion of melatonin (a hor- patient at risk for other potentially serious inju-
mone that facilitates sleep) is inhibited by light and ries, including falls, fractures, and strangulation.
stimulated by darkness; the constant, high-intensity Alternatives to physical restraints must always be
lighting typical of the critical care unit disrupts sought and tried rst (Box 2-9). Standards on phys-
this normal rhythm. Sleep deprivation contrib- ical restraint use are published and monitored by
utes to stress and, if prolonged, can lead to altered the Joint Commission and the Centers for Medicare
cognition, confusion, and difculty with ventilator and Medicaid Services. These standards are sum-
weaning. marized in Box 2-10.

Morton_Chap02.indd 15 2/4/2012 2:21:27 PM

16 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

BOX 2-9 Alternatives to Physical Restraints

Environmental Modifications Ensure comfort by meeting the patients physical

Keep the bed in the lowest position. needs (eg, frequent toileting, skin care, pain manage-
Minimize the use of side rails to what is needed for ment, hypoxemia management, positioning).
positioning. Mobilize the patient as much as possible.
Optimize room lighting. Allow the patient to make choices and exert some
Activate bed and chair exit alarms where available. degree of control when possible.
Remove unnecessary furniture or equipment.
Diversionary Activities
Ensure that the bed wheels are locked.
Enlist family members or volunteers to provide
Position the call light within easy reach.
company and diversion.
Ensure that the patient has needed vision and hearing
Facilitate solitary diversionary activities (eg, music,
videos or television, audio books).
Therapeutic Interventions
Therapeutic Use of Self
Frequently assess the need for treatments and discon-
Use calm, reassuring tones.
tinue lines and catheters at the earliest opportunity.
Introduce yourself and let the patient know he or she
Orient the patient to invasive medical equipment.
is safe.
Help the patient explore the equipment by guiding
Find an effective method of communicating with
the patients hand over it. Explain the purpose of the
intubated or nonverbal patients.
equipment, as well as the meaning of any alarms that
Reorient patients frequently by explaining treatments,
may sound.
medical devices, care plans, activities, and unfamiliar
Disguise treatments, if necessary (eg, keep IV solution
sounds, noises, or alarms.
bags out of the patients eld of vision, apply a loose
stockinette or long-sleeved gown over IV sites).

BOX 2-10 Summary of Care Standards CAS E S T U DY

Regarding Physical Restraints

Initiating Restraints
M s. J. is a 40-year-old pregnant woman who
is admitted to the hospital at 34 weeks, 5 days
Restraints require the order of a licensed indepen-
of gestation with complaints of vaginal bleeding,
dent practitioner who must personally see and evalu-
painful contractions, and nausea and vomiting.
ate the patient within a specied time period.
Until this time, she has received routine prenatal
Restraints are used only as an emergency measure
care, and the pregnancy has been uneventful.
or after restraint alternatives have failed. (The
Before her admission to the hospital, she was
restraint alternatives that were tried and the patients
eating lunch at work when she felt a pop in her
responses to them are documented.)
abdomen; shortly afterward, her symptoms began.
Restraints are instituted by staff who are trained and
She states that the last time she felt fetal move-
competent to use restraints safely. (A comprehensive
ment was earlier in the morning. At the hospital,
training and monitoring program must be in place.)
an external fetal monitor and portable ultrasound
Restraint orders must be time limited. (A patient must
detect no fetal heart tones. There is blood in the
not be placed in a restraint for longer than 24 hours,
vaginal vault and no active bleeding, and the cervix
with reassessment and documentation of continued
is long and closed.
need for restraint at more frequent intervals.)
Ms. J. is admitted to the labor and delivery unit
Patients and families are informed about the ratio-
with the diagnosis of a fetal death in utero, prob-
nale for the use of the restraint.
ably due to an abruption of the placenta, and the
Monitoring Patients in Restraints plan is to deliver her by induction of labor. Shortly
The patients rights, dignity, and well-being are after admission, she complains of increasing pel-
protected. vic pressure. Examination reveals that she is fully
The patient is assessed every 15 minutes by trained dilated, and she spontaneously delivers a stillborn
and competent staff. male child. Delivery of the placenta, as well as a
The assessment and documentation must include 250-mL clot, follows, confirming the diagnosis of
evaluation of the patients nutrition, hydration, placental abruption. Despite administration of med-
hygiene, elimination, vital signs, circulation, range ications to assist the uterus to contract and control
of motion, injury due to the restraint, physical and bleeding, Ms. J. begins to bleed steadily. Clinicians
psychological comfort, and readiness for discontinu- decide to perform dilation and curettage (D&C).
ance of the restraint.

Morton_Chap02.indd 16 2/4/2012 2:21:27 PM

The Patients and Familys Experience With Critical Illness C H A P T E R 2 17

Following the D&C, Ms. J.s uterus becomes well
contracted, bleeding decreases, and coagulation 1. Curtis R, White D: Practical guidance for evidence based
ICU family conference. Chest 134(4):835843, 2008
parameters begin to improve. Her estimated blood 2. Borges K, Mello M, David C: Patient families in ICU:
loss is 8000 mL. Describing their strategies to face the situation. Crit Care
Ms. J. begins to bleed again later that evening 15:P527, 2011
and is again transferred to the operating room, 3. Davidson J, et al.: Clinical practice guidelines for support of
where a uterine artery embolization is performed. family in patient centered intensive care unit: An American
College of Critical Care Medicine Task Force 20042005. Crit
Ventilation becomes difficult, and she is intubated. Care Med 35(2):605622, 2007
She is transferred to the critical care unit for 4. Miracle V: A closing word: Critical care visitation. Dimens
closer surveillance, ventilatory support, and fluid Crit Care Nurs 24(1):4849, 2005
resuscitation. Clinicians make an additional diag- 5. Curtis JR, Patrick DL, Shannon SE, et al.: The family confer-
ence as a focus to improve communication about end-of-life
nosis of disseminated intravascular coagulation care in the intensive care unit: Opportunities for improve-
(DIC). Ms. J.s husband stays with Ms. J. through- ment. Crit Care Med 29(2 suppl):N26N33, 2001
out the night during her first 2 days the critical 6. American Association of Critical-Care Nurses: Family
care unit. On day 3, Ms. J. is extubated and is presence during CPR and invasive procedures. Practice
hemodynamically stable. She is transferred to the alert. Retrieved October 20, 2006, from http://www.aacn.
org/AACN/practice Alert.nsf/Files/FP/$le/Family%20
progressive care unit after she is weaned from Presence%20During%20CPR%20112004.pdf
the ventilator. 7. Nelson J: Family meetings made simpler: A toolkit for ICU.
J Crit Care 24:626e7627e14, 2009
1. Mr. J. stayed at his wifes bedside throughout her 8. Jansen MPM, Schmitt NA: Family-focused interventions.
first 2 days in the critical care unit. How does this Crit Care Nurs Clin N Am 15(3):347354, 2003
demonstrate the critical care staffs commitment 9. Dogan O, Ertekin S, Dogan S: Sleep quality in hospitalized
to meeting both the patients and the familys patients. J Clin Nurs 14:107113, 2005
2. Describe actions the critical care nursing staff
can take to ensure that Ms. J. and her husband Want to know more? A wide variety of resources to enhance your learn-
view this difficult time in their lives in the most ing and understanding of this chapter are available on . Visit
positive way possible. to access chapter review
questions and more!

Morton_Chap02.indd 17 2/4/2012 2:21:27 PM

Patient and Family Education in

3 Critical Care

Based on the content in this chapter, the reader should be able to:
1 Describe barriers to learning and ways to manage them.
2 Describe the assessment of learning in the critical care environment.
3 Describe how the three domains of learning and the six principles of adult
learning can be used when developing a teaching plan.
4 Explain the importance of evaluating the effectiveness of teaching and

n the critical care setting, it is always a challenge
to meet the educational needs of patients and fami-
Effects of Critical Illness and Therapeutic
lies because of the life-threatening nature of criti- Interventions
cal illness. The nurse must deal with the anxiety and Altered metabolic responses, exposure to general
fear that is associated with a diagnosis of critical anesthesia, use of cardiopulmonary bypass, epi-
illness while trying to teach difcult concepts in an sodes of hypoxia, and marked sleep deprivation can
environment that is poorly suited to learning. In the compromise mental acuity and decrease a persons
current healthcare environment, it is not unusual learning capacity and recall. In addition, combat-
for a patient to be discharged home directly from ing a severe illness consumes most of the patients
the critical care unit, placing even greater responsi- energy, leaving little energy left to devote to learning.
bility on the patient and family to provide for com-
plex care at home and further increasing the need
for adequate patient and family education. Emotional and Environmental
Recognizing and Managing Barriers to The critical care nurse must be very sensitive to the
heightened anxiety that accompanies an admission
Learning to the critical care unit. This anxiety can markedly
reduce the ability of the patient and family to con-
Several factors can present barriers to learning, centrate and focus attention on learning. Conveying
including the illness itself and interventions to man- information in a concise, clear manner and avoid-
age it, emotional and environmental distractions, ing long, tedious explanations can help patients and
language barriers, and sensory decits. family members focus on the information they are


Morton_Chap03.indd 18 2/4/2012 2:23:56 PM

Patient and Family Education in Critical Care C H A P T E R 3 19

being given. Even so, intense anxiety may cause

patients and families to forget much of this informa-
BOX 3-1 Guidelines for Communication Using
an Interpreter
tion, so the nurse must be prepared to repeat infor-
mation and answer identical questions repeatedly. Before the session, meet with the interpreter to give
The environment itself also poses many dis- background information and explain the purpose of
tractions. Actions such as closing the door to the the session.
patients room, placing a comfortable chair at the If possible, have the interpreter meet with the patient
bedside, and reducing the alarm volumes on bedside or family to determine their educational level,
equipment can minimize the number of interrup- healthcare beliefs, and healthcare attitudes to plan
tions and may improve the learners ability to focus the depth of information needed.
on the topic of a teaching session. Speak in short units of speech and avoid long expla-
nations and use of medical jargon, abbreviations,
Language Barriers and colloquialisms.
When speaking, look directly toward the patient and
An inability to speak or read English can pose a major family members, not at the interpreter. Watch the
obstacle to patient and family education, especially patients and family members body language and
in the stressful critical care environment. A medical nonverbal communication response.
interpreter must be obtained for patients and family Be aware that interpreted interviews take a long
members who do not speak English. Asking a friend time to complete and may become tiresome for the
or family member to translate is inappropriate and patient.
can pose many problems: Written instructions should also be translated and
Complex medical information and terminology reviewed in the presence of an interpreter so that
may be unfamiliar to the person translating. any questions can be addressed immediately.
It may be difcult for a family member or friend to Have the patient and family members validate the
translate without bias. information given to them through the interpreter, to
In many cultures, decision making is assumed make sure that they understand the instructions or
by the eldest member of the family, and asking message that has been given.
another family member to interpret medical infor-
mation may disrupt the social order of the family.1
Having a family member or friend translate per-
sonal medical information may be awkward of treatment options; to provide background infor-
for the patient, the family member or friend, or mation before obtaining informed consent for pro-
both. It may also represent a breach of patient cedures, blood administration, or surgery; and to
condentiality. explain discharge instructions.
Vision impairment must also be taken into con-
Guidelines for communicating through an inter- sideration when preparing written resources for the
preter are given in Box 3-1. patient and family (Box 3-2).
Patients and family members who speak English
may still struggle with reading the language. The
nurse should not assume that a document such as a Providing Patient and Family
consent form is clearly understood when it is returned
signed and unquestioned; the document may be writ- Education
ten beyond the patients reading and comprehension
level. Written educational material should always be Patient and family education entails more than just
in the active voice and targeted for a fth- to eighth- providing an educational brochure or turning on an
grade reading level.2 In addition, the nurse should instructional video; it is an interactive process based
verbally review any written material with the patient
or family in case they are unable to read the docu-
ment and are too embarrassed to admit it. BOX 3-2 Guidelines for Preparing Printed
Educational Materials
Sensory Deficits
Use a large font (12 point or greater).
Effective education for deaf and hearing-impaired Use a serif font (eg, M) instead of a sanserif font
patients and families necessitates planning and (eg, M).
additional resources. The nurse asks deaf or hear- Avoid script or stylized fonts.
ing-impaired patients or family members about Avoid the use of all uppercase letters, except in
their preferred mode of communication (eg, sign headings.
language, written notes, lip reading, oral interpret- Keep line lengths short (eg, less than 5 in).
ers, or other assistive devices).3 To ensure that deaf Use a matte, rather than a glossy, paper to cut down
or hearing-impaired patients or family members can on glare.
communicate concerns and questions effectively, an Use black ink on plain white or off-white paper.
oral interpreter should be used for the discussion

Morton_Chap03.indd 19 2/4/2012 2:23:58 PM

20 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

use of formal assessment tools with overly generic

BOX 3-3 Content Areas for Patient and
questions about health beliefs and learning styles.
Family Education
It is better to use an informal style and open-ended
The pathophysiology of the patients illness dialogue to establish what the patient and family
Diagnostic studies (purpose, method of performing, need to know. Use of open-ended questions such as
preparation, and follow-up) What is your understanding of your mothers condi-
The treatment plan tion? or What did the physician tell you about the
Medications (purpose, desired and adverse effects, surgery? gives the nurse a starting point for teach-
safe administration) ing. It also validates whether the patient or family
Pain management techniques member clearly understands previous explanations
Medical equipment (purpose, safe and effective use) given by other members of the healthcare team. It
Rationale for restraint or seclusion may be necessary for the nurse to bridge the knowl-
Future and ongoing care (eg, information about edge gap between the physicians explanation and
step-down unit, available community resources) the patients or family members baseline knowledge
of medical terminology and concepts. Assessing the
persons level of education and degree of health lit-
eracy can help the nurse tailor information to the
on a therapeutic relationship. Frequently, assess- patients or family members level of understanding.
ment of learning needs and the provision of infor- This is particularly important within the critical
mation are integrated naturally into the process of care setting, where healthcare problems are often
providing care. Teachable moments, which often complex and patients or family members are often
occur during the course of providing routine patient required to make urgent decisions about care.4
care, are those instances when the nurse and learner
together recognize the need for education and the
learner is open to hearing information and learn- Developing Effective Teaching Strategies
ing new problem-solving skills.1 Patient and family Successful teaching plans take into account basic
teaching encompasses many areas (Box 3-3). principles of adult learning (Table 3-1). Considering
the three domains of learning while developing a
Assessing Learning Needs teaching plan also assists the nurse in selecting suit-
able teaching methods (Fig. 3-1):
Assessment is a dynamic and ongoing process, pro-
viding the critical care nurse with many opportunities The cognitive domain is concerned with the
to meet the learning needs of patients and families. acquisition and application of knowledge.
Understanding the learning needs of patients and Teaching methods that are used in the cogni-
families does not require a protracted interview or tive domain seek to develop the knowledge that

TA B L E 3 - 1 Six Principles of Adult Learning

Principle Underlying Concept Teaching Strategy

The need to know Adults need to understand why they need to learn Ensure that the learner understands why
something before they are willing to commit the the information is important to learn.
energy and time to learn it.
The learners Adults are self-directed and responsible for their Create learning situations that are more
self-concept own decision making. In general, adults resent self-directed and independent.
the feeling that others are making choices for
The learners life Adults have accumulated many experiences Emphasize experiential techniques (eg,
experience over the course of their lives, and these life case studies, simulation, problem-solving
experiences define and shape adult beliefs, exercises) and techniques that draw
values, and attitudes. on the experiences of peers (eg, group
Readiness to learn Adults are ready to learn the things they need to Help the learner see how the information is
know. applicable to real-life situations.
Orientation to Adults are motivated to learn if the information will Help the learner see how the information is
learning help them to perform useful tasks or to deal with applicable to real-life situations.
problems in their life.
Motivation to learn Adults are more motivated by internal forces Help the learner see how the information
such as improved quality of life, increased job will meet these needs.
satisfaction, and improved self-esteem.

Adapted from Meleis A, Isenberg M, Koerner J, et al.: Diversity, Marginalization, and Culturally Competent
Health Care: Issues in Knowledge Development. Washington, DC: Academy of Nursing, 2000.

Morton_Chap03.indd 20 2/4/2012 2:23:58 PM

Patient and Family Education in Critical Care C H A P T E R 3 21


Activities Action Words

Lecture Listening
Independent study Indentifying
(books, videos, Locating
on-line modules) Labeling
Question and Summarizing
answer Selecting


Activities Action Words Activities Action Words

Role playing Advocating Skill Assembling
Group activities Supporting demonstration Changing
Question and Refusing (live, video) Emptying
answer Defending Simulation Filling
Debating Return Adding
demonstration Removing
and repeated

F I G U R E 3 - 1 Teaching methods based on the domains of learning.

provides a basis for understanding the situation or unrealistic educational goals hinders learning and
modifying behavior.5 frustrates both the nurse and the learner. A teaching
The affective domain is concerned with the acqui- plan that is ineffective, poorly timed, or not meeting
sition or modication of values, attitudes, and the learners needs must be altered.
behaviors.5 Values and attitudes inuence what Immediate feedback can be gained by asking
the patient considers important enough to learn as questions to validate the learners grasp of the
well as the patients willingness to learn. Exercises information presented. The nurse avoids using
that allow the learner to consider different points leading questions to achieve a desired answer.
of view or behaviors (eg, role playing, group learn- Phrasing questions as a request for help (eg, Can
ing activities) are often used when appealing to the you repeat back to me what I just told you so I
affective domain. can make sure I didnt forget anything?) is often
The psychomotor domain is concerned with the less intimidating than quizzing the learner. Direct
development of motor skills (eg, learning how to observation of newly learned skills is also part
inject insulin). Step-by-step demonstrations, vid- of the evaluation. Cultivating a relaxed, positive
eos, simulations, and the opportunity to practice learning environment and developing a good rap-
and demonstrate the newly acquired skill are port with the patient or family member can help
teaching methods employed in the psychomo- minimize the self-consciousness many adults feel
tor domain. Learning new skills is intimidating when asked to perform a newly acquired skill in
to many adults; therefore, it is important that the front of others.
nurse provide praise and encouragement with
each teaching session.
RED FLAG! Learning is best accomplished The Joint Commissions patient care standards
when the message is consistent and the knowledge place an emphasis on patient and family education.
progresses from simple to more complex concepts. The goal of these educational standards is to guide
hospitals to create an environment in which both
the patient and the healthcare team members are
Evaluating Teaching and Learning responsible for teaching and learning. The medical
Evaluation of teaching and learning is an essential record should reect an interdisciplinary approach
component of the healthcare continuum. Evaluation toward patient education that begins on admis-
helps the nurse determine the adequacy of instruc- sion and continues throughout the hospital stay.
tion by revealing knowledge gaps and elements of Components of teaching documentation are given
the teaching plan that are not working.6 Setting in Box 3-4.

Morton_Chap03.indd 21 2/4/2012 2:23:58 PM

22 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

BOX 3-4 Components of Teaching twice a day; carvedilol, 25 mg twice a day; digoxin,
Documentation 0.25 mg daily; amlodipine, 5 mg daily; furosemide,
Participants (Who was taught?) 40 mg daily; and milrinone, 0.50 g/kg/min. She is
Content (What was taught?) also on a low-sodium diet and fluid restriction. This
Date and time (When was it taught?) morning her vital signs are as follows: temp, 98.2F
Patient status (What was the patients condition at (36.8C); BP, 90/52 mm Hg; HR, 120 beats/min; RR,
the time?) 28 breaths/min; and pulse oximetry, 92% on 2 L by
Patients readiness to learn (Was the patient open to nasal cannula. Telemetry reveals sinus tachycardia
receiving the information?) with frequent premature ventricular contractions.
Evaluation of learning (How well did the learner Crackles are present in both lung bases. Laboratory
appear to understand the information?) results are as follows: K+, 2.9 mEq/L; BUN, 45 mg/dL;
Teaching methods (How was the patient taught?) creatinine, 2.0 mg/dL; brain natriuretic peptide,
Follow-up and learning evaluation (If teaching was 50 pg/mL; troponin, 0.02 ng/mL; WBCs, 9.0 103 mL;
incomplete, what was the reason? What additional hemoglobin, 10.0 g/dL; and hematocrit, 30.3%.
education needs does the patient have?) During morning report, the nurse coming onto
the unit learns that Ms. V. has been refusing the
medications, stating that they are making her feel
bad. She has also been refusing the prescribed
Although it may be difcult for critical care low-sodium diet, preferring instead food brought
nurses to think in terms of teaching plans and inter- to her by a relative. Much of the food the relative
disciplinary learning because critically ill patients brings is high in calories and sodium.
require so much care just to maintain physiological 1. Formulate a teaching plan for Ms. V. and her
function, it is important to remember that much of family. What should the nurse address, and in
the teaching the nurse does is informal. Every time what order? What measures can the nurse use to
nurses explain what they are doing and why they evaluate the effectiveness of the teaching plan?
are doing it, they are providing a form of education! 2. What strategies might help the nurse implement
This type of informal instruction meets the Joint the teaching plan effectively?
Commission standard for patient education, and
should be documented. 3. What is the best way for the nurse to communi-
cate through an interpreter?

M s. V. is a 19-year-old Hispanic woman who References
has been admitted to the critical care unit from the
1. Rankin SH, Stallings KD, London F: Patient Education
delivery room for an episode of acute pulmonary in Health and Illness, 5th ed. Philadelphia, PA: Lippincott
edema that developed during the birth of her first Williams & Wilkins, 2005, pp 224250
child. She has recently immigrated to the United 2. Irnik M, Jett M: Creating written patient education materi-
States from Central America, and she speaks very als. Chest 133(4):10381040, 2008
little English. Through an interpreter, it is determined 3. Michigan Association for Deaf, Hearing, and Speech
Services: Hospitals responsibilities to the deaf under the
that she has received no prenatal care and is taking ADA. Retrieved November 1, 2006, from http://www.deaf-
no medications. She denies any past medical prob- hospitalresponsibilites.pdf
lems, but she has never seen a physician before. 4. Riley JB, Cloonan P, Norton C: Low health literacy: A chal-
She denies using tobacco, alcohol, or drugs. lenge to critical care. Crit Care Nurs Q 29(2):174178, 2006
5. Redman BK: The Practice of Patient Education: A Case
Physical examination reveals an enlarged heart, Study Approach, 10th ed. St. Louis, MO: Mosby Elsevier,
presence of an S3 and S4, and a murmur of mitral 2007, pp 126
regurgitation. A chest radiograph demonstrates 6. Redman BK: The Practice of Patient Education: A Case
marked cardiac enlargement. A transthoracic echo- Study Approach, 10th ed. St. Louis, MO: Mosby Elsevier,
cardiogram reveals severe left ventricular enlarge- 2007, pp 5673
ment and dysfunction; ejection fraction is estimated
at 35% (normal is 50% to 70%). Based on the
results of these tests, Ms. V. is diagnosed with
Want to know more? A wide variety of resources to enhance your learn-
peripartum cardiomyopathy.
Ms. V. is currently on the cardiac step-down unit ing and understanding of this chapter are available on . Visit
receiving the following medications: enalapril, 5 mg to access chapter review
questions and more!

Morton_Chap03.indd 22 2/4/2012 2:23:59 PM

Ethical and Legal Issues in

4 Critical Care Nursing

Based on the conte
ent in this chapter, the reader should be able to:
11 Compare
Explain the
assists nurses
off trauma
and otherinjury.
clinicians in resolving moral
2 Describe
problems.phasess of initial assessment and related care of the e trauma patient.
32 Discuss
the assessment
the applicability
the Code
ment of of
for Nurses
with th
of the American
Nurses Association
to everyday
and maxillofacial
practice. trauma.
3 Identify resources available to nurses to resolve ethical dilemmas.
4 Describe steps in the process of ethical decision making.
5 Discuss examples of ethical issues confronted by critical care nurses in
6 Describe major areas of the law that affect critical care nursing practice.
7 State five legal responsibilities of every registered nurse.
8 Explain the concept of duty and the potential consequences of breach of
9 Explain types of vicarious liability.
10 Discuss laws that are of particular applicability to the critical care nurse.

In the complex arena of critical care, questions

regarding the appropriate use of technology and
to answer questions about what is right or good, or
what ought to be done in specic situations. Several
information abound and crucial decisions about general approaches to ethics exist (Box 4-1). Ethical
life and death are made with striking frequency analysis helps the nurse to clarify moral issues and
and urgency. Although advancements in healthcare principles involved in a situation, examine his or
technology and information provide indisputable her responsibilities and obligations, and provide an
benets, these same advancements also raise pro- ethically adequate rationale for any decision made
found ethical and legal challenges. The nurse relies or action taken.
on an understanding of ethical principles and legal Informed clinicians and clear organizational
requirements to make sound decisions. policies help to prevent and resolve ethical
dilemmas in healthcare organizations. The Joint
Commission requires policy statements and guide-
lines addressing issues such as the resolution of
Ethics in Critical Care ethical dilemmas, informed consent, use of sur-
rogate decision makers, decisions about care and
Ethics can be dened as a set of principles of right treatment at the end of life, and condentiality of
conduct or a system of moral values. Ethics help us information.


Morton_Chap04.indd 23 2/4/2012 2:24:44 PM

24 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

Code of Ethics for Nurses With Interpretive Statements

BOX 4-1 General Approaches to Ethics
(Box 4-3).1 Nursing ethics encompasses the nurses
specic professional roles and responsibilities and
Consequentialism: Consequences of actions deter-
the relationships the nurse has with patients, other
mine whether an action is right or wrong.
healthcare providers, the facilities with which he or
Nonconsequentialism (deontological approach):
she is afliated, and society. A nurse never practices
Conformity to moral rules (not consequences) deter-
in isolation. Decision making, conict resolution
mines whether an action is right or wrong.
related to ethical issues, and ethical practice are
Utilitarianism: The right action is that which offers
accomplished through communication and collab-
the greatest benet with the least amount of burden to
oration with patients, peers, and colleagues on the
all affected.
healthcare team.
Paternalism: The right action is that which is
The code of ethics for nursing is strongly based
believed to bring the best outcome for the person,
on the principle of caring. Caring is considered
regardless of the persons autonomous actions or
essential to nursing and has been long valued in the
nursepatient relationship. In caring for patients,
Ethics of care: The right action is determined based
nurses are committed to promoting the health and
on the characteristics of caring relationships between
welfare of patients and respecting human dignity.
The care ethic is based on the understanding that
Principlism: A specic set of principles is used to
people are unique, that relationships and their value
identify and analyze the ethics of a situation.
are crucial in moral deliberations, and that emotions
Virtue ethics: What matters is not only what a person
and character traits play a role in moral judgment.
does but also how the persons actions reect the per-
Sympathy, compassion, trust, solidarity, delity, col-
sons virtues.
laboration, and discernment are emphasized.
Sometimes the desire to cure interferes with
the ability to care and provide relief of suffer-
ing. Especially in the critical care setting, aggres-
Principles of Bioethics sive treatments are frequently used in an attempt
Bioethics is the study of ethical issues and judg- to stabilize patients and keep them alive. The desire
ments made within the biomedical sciences, includ- to prevent harm by postponing death is shaped by
ing care of patients, the delivery of healthcare, public benecence. However, physical and psychological
health, and biomedical research. Bioethics takes suffering caused by aggressive treatment, especially
into account the difcult and practical realities that treatment of questionable or slight benet, some-
arise in the clinical care of people with illnesses. Six times constitutes a greater harm than death, and
widely accepted bioethical principles, summarized less aggressive treatment and more comfort may be
in Box 4-2, are often applied to ethical problems in a more benecent course. To determine what is best
healthcare and nursing practice. for the patient, the nurse involves the patient or sur-
rogate decision maker in discussions and decisions
about treatment goals and the risks and benets of
The Nurses Ethical Responsibilities various treatment options.
Most professional groups have formal codes of eth- Nurses promise to act in their patients best inter-
ics for their members; the nursing profession is ests, respect their autonomy, and advocate for them.
guided by the American Nurses Association (ANA) Communicating honestly with patients and families,
discussing and respecting their wishes regarding
treatment and care, convening patient care confer-
ences for all involved parties when indicated, and
BOX 4-2 Principles of Bioethics facilitating advance care planning discussions and
the use of advance directives are all important meth-
Nonmalecence: An obligation to never deliberately ods of fullling these obligations.
harm another
Benecence: An obligation to promote the welfare of RED FLAG! In the critical care unit, patients
others, to maximize benets and minimize harms frequently are unable to make decisions for
Respect for autonomy: An obligation to respect, themselves due to their clinical status, the effects
and not to interfere with, the choices and actions of treatments they are receiving, or both. The nurse
of autonomous individuals (ie, those capable of frequently and carefully assesses the patients
self-determination) ability to understand treatment options and make
Justice: An obligation to be fair in the distribution of decisions.
burdens and benets and in the distribution of social
goods, such as healthcare or nursing care Ethics Committees and Consultation
Veracity: An obligation to tell the truth Services
Fidelity: An obligation to keep promises and fulll
commitments Many healthcare organizations have an ethics com-
mittee or an ethics consultation service. Institutional

Morton_Chap04.indd 24 2/4/2012 2:24:47 PM

Ethical and Legal Issues in Critical Care Nursing C H A P T E R 4 25

BOX 4-3 The American Nurses Associations (ANA) Code of Ethics for Nurses

1. The nurse, in all professional relationships, prac- 6. The nurse participates in establishing, maintaining,
tices with compassion and respect for the inherent and improving healthcare environments and condi-
dignity, worth, and uniqueness of every individual, tions of employment conducive to the provision of
unrestricted by considerations of social or economic quality healthcare and consistent with the values
status, personal attributes, or the nature of health of the profession through individual and collective
problems. action.
2. The nurses primary commitment is to the patient, 7. The nurse participates in the advancement of the pro-
whether an individual, family, group, or community. fession through contributions to practice, education,
3. The nurse promotes, advocates for, and strives to administration, and knowledge development.
protect the health, safety, and rights of the patient. 8. The nurse collaborates with other health profession-
4. The nurse is responsible and accountable for individ- als and the public in promoting community, national,
ual nursing practice and determines the appropriate and international efforts to meet health needs.
delegation of tasks consistent with the nurses obliga- 9. The profession of nursing, as represented by associa-
tion to provide optimum patient care. tions and their members, is responsible for articulat-
5. The nurse owes the same duty to self as to others, ing nursing values, for maintaining the integrity of
including the responsibility to preserve integrity the profession and its practice, and for shaping social
and safety, to maintain competence, and to continue policy.
personal and professional growth.

Reprinted with permission from American Nurses Association: Code of Ethics for Nurses with Interpretive
Statements. Washington, DC: American Nurses Publishing, American Nurses Foundation/American
Nurses Association, 2001.

ethics committees are usually multidisciplinary and consider all important aspects of a situation before
include representatives from various patient care taking action (Box 4-4).
professions and disciplines (eg, nursing, medicine, Ethical principles, professional guidelines, per-
social work, spiritual care). They may also include sonal values, emotions, and judgment help guide
one or more members from the lay community. the nurses actions and decisions. How the nurse
Ethics committee members may offer education feels about an issue is a manifestation of his or her
to the professional staff and community on issues moral convictions that should not be ignored. The
related to clinical ethics and serve as a resource for nurse strives, though, to reach ethical decisions by
institutional policies concerning ethical matters. allowing reason to temper emotions and emotions
Individual committee members may also consult to tutor reason. Differing personal, professional,
at the bedside, providing education, clarication, and institutional values can compound moral con-
or dialogue necessary to assist decision makers in ict. Awareness of differences in professional and
resolving an ethical problem. In more complicated personal values and obligations can provide insight
cases or when conict exists among decision mak- into sources of interprofessional or interpersonal
ers, consultation by the entire ethics committee may ethical conict. Ideally, competing values are
be appropriate. Some committees aim to make a weighed and assigned priority in light of guiding
single recommendation for the resolution of the eth- ethical norms.
ical problem, whereas others attempt to frame the Moral distress occurs when nurses cannot turn
morally acceptable options and assist key decision moral choices into moral action,2 that is, when the
makers in choosing a course of action. nurse knows the proper course of action to take,

Ethical Decision Making

Resolving ethical dilemmas can be difcult. Ethical BOX 4-4 Model for Ethical Decision Making
dilemmas are dilemmas precisely because compel-
ling reasons exist for taking each of two or more 1. Gather the relevant facts and identify the decision
opposing actions. Systematically applying avail- maker(s) and the stakeholders.
able codes of ethics and ethical principles can help 2. Identify the ethical problem(s). Involve others
members of the healthcare team and ethics commit- in the process and use consultation resources as
tee identify ethical obligations and systematically appropriate.
decide which right actions can help to meet these 3. Analyze the problem using ethical principles and
obligations. Multidisciplinary collaboration and resources.
dialogue are also critical to satisfactorily resolving 4. Identify action alternatives in light of the ethical
ethical problems. Ethical decision-making models principles; choose one and justify the choice.
provide a process for systematically and thought- 5. Evaluate and reect.
fully examining a conict, ensuring that participants

Morton_Chap04.indd 25 2/4/2012 2:24:47 PM

26 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

but institutional or interpersonal constraints make To presume to understand the needs of a patient
it nearly impossible to pursue it.2 For example, and act against the patients expressed wishes (or
nurses tend to recognize when therapies are no lon- to avoid ascertaining what those wishes might be)
ger benecial to a patient sooner than family mem- can be paternalistic. Discussions about treatment
bers, which can be a source of moral distress. The preferences ideally occur when the patient is alert
Four As to Moral Distress, a resource developed by and has a reasonably clear sensorium. The nurse
the American Association of Critical-Care Nurses helps to ensure that the patient receives adequate
(AACN), provides a framework for addressing and information, has the capacity to understand avail-
resolving moral distress (Fig. 4-1). In addition, hos- able options, and can deliberate and make a health-
pital ethics committees are available to help staff care decision. If a patient is incapable of making an
work through situations in which moral distress is informed decision, a legally authorized surrogate
a factor. is asked to consent for the patient. Before making
a voluntary and informed decision to accept or to
Common Ethical Dilemmas in Critical refuse any treatment, the patient or surrogate must
understand what the treatment entails and how it
Care will most likely affect the disease process and future
Withholding or Withdrawing Treatment quality of life. Healthcare providers are responsible
In some cases, a patient or surrogate decision maker for presenting information in an understandable
may decide to withhold or withdraw a treatment, and sensitive manner and for assessing the level of
especially at the end of life. Withholding refers to the patients or surrogates understanding.
never initiating a treatment, whereas withdrawing In some cases, the nurse may have a personal
refers to stopping a treatment once started. The moral conviction contrary to a certain decision or
distinction between not starting a treatment and may believe that the particular decision is against
stopping it is not itself of ethical signicance; what the patients best interests or wishes. The nurse is
matters most is whether the decision is consistent morally permitted to refuse to participate in with-
with the patients interests and preferences. When holding or withdrawing treatment from a patient
the patient or surrogate decides in good faith that as long as the patients care is assumed by someone
a proposed treatment will impose undue burdens else. The nurse is justied in refusing to participate
and refuses such treatment, it is morally correct for on moral grounds, but the nurse must communicate
the healthcare professional to respect that decision. the decision in appropriate ways.
If the patient or surrogate decides that a treatment
in progress and the life it provides have become too Limits to Treatment and Futility of Care
burdensome, then the treatment may permissibly In contrast to cases in which healthcare workers want
be stopped. to treat patients against their wishes, sometimes a

Ask yourself if you
are distressed and
if it is work related

Prepare to act; take AACN Affirm your distress
action; maintain Four As and your committment
desired change to self-care

Identify sources
of your stress

F I G U R E 4 - 1 The four As (ask, affirm, assess, act) provide a framework for resolving moral distress.

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Ethical and Legal Issues in Critical Care Nursing C H A P T E R 4 27

patient, family member, or surrogate wants treat- decisions must be made about who receives the
ment that physicians, nurses, or other members of organs that are available. In the United States, the
the healthcare team feel is inappropriate or even Organ Procurement and Transplantation Network
futile. Providing care perceived as excessive, espe- maintains a national registry for organ matching5
cially for dying patients, is a source of great concern and includes all patients on a transplant centers
among care providers, especially critical care nurses.3 waiting list. When an organ becomes available,
There is a great deal of discussion among ethicists, information is entered into a computerized organ-
healthcare professionals, and patients rights groups matching system that generates a list of potential
about when, if ever, a patients request for treatment recipients according to objective criteria. Many
can be denied because of futility. Futility is a com- factors inuence who among those potential recipi-
plex concept that can be understood in at least one of ents actually receives an organ for transplantation.
two different ways: (1) when an intervention would Allocation of beds. The number of patients that
be ineffective at producing its intended effect and can be cared for on the critical care unit at any
(2) when an intervention might be physiologically given time is limited both by the number of beds
effective but is unlikely to provide meaningful ben- and the availability of qualied staff to provide
et. Lack of consensus on a denition of (and crite- care. Decisions about admitting or discharging
ria for) futility, coupled with concern about whether patients from critical care often involve some sort
healthcare providers can be objective enough to of triage to maximize the effective and efcient use
make these determinations, make this a particularly of resources. Triage decisions are usually based on
difcult ethical dilemma to resolve. considerations of medical utility (ie, a compara-
The Council on Ethical and Judicial Affairs of tive judgment about the probability of success of
the American Medical Association recommends critical care for the individual patients involved).
that facilities adopt a policy that follows a fair
process approach to determine futility of interven-
tions.4 Most such policies require deliberation by Law in Critical Care
multidisciplinary committees, such as ethics com-
mittees, rather than unilateral decisions by a physi- Legal issues involving critical care are of increasing
cian, and require genuine attempts to transfer the concern to the nurse because the number of mal-
patients care to another facility if the dilemma can- practice suits that name or involve nurses is increas-
not be resolved by the facility currently providing ing. There are three areas of the law that affect
care. Some facilities allow a physician, under care- critical care nursing practice:
fully delineated circumstances and after consulta-
tion with others, to write a do-not resuscitate (DNR) Administrative law. Every state legislature has
order or withhold certain treatments without the enacted a nurse practice act. Within each of these
consent of the patient. acts, the practice of nursing is dened, and pow-
ers are delegated to a state agency, usually the
Allocation Decisions State Board of Nursing. The state agency develops
regulations that dictate how the nurse practice act
The principle of justice comes into play when deci-
is to be interpreted and implemented. Practicing
sions must be made about the allocation of limited
nurses are expected to know the provisions of the
resources, treatments, and even time and attention
nurse practice act in their state and any regula-
among patients. Every time a decision is made to
tions dealing with the practice of nursing. If a
transplant a kidney into one person and not another,
citizen feels that he or she has not received rea-
to respond to one patients need before anothers, or
sonable nursing care, the citizen may contact
to admit one patient to the critical care unit instead
the state agency and le a complaint against the
of another, a decision is made about the distribution
nurse or nurses involved in the care. The state
of resources using justice criteria. Justice requires
is then responsible for conducting an investiga-
that decisions about the distribution of healthcare
tion to determine whether the patients claim has
be based on morally signicant characteristics, and
merit. Due process rights are attached to a nurs-
not on factors such as race, ethnicity, gender, social
ing license, so certain due process requirements
standing, or religious beliefs. Allocation decisions
must be met before a state agency can revoke, dis-
are ordinarily made independent of the wishes of
cipline, or place conditions on a nursing license.
the patient or family and usually require balanc-
Although the nurses right of due process cannot
ing potential harms and benets between people.
be abridged, the state agency has the right to tem-
Allocation decisions can be very difcult, and not
porarily suspend a nurses license immediately for
everyone will be happy with the decisions that are
made. Two examples of difcult allocation decisions acts the agency deems dangerous to the welfare of
involve the allocation of organs for transplantation the general public.
and the allocation of beds in the critical care unit. Civil law. In civil cases, one private party les a
lawsuit against another. One specic area of civil
Allocation of organs for transplantation. The law, tort law, forms the foundation of most civil
need for organs is greater than the available sup- cases involving nurses. Examples of torts include
ply. When a donation occurs, difcult distribution negligence, malpractice, assault, and battery.

Morton_Chap04.indd 27 2/4/2012 2:24:47 PM

28 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

Criminal law. In criminal cases, the local, state, Nursing texts, professional journals, and drug
or federal government les a lawsuit against an reference books
individual. Criminal offenses, which are extremely Standards and guidelines set by professional orga-
rare in nursing situations, include criminal assault nizations (eg, AACN, American Heart Association)
and battery, negligent homicide, and murder. Equipment manufacturers instructions
The legal responsibility of the registered nurse in Once duty is established, a breach of that duty is
critical care settings does not differ from that of the required for the nurse to be found negligent. A
registered nurse in any work setting. The registered breach of duty is determined by comparison of the
nurse adheres to ve principles for the protection of nurses conduct with the standard of care; that is,
the patient and the practitioner (Box 4-5). the nurse must be found to be negligent. Negligence
is found or refuted by a comparison of the nurses
conduct with the standard of care. In general, neg-
Common Legal Issues in Critical Care ligence is either ordinary or gross. Ordinary negli-
Negligence (Breach of Duty) gence implies professional carelessness, whereas
The most common lawsuits against nurses and their gross negligence suggests that the nurse willfully
employers are based on the legal concept of mal- and consciously ignored a known risk for harm to
practice, known as negligence by a professional. In a the patient. Most cases involve ordinary negligence.
malpractice suit, the plaintiff has to show that some Examples of actions that could lead to charges of
type of injury or harm occurred as a result of the gross negligence include acting in a way that con-
nurses actions or inaction. Malpractice law requires tradicts sound nursing advice, or providing patient
that there be a causal relationship between the con- care while under the inuence of drugs or alcohol.
duct of the nurse and the injury to the patient, and The law attempts to return the plaintiff to a posi-
that the injury that the patient experienced must be tion he or she would have been in had an injury not
reasonably anticipated. been suffered. Unfortunately, injuries to patients usu-
In a malpractice suit, the rst task is establishing ally cannot be undone. As such, most courts attempt
duty. A duty is a legal relationship between two or to give monetary awards to compensate for the inju-
more parties. In most nursing cases, duty arises out ries sustained by the plaintiff. Examples of economic
of a contractual relationship between the patient damages (ie, damages that can be calculated within
and the healthcare facility. A nurse who cares for a a degree of certainty) include medical costs and lost
patient is legally responsible for providing reason- wages. Noneconomic damages, such as pain and suf-
able care under the circumstances present at the fering and loss of consortium (services) that occurred
time of the incident. A nurse who fails to provide rea- as a result of the malpractice, are somewhat more
sonable care under the circumstances has breached difcult to calculate. Many state and federal govern-
(violated) his or her duty toward the patient. Many ments place monetary limits on the amount a plain-
different methods are used to determine whether the tiff can recover for pain and suffering, regardless of
nurse complied with reasonable standards of care the amount that may be awarded by a jury.
under the circumstances that existed at the time of
the incident. The following resources can be used to Vicarious Liability
establish standards of care:
In some cases, a person or facility can be held liable
Testimony from nurse experts in critical care for the conduct of another. This is called vicarious
The healthcare facilitys procedure and protocol liability. There are various types of vicarious liability:
Nursing job descriptions Respondeat superior (let the master answer
State Board of Nursing standards of care for the sins of the servant) is the major legal
theory under which hospitals are held liable for
the negligence of their employees. In some situ-
ations, respondeat superior is not applicable. For
BOX 4-5 Five Legal Responsibilities of the instance, hospitals are not usually responsible
Registered Nurse for temporary agency personnel because they are
usually employees of the agency, not the hospital.
The registered nurse is legally responsible for: Similarly, physicians, unless they are employed
Performing only those functions for which he or she by the hospital, do not typically come within the
has been prepared by education and experience sphere of this doctrine.
Performing those functions competently Corporate liability occurs when a hospital is
Delegating responsibility only to personnel found liable for its own unreasonable conduct.
whose competence has been evaluated and found For example, if it is found that a unit is chroni-
acceptable cally understaffed and a patient suffers an injury
Taking appropriate measures as indicated by obser- as a result of short stafng, the hospital can be
vations of the patient held accountable. Corporate liability may also
Being familiar with the employing agencys policies apply in oating situations. A nurse working in
a critical care setting must be competent to make

Morton_Chap04.indd 28 2/4/2012 2:24:47 PM

Ethical and Legal Issues in Critical Care Nursing C H A P T E R 4 29

immediate nursing judgments and to act on those

decisions. If the nurse does not possess the knowl-
BOX 4-6 Commonly Asked Questions When
Rotating to an Unfamiliar Unit
edge and skills required of a critical care nurse,
he or she should not be providing critical care. 1. If I am asked to go to another unit, must I go?
Box 4-6 addresses issues of concern to the oating Usually, you will be required to go to the other unit.
nurse. If you refuse, you can be disciplined under the
Negligent supervision is claimed when a supervi- theory that you are breaching your employment
sor fails to reasonably supervise people under his contract or that you are failing to abide by the poli-
or her direction. For example, if a nurse is rotated cies and procedures of the hospital. Some nursing
to an unfamiliar unit and informs the charge nurse units negotiate with hospitals to ensure that only
that she has never worked in critical care, it would specially trained nurses rotate to specialty units.
be unreasonable for the charge nurse to ask her to 2. If I rotate to an unfamiliar unit, what types of
perform invasive monitoring. nursing responsibilities must I assume?
Rule of personal liability. In the past, the nurse You will be expected to carry out only those nurs-
was expected to implement the physicians orders ing activities that you are competent to perform.
without question, and as the captain of the In some instances, this will be the performance of
ship, the physician was legally responsible for basic nursing care activities (eg, blood pressures)
these actions. However, the captain of the ship and uncomplicated treatments. If you are unfamil-
doctrine has largely been replaced by the rule of iar with the types of medications used on the unit,
personal liabilitythat is, nurses are expected to you should not be administering them until you are
make sound decisions by virtue of their special- thoroughly familiar with them.
ized education, training, and experience. If the 3. What should I do if I feel unprepared when I get
nurse is unsure about the propriety of a physi- to the unit?
cians order, the nurse must seek clarication Suggest that you assist the unit with basic nursing
from the physician. When questioning an order, care requirements and that specialized activities
the nurse rst shares his or her specic concerns (eg, invasive monitoring, cardiac monitoring, or the
with the physician who wrote the order. This fre- administration of unfamiliar drugs) be performed
quently results in an explanation of the order and by staff who are adequately prepared.
a medical justication for the order in the patients 4. What if the charge nurse orders me to do some-
medical record. If this approach is unsuccessful, thing I am not able to do safely?
the nurse follows the established chain of com- You are obligated to say you are unqualied and
mand for resolving the issue, per facility policy. request that another nurse carry out the task. The
Similarly, if a nurse is required to perform medi- charge nurse can be held liable for negligent super-
cal acts and is not under the direct and immediate vision if she orders you to do an unsafe activity and
supervision of a delegating physician, the activi- a patient injury results.
ties must be based on established protocols cre-
ated by the medical and nursing departments and
reviewed for compliance with state nurse practice
acts. In the event of a malpractice suit, the criti- hospitals provide information to adults about their
cal care protocols and procedures can be intro- rights concerning decision making in that state.
duced as evidence to help establish the applicable The material distributed must include informa-
standard of care. tion about the types of advance directives that are
legal in that state. Documentation that the patient
has received this information must be placed in
Laws Affecting Nursing Practice the medical record. If the patient is incapacitated
on admission, the information must be provided
Laws of particular applicability to the critical care
to a family member, if available.
nurse include the following:
Safe Medical Devices Act of 1990. A medical
Informed consent doctrine. In most instances, the device, dened as virtually anything used in patient
law requires that the patient be given enough infor- care that is not a drug, includes complex pieces of
mation before a treatment to make an informed, equipment (eg, intraaortic balloon pumps, pace-
intelligent decision. Usually, obtaining informed makers, debrillators), along with less complicated
consent from the patient or the family is the respon- ones (eg, endotracheal tubes, suture materials,
sibility of the physician, but the nurse is frequently restraints). Since 1976, medical devices have been
asked to witness signing of the consent form. By regulated by the U.S. Food and Drug Administration
witnessing the signing, the nurse is attesting that (FDA). The Safe Medical Devices Act of 1990
the signature on the consent form is the patients or requires user facilities to report to the manufacturer
the family members. medical device malfunctions that result in serious
Patient Self-Determination Act of 1991. This illness, injury, or death to a patient. Facilities are
federal statute is applicable to facilities that receive also required to report to the FDA medical devices
Medicare reimbursement for patient care. As a that result in a patients death. Nurses and other
condition of reimbursement, the law requires that staff are required to participate in reporting device

Morton_Chap04.indd 29 2/4/2012 2:24:47 PM

30 P A R T O N E The Concept of Holism Applied to Critical Care Nursing Practice

malfunctions, including those associated with user References

error, to a designated hospital department. There is
a duty not to use equipment that is patently defec- 1. American Nurses Association: Code of Ethics for Nurses
With Interpretive Statements. Washington, DC: American
tive. If the equipment suddenly ceases to do what it Nurses Publishing, 2001. Retrieved July 30, 2006, from
was intended to do, makes unusual noises, or has a
history of malfunction and has not been repaired, 2. AACN Position statement on Moral Distress. Revised
the hospital could be liable for damage caused by in 2008. American Association of Critical Care Nurses.
Retrieved from
it. Likewise, the nurse could be liable if he or she 3. Beckstrand R, Callister L, Kirchhoff K: Providing a good
knows or should know of these problems and uses death: Critical care nurses suggestions for improving end
the equipment anyway. of life care. Am J Crit Care 15(1):3845, 2006
Uniform Anatomical Gift Act. Every state in the 4. Council on Ethical and Judicial Affairs, American Medical
United States has a law based on the Uniform Association: Medical futility in end-of-life care. JAMA
281:937941, 1999
Anatomical Gift Act. The laws establish the legal- 5. The Organ Procurement and Transplantation Network:
ity of organ donation by patients and their families About transplantation. Retrieved July 28, 2006, from http://
and set procedures for making and accepting the
gift of an organ. Every state also has some provi-
sion to enable people to consent to organ dona-
tion using a designated place on a drivers license.
Many states have also enacted required request Want to know more? A wide variety of resources to enhance your learn-
laws, which seek to increase the supply of organs ing and understanding of this chapter are available on . Visit
for transplantation by requiring hospital person- to access chapter review
nel to ask patients families about an organ gift at questions and more!
the time of the patients death.

M r. R., a 62-year-old triathlete, was riding his
bicycle when he lost control and flipped over the
front, landing on the pavement headfirst. Mr. R.
was wearing a helmet. A bystander called 911.
When the paramedics arrived, they intubated Mr. R.
and transported him to the hospital, where he
was found to have a complete spinal cord injury
at the C2 level. Mr. R. was placed on mechanical
ventilation and will be ventilator dependent for the
rest of his life.
Mr. R. is awake and alert, and it has been
determined that he is able to make his own deci-
sions. During the course of Mr. R.s hospitaliza-
tion, patient/family conferences are held at regular
intervals so that the healthcare team, Mr. R., and
Mr. R.s family can discuss Mr. R.s status and
prognosis. After several weeks pass, Mr. R. states
that he wishes to be taken off the ventilator, even
though he is aware that this will result in his death.
Mr. R.s family members are supportive of him, and
they state that they will agree with any decision
Mr. R. makes. The physician is uncomfortable with
implementing Mr. R.s request to be removed from
the ventilator and refers Mr. R.s case to the ethics
1. What ethical dilemma does Mr. R.s case
2. Which of the ethical principles may be used to
resolve this dilemma?
3. What role does the nurse have in resolving this
ethical dilemma?

Morton_Chap04.indd 30 2/4/2012 2:24:47 PM

Essential Interventions
in Critical Care

Relieving Pain and Providing Comfort

Based on the content in this chapter, the reader should be able to:
1 Differentiate between acute and chronic pain.
2 Identify factors that exacerbate the experience of pain in the critically ill.
3 Prepare patients for the common sources of procedural pain in critical care.
4 Compare and contrast tolerance, physical dependence, and addiction.
5 Discuss national guidelines and standards for pain management.
6 Identify appropriate analgesics for high-risk critically ill patients.
7 Describe nonpharmacological interventions for alleviating pain and anxiety.

Pain is one of the most common experiences

and stressors in critically ill patients. Symptoms
Pain Defined
of critical illnesses as well as many interventions Pain is a complex, subjective phenomenon. The
and procedures in the critical care unit increase International Association for the Study of Pain
pain. Even though pain management has become denes pain as an unpleasant sensory and emo-
a national priority in recent years (Table 5-1), pain tional experience associated with actual or poten-
continues to be misunderstood, poorly assessed, tial tissue damage or described in terms of such
and undertreated in critical care units and many damage.1 An operational denition of pain is
other healthcare settings. Uncontrolled pain trig- based on the premise that the individual experienc-
gers physical and emotional stress responses, ing the pain is the true authority, pain is subjective
inhibits healing, increases the risk for other and that pain is whatever the experiencing person
complications, and increases the length of stay in says it is.
the critical care unit.


Morton_Chap05.indd 31 2/4/2012 2:31:41 PM

32 P A R T T W O Essential Interventions in Critical Care

TA B L E 5 - 1 National Standards and Guidelines Related to Pain Management

Agency or Source Standard or Guideline Content Highlights
Society of Critical Care Medicine Clinical Practice Guidelines for the The summary contains 28 explicit
(SCCM) and the American Sustained Use of Sedatives recommendations related to analgesia and
Society of Health-System and Analgesics in the Critically sedation targeted to the critically ill, including
Pharmacists (ASHP) Ill Adult (2002) the following:
Patient report is the most reliable standard for
pain assessment.
Scheduled doses or continuous infusions of
opioids are preferred over PRN regimens.
Sedation of agitated patients should be
provided only after providing adequate
American Geriatric Society The Management of Persistent Major recommendations include:
Pain in Older Persons All older persons should be screened for
persistent pain on admission to any health
care facility.
The verbal 0 to 10 scale is a good first choice
for assessment of pain intensity; however,
other scales such as word descriptor scales or
pain thermometers may be more appropriate
for some older patients.
For patients with cognitive impairment,
assessment of behaviors and family
observations are essential.
Opioid analgesic drugs are effective, with a
low potential for addiction, and may have fewer
long-term risks than other analgesic drugs.
American College of Cardiology/ Guidelines for Cardiovascular Guidelines that are relevant to painful conditions
American Heart Association Disease Management experienced by critically ill patients, including
Task Force on Practice chronic stable angina, unstable angina,
Guidelines peripheral arterial disease, ST-elevation
myocardial infarction, and coronary artery
bypass graft (CABG) surgery

The pain most critical care unit patients experience Factors Affecting Pain
is classied as acute because it has an identied cause
and is expected to resolve within a given time frame. Multiple factors inherent in the critical care unit
For example, the pain experienced during endotra- environment affect the patients pain experience
cheal suctioning or a dressing change can be expected (Box 5-1). The effects of each of these factors
to end when the treatment is completed. Similarly, increase when they are experienced together. For
pain at an incision or area of injury is expected to example, pain and anxiety exacerbate each other.
cease once healing has occurred. In contrast, chronic
pain is caused by physiological mechanisms that are Procedural Pain
less well understood. Chronic pain differs from acute
pain in terms of etiology and expected duration. It Efforts to provide pain relief and comfort mea-
may last for an indenite period and may be dif- sures are complicated by the fact that critical care
cult or impossible to treat completely. Many critical nurses must continuously perform procedures or
care unit patients, particularly those who are elderly, treatments that cause pain to the patient, such as
experience both acute and chronic pain. chest tube insertion and removal, wound debride-
ment, and even turning a patient in bed. Critical
care nurses must be attuned to the pain the patient
Pain in the Critically Ill is experiencing before the procedure to provide the
best interventions and guidance to help the patient
Previously it was thought that critically ill patients during the procedure. Before undergoing proce-
were unable to remember their painful experiences dures known to be associated with pain, patients
because of the acute nature of the illness or injury. should be premedicated, and the procedure should
Research demonstrates, however, that critical care be performed only after the medication has taken
unit patients do remember painful experiences, and effect. In addition, the nurse can use interventions
they frequently describe their pain as being moder- such as imagery, distraction, and family support
ate to severe in intensity.2 during procedures.

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Relieving Pain and Providing Comfort C H A P T E R 5 33

syndromes after discharge. Pain produces many

BOX 5-1 Factors Contributing to Pain and
harmful effects on the body that inhibit healing and
Discomfort in the Critically Ill
recovery from critical illness; these effects are sum-
Physical marized in Table 5-2 .
Illnesses and injuries treated in the critical care set-
ting (eg, myocardial infarction, thoracic and neuro-
surgery, multiple trauma, extensive burns) Promoting Effective Pain Control
Woundspost-trauma, postoperative, or
postprocedural Barriers to Effective Pain Control
Sleep disturbance and deprivation
Immobility, inability to move to a comfortable posi- Critical care nurses are often concerned that anal-
tion because of tubes, monitors, or restraints gesic administration for pain control may create
Temperature extremes associated with critical illness problems, such as hemodynamic and respiratory
and the environmentfever or hypothermia compromise, oversedation, or drug addiction. The
fear of addiction is one of the greatest concerns and
Psychosocial impediments associated with analgesia and pain
Anxiety and depression control. The differences between, and implications
Loss of control of, addiction, tolerance, and dependence are sum-
Impaired communication, inability to report and marized in Table 5-3.
describe pain
Fear of pain, disability, or death
Separation from family Patient and Family Education
Unfamiliar and unpleasant surroundings To balance pain control and risks of treatment,
Boredom or lack of pleasant distractions communication between nurse, patient, and family
Environment and Routine is essential. Emphasis is on the prevention of pain
Continuous noise from equipment and staff because it is easier to prevent pain than to treat it.
Continuous or unnatural patterns of light Patients need to know that most pain can be relieved
Awakening and physical manipulation every and that unrelieved pain may have serious conse-
1 to 2 hours for vital signs or positioning quences for physical and psychological well-being
Continuous or frequent invasive, painful procedures and may interfere with recovery. The nurse helps
Competing priorities in careunstable vital signs, patients and families understand that pain man-
bleeding, dysrhythmias, poor ventilationmay take agement is an important part of their care and that
precedence over pain management the healthcare team will respond quickly to reports
of pain.
The nurse discusses plans for pain management
The Older Patient. Be aware that arthritis, the most with patients when they are best able to understand,
common cause of chronic pain in older patients, can such as before surgery rather than during recovery.
increase the pain of turning in the ICU. Also, the patient needs a clear understanding of
any specialized pain management technology, such
as patient-controlled analgesia (PCA), to alleviate
Consequences of Pain the fear of overdosage. It is necessary to reinforce
this information during the course of therapy and
Patients who have a high level of uncontrolled encourage patients and family to verbalize ques-
pain during an acute hospitalization are at risk for tions and concerns. Box 5-2 provides key teaching
delayed recovery and development of chronic pain points for promoting effective pain control.

TA B LE 5- 2 Effects of Pain
System Effect Outcome
Cardiovascular Increased heart rate, blood pressure, Increases myocardial workload, thereby promoting or
contractility, vasoconstriction exacerbating ischemia
Pulmonary Splinting; decreased respiration; Increased incidence of pulmonary complications
reduced pulmonary volume and flow (eg, atelectasis, pneumonia)
Neurologic Increased anxiety and mental Delayed recovery; more pain
confusion; disturbed sleep
Gastrointestinal, Decreased gastric emptying and Impaired function; ileus; inhibits positive nitrogen balance
nutritional intestinal motility
Musculoskeletal Muscle contractions, spasms, and Inhibits movement and coughing and deep breathing, putting
rigidity patient at risk for complications of immobility
Immune Suppressed immune function Increases risk for pneumonia, wound infections, and sepsis

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34 P A R T T W O Essential Interventions in Critical Care

TA B L E 5 - 3 Tolerance, Physical Dependence, and Addiction

Definition Implication
Tolerance A state of adaptation in which exposure to a drug Increase dose by 50% and assess effect.
induces changes that result in a diminution of Tolerance to side effects, such as
one or more of the drugs effects over time respiratory depression, increases as the
dose requirement increases.
Physical dependence A state of adaptation that is manifested by a drug Gradually taper opioid dosage to
classspecific withdrawal syndrome that can discontinuation to avoid withdrawal
be produced by abrupt cessation, rapid dose symptoms.
reduction, decreasing blood level of the drug,
and/or administration of an antagonist
Addiction A primary, chronic, neurobiological disease, with Rarely seen in critical care patients, unless
genetic, psychosocial, and environmental factors patient is admitted for drug overdose
influencing its development and manifestations. or a history of drug abuse
It is characterized by behaviors that include
one or more of the following: impaired control
over drug use, compulsive use, continued use
despite harm, and craving.

Definitions from American Pain Society: Definitions related to the use of opioids for the treatment of pain.
Retrieved May 12, 2011, from opioids2.htm

Pain Assessment of pain. If the patient can communicate, the nurse

must accept the patients description of pain as valid.
The failure of healthcare providers to assess pain Behavioral and physiological manifestations of pain
and pain relief routinely is one of the most common are extremely individualized and may be minimal or
reasons for unrelieved pain in hospitalized patients.3 absent, despite the presence of signicant pain.
Assessment of pain is as important as any assessment In assessing pain quality, the nurse elicits a spe-
of the other body systems. The patient is assessed at cic verbal description of the patients pain, in
regular intervals to determine the presence of pain their own words, such as burning, crushing,
or breakthrough pain, the effectiveness of therapy, stabbing, dull, or sharp, whenever possible.
the presence of side effects, the need for dose adjust- These terms help pinpoint the cause of the pain.
ment, or the need for supplemental doses to offset The Older Patient. When assessing pain in an older
procedural pain. In critical care, assessment and patient, be aware of the following points:
treatment of the patients pain may be hindered by:
When reporting pain, an older patient may use
The acuity of the patients condition words such as aches or tenderness, rather than
Altered levels of consciousness pain.
An inability to communicate pain Some older patients can experience acutely
Restricted or limited movement painful conditions, such as myocardial infarction or
Endotracheal intubation appendicitis, without the presence of significant pain.
To perform an effective pain assessment, the critical
care nurse rst attempts to elicit a self-report from
the patient. Behavioral observation and changes in BOX 5-2 Promoting Safe and Effective
physiological parameters are considered along with Pain Control
the patients self-report.
Emphasize the importance of preventing pain before
Patient Self-Report it occurs or becomes severe.
Help patients and caregivers to understand the dif-
Because pain is a subjective experience, the patients ference between tolerance and addiction. This helps
self-report is considered the foundation of pain to ensure that fears of addiction do not impede nec-
assessment; however, family members and caregivers essary analgesic administration.
are often used as proxies for patients unable to self Discuss nonpharmacological interventions for mini-
report, which can pose signicant communication mizing pain (eg, splinting in incision area with a
barriers.3 A self-report or proxy assessment of pain pillow while coughing or ambulating).
should be obtained not only at rest, but also during Explain to caregivers the impact of analgesics on
routine activity, such as coughing, deep breathing, pain and respiratory status if theyre responsible for
and turning. In the conscious and coherent patient, administering PCA in the hospital or administering
behavioral cues or physiological indicators should medication after discharge.
never take precedence over the patients self-report

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Relieving Pain and Providing Comfort C H A P T E R 5 35

Pain scales and rating instruments based on the Contradictions in Pain Assessment
patients self-report provide a simple but consistent
measure of pain trends over time. Numerical rat- Occasionally, there may be discrepancies between the
ing scales and visual analog scales are used to mea- patients self-report and behavioral and physiological
sure pain intensity. With these scales, the patient is manifestations. For example, one patient may report
asked to choose a number, word, or point on a line pain as 2 out of 10, while being tachycardic, diapho-
that best describes the amount of pain he or she is retic, and splinting with respirations. Another patient
experiencing. The Society of Critical Care Medicine may give a self-report of 8 out of 10 while smiling.
(SCCM) clinical practice guideline suggests that These discrepancies can be due to the use of diver-
the numerical rating scale is the preferred type of sionary activities, coping skills, beliefs about pain, cul-
scale for use in critical care units.4 With this type tural background, fears of addiction, or fears of being
of scale, the patient is asked to rate the pain, with 0 bothersome to the nursing staff. When these situations
being no pain and 10 being the worst possible pain occur, they are discussed with the patient, and any
imaginable. misconceptions or knowledge decits are addressed.
Pictures or word boards can also facilitate com-
munication about the patients pain. The board
should include open-ended questions, such as Do Pain Intervention
you have pain?, Where is the pain located?,
How bad is your pain?, and What helps your Although pharmacological intervention is the most
pain? commonly used strategy, nursing management of pain
also includes physical, cognitive, and behavioral mea-
Observation sures. In addition to administering medications or pro-
viding alternative therapies, the nurses role involves
Research has demonstrated that nurses can rely on measuring the patients response to those therapies.
behavioral and physiological indicators of pain in
critically ill patients who cannot provide a verbal
self-report.3 Patients who are unable to speak may Pharmacological Interventions
use eye or facial expressions or movement of hands Most drug therapy regimens that nurses use in the
or legs to communicate their pain. Additionally, critical care setting include a combination of nonopi-
protective behaviors (eg, guarding, avoidance of oid analgesics, opioids, and sometimes anxiolytics or
movement, touching or rubbing the area, chang- sedatives. Use of these drugs is explained in the sec-
ing positions, muscular bracing) are suggestive of tions that follow; examples, mechanisms of action,
pain. Other nonverbal behaviors such as frowning, and special considerations are outlined in Table 5-4 .
grimacing, clenching the teeth, tightly closing the
eyes, and exhibiting restlessness and agitation can
indicate pain as well. Nonopioid Analgesics
Input from family members or other caregivers Ideally, analgesic regimens should include a nono-
is helpful in interpreting specic behavioral mani- pioid drug, even if the pain is severe enough to also
festations of pain based on their knowledge of the require an opioid. In many patient populations, non-
patients behavior before hospitalization. steroidal anti-inammatory drugs (NSAIDs) are the
preferred choice for the nonopioid component of
analgesic therapy. NSAIDs decrease pain by inhibit-
Physiological Parameters ing the synthesis of inammatory mediators (pros-
The observation of the physiological effects of pain taglandin, histamine, and bradykinin) at the site of
assists to some extent in pain assessment; how- injury and effectively relieve pain without causing
ever, much like nonverbal cues, the physiological sedation, respiratory depression, or problems with
response to pain is highly individualized. Vital signs, bowel or bladder function. When NSAIDs are used
such as heart rate, blood pressure, and respiratory in combination with opioids, the opioid dose can
rate, may increase or decrease in the presence of often be reduced and still produce effective analge-
pain. Additionally, it can be difcult to attribute sia. This decreases the incidence of opioid-related
these physiological changes specically to pain side effects.
rather than to other causes. For example, an unex- Many NSAIDs are supplied only in oral forms but
pected increase in the severity of the patients pain this is not satisfactory in many critically ill patients
may cause hypotension and tachycardia but could whose oral intake is restricted. In addition to the
also signal the development of life-threatening com- concerns about route of administration, a major con-
plications, such as wound dehiscence, infection, cern associated with NSAID use is the potential for
or deep venous thrombosis. The absence of physi- adverse effects, including gastrointestinal bleeding,
ological or behavioral cues should never be inter- platelet inhibition, and renal insufciency. Second-
preted as absence of pain. If the procedure, surgery, generation NSAIDs are more selective in their site
or condition is believed to be associated with pain, of action and therefore do not cause these harmful
the presence of pain should be assumed and treated adverse effects, but their slow onset of action may
appropriately. decrease their utility in critically ill patients.

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36 P A R T T W O Essential Interventions in Critical Care

TA B L E 5 - 4 Medications Used in Pain Management

Medication Mechanism of Action Nursing Considerations
Acetaminophen Inhibit prostaglandins Lacks anti-inflammatory action
Avoid use in patients with liver or kidney disease
Doses exceeding 4000 mg/d increase risk for hepatic
Perform routine liver and renal profile testing for patients
on a continuous, high-dose regimen
Aspirin Inhibit prostaglandins and Adverse effects include gastrointestinal or postoperative
thromboxanes bleeding
Contraindicated in patients with bleeding ulcers,
hemorrhagic disorders, asthma, and renal insufficiency
NSAIDs Inhibits prostaglandin synthesis Adverse effects include gastrointestinal bleeding,
Ibuprofen (Motrin) by inhibiting the action of the platelet inhibition, and renal insufficiency
Naproxen (Naprosyn) enzyme cyclooxygenase, Avoid use in patients with liver or renal disease
Celecoxib (Celebrex) which is responsible for Perform routine liver and renal profile testing for patients
prostaglandin synthesis on a continuous, high-dose regimen
Opioid analgesics Bind to receptor sites in the Adverse effects include respiratory depression,
Morphine central and peripheral oversedation, constipation, urinary retention, and
Fentanyl nervous system, changing nausea
Hydromorphone the perception of pain IV administration is usually the preferred route
(Dilaudid) Older patients are often more sensitive to the effects of
Codeine opioids
Methadone (Dolophine) Patients and families need education about tolerance
Oxycodone and the risk of dependence
Local anesthetics Act synergistically with Adverse effects include CNS excitation, drowsiness,
Bupivacaine intraspinal opioids and block respiratory depression, apnea, hypotension,
Chloroprocaine pain by preventing nerve cell bradycardia, arrhythmias, and/or cardiac arrest
depolarization Commonly administered by the epidural route in
combination with epidural or intrathecal analgesia
Antiemetics Antagonizes central and Adverse effects include hypotension, restlessness,
Promethazine peripheral H1 receptors tremors, and extrapyramidal effects in the older patient
Hydroxyzine In high doses, can create auditory and visual
hallucinations causing panic and intense fear
During long-term therapy, monitor blood cell counts,
liver function studies; perform electrocardiogram and
Opioid antagonists Antagonizes various opioid Administering the drug too quickly or giving too much
Naloxone receptors can precipitate severe pain, withdrawal symptoms,
Naltrexone tachycardia, dysrhythmias, and cardiac arrest; patients
who have been receiving opioids for more than a week
are particularly at risk
Drug should be diluted and given intravenously, very
Monitor for acute withdrawal syndrome patients who are
physically dependent on opioids, or who have received
large doses of opioids
Benzodiazepines Increase the efficiency of a Adverse effects include phlebitis, acidosis, renal
Diazepam natural brain chemical, failure, prolonged wakening and delayed weaning from
Lorazepam GABA, to decrease the ventilator, and pain on injection site
Midazolam excitability of neurons Monitor the patient for oversedation and respiratory
Commonly administered intravenously
Benzodiazepine-specific Antagonizes benzodiazepine Adverse effects include CNS manifestations,
reversal agent receptors re-sedation, cardiovascular effects, seizures, and
Flumazenil alterations in intracranial pressure and cerebral
perfusion pressure
Re-sedation may occur within 12 h after administration,
so repeated doses or a continuous infusion may be
required to maintain therapeutic efficacy
Sedative-hypnotic Adverse effects include low blood pressure, apnea, and
Propofoli pain at the injection site
Monitor the patients blood pressure
Contraindicated in patients allergic to eggs or soy

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Relieving Pain and Providing Comfort C H A P T E R 5 37

Opioid Analgesics Medications should be titrated based on the

patients response, and the drug should be quickly
Opioids are the pharmacological cornerstone of
eliminated when analgesia is no longer needed.
postoperative pain management. They provide pain
Most clinicians agree that when using a numerical
relief by binding to various receptor sites in the spi-
scale for assessment, pain medications should be
nal cord, central nervous system (CNS), and periph-
titrated according to the following goals:
eral nervous system, thus changing the perception
of pain. The patients reported pain score is less than his
Opioids are selected based on individual patient or her own predetermined pain management goal
needs and the potential for adverse effects. According (eg, 3 on a scale of 1 to 10).
to the SCCM, morphine sulfate, fentanyl, and hydro- Adequate respiration is maintained.
morphone are the preferred agents when IV opioids
are needed.4 Other opioids used in critical care Because pain may diminish or the pain pattern may
include codeine, oxycodone, and methadone. Even change, therapy adjustments may be needed before
though meperidine continues to be widely used in improvements are seen. Pain reassessment should
some settings, national experts and national prac- correspond to the time of onset or peak effect of the
tice guidelines consider it to be dangerous and do drug administered and the time the analgesic effect
not recommend it for most patients.4 is expected to dissipate. Response to therapy is best
The efcacy of analgesia depends on the pres- measured as a change from the patients baseline
ence of an adequate and consistent serum drug pain level.
level. Although opioids may be administered on an Administration
as needed (PRN) basis, the PRN order poses many The two most commonly used routes for opioid
barriers to effective pain control. Per the PRN order, administration in the critical care setting are the
the nurse administers a dose of analgesic only when intravenous route and the spinal route. Other routes
the patient requests it and only after a certain time that are less commonly used in the critical care set-
interval has elapsed since the previous dose. Usually, ting are reviewed in Box 5-3 .
delays occur between the time of the request and
the time the medication is actually administered.
PRN orders also pose a problem when the patient
is asleep. As serum drug levels decrease, the patient BOX 5-3 Less Commonly Used Methods of
may be suddenly awakened by severe pain, and a Administering Opioids in the Critical
greater amount of the drug is needed to achieve Care Setting
adequate serum levels. For these reasons, scheduled
opioid doses or continuous infusions are preferred Oral route. The oral route is used infrequently in
over PRN administration. the critical care setting because many patients are
unable to take anything by mouth. Serum drug levels
Dosing Guidelines obtained after oral administration of opioids are vari-
Opioid dosage varies depending on the individ- able and difcult to titrate. In addition, the transfor-
ual patient, the method of administration, and mation of oral opioids by the liver causes a signicant
the pharmacokinetics of the drug. Adequate pain decrease in serum levels.
relief occurs once a minimum serum level of the Rectal route. The rectal route has many of the same
opioid has been achieved. The dosing and titra- disadvantages as the oral route, including variability
tion of opioids must be individualized, and the in dosing requirements, delays to peak effect, and
patients response and any undesirable effects, unstable serum drug levels.
such as respiratory depression or oversedation, Transdermal route. The transdermal route is used
must be closely assessed. If the patient has previ- primarily to control chronic cancer pain because it
ously been taking opioids prior to admission, doses takes 12 to 16 hours to obtain substantial therapeutic
should be adjusted above the previous required effects and up to 48 hours to achieve stable serum
dose to achieve an optimal effect. Factors such as concentrations. If used for acute pain, such as postop-
age, individual pain tolerance, coexisting diseases, erative pain, high serum concentrations may remain
type of surgical procedure, and the concomitant after the pain has subsided, putting the patient at risk
use of sedatives warrant consideration as well. for respiratory depression.17
Appropriate dosing and titration can be difcult Intramuscular route. The intramuscular route
because many critically ill patients have hepatic or should not be used to provide acute pain relief for the
renal dysfunction that result in decreased metabo- critically ill patient. Intramuscular drug absorption
lism of the opioid. is extremely variable in critically ill patients, due to
alterations in cardiac output and tissue perfusion. In
The Older Patient. Older patients are often more addition, intramuscular injections are painful.
sensitive to the effects of opioids because in older Subcutaneous route. In some situations, venous
people, opioids achieve higher peak concentrations access may be limited or impossible to obtain. When
and have a longer duration of effect. Decreasing the this occurs, continuous subcutaneous infusion and
initial opioid dose and slow titration are subcutaneous PCA may be used.
recommended for older patients.

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38 P A R T T W O Essential Interventions in Critical Care

IV Administration. IV opioids have the most between the dura mater and vertebral arch. Opioids
rapid onset and are easy to administer. Intermittent diffuse across the dura and subarachnoid space and
IV injections may be used when the patient requires bind with opioid receptor sites. Epidurals may take
short-term acute pain relieffor example, during pro- the form of:
cedures such as chest tube removal, diagnostic tests,
Intermittent injections given before, during, or
suctioning, or wound care. Continuous IV adminis-
after a surgical procedure
tration has many benets for critically ill patients,
Continuous epidural infusions, which are recom-
especially those who have difculty communicating
mended for more sustained pain relief
their pain because of an altered level of consciousness
Patient-controlled epidural analgesia (PCEA),
or an endotracheal tube. Continuous IV infusions are
which uses the same parameters as IV PCA except
easily initiated and maintain consistent serum drug
in smaller doses
levels compared to intermittent IV injections, which
can cause serum levels to uctuate. When a patient Although the incidence of serious respiratory
is receiving continuous IV infusions, pain occur- depression is extremely low with epidural analge-
ring during painful procedures may not be managed sia, respiratory assessments should be performed
unless additional IV bolus injections are given. hourly during the rst 24 hours of therapy and
PCA is an effective method of pain relief for the every 4 hours thereafter. In addition, because epi-
critically ill patient who is conscious and able to dural analgesia is invasive, the patient must be
participate in pain management therapy. With PCA, closely monitored for signs of local or systemic
the patient self-administers small, frequent IV anal- infections. The insertion site is covered with a ster-
gesic doses using a programmable infusion device. ile dressing, and the catheter is taped securely. To
The PCA device limits the opioid dose within a spe- avoid accidental injection of preservative-contain-
cic time period, thus preventing oversedation and ing medications (which can be neurotoxic), the epi-
respiratory depression. PCA produces good-quality dural catheter, infusion tubing, and pump must be
analgesia, stable drug concentrations, less sedation, clearly marked.
less opioid consumption, and fewer adverse effects.4
PCA individualizes pain control therapy; and offers Intrathecal Analgesia. With intrathecal analge-
the patient greater feelings of control and well-being. sia, the opioid is injected into the subarachnoid
space, located between the arachnoid and pia mater.
Spinal Administration. Spinal opioids selec- Intrathecal opioids are signicantly more potent
tively block opioid receptors while leaving sensation, than those given epidurally; therefore, less medica-
motor, and sympathetic nervous system function tion is needed to provide effective analgesia. The
intact, resulting in fewer opioid-related side effects. intrathecal method is usually used to deliver a one-
Analgesia from spinal opioids has a longer dura- time dose of analgesic, such as before surgery, and is
tion than other routes, and signicantly less opioid infrequently used as a continuous infusion because
is needed to achieve effective pain relief. Opioids of the risk for CNS infection.
can be given as a single injection in the epidural or
intrathecal space, as intermittent injections, as con- Side Effects
tinuous infusions through an epidural catheter, or Opioids cause undesirable side effects, such as
through epidural PCA. With epidural or intrathe- constipation, urinary retention, sedation, respira-
cal analgesia, a local anesthetic can be added to the tory depression, and nausea. These are managed in
continuous opioid infusion. Less opioid is needed many ways, including decreasing the opioid dose,
to provide effective analgesia when used in combi- avoiding PRN dosing, and adding other medications
nation with local anesthetics, and the incidence of to supplement opioid doses or to counteract opioid
opioid-related side effects is decreased. side effects. However, medications commonly pre-
scribed to treat opioid-related adverse effects, such
Epidural Analgesia. Epidural analgesia is noted as antiemetics for nausea, can cause other adverse
for providing effective pain relief and improved post- effects, such as hypotension, restlessness, and
operative pulmonary function. In a classic study, tremors.
patients whose pain was controlled with epidural Respiratory depression, a life-threatening com-
anesthesia and epidural analgesia had shorter criti- plication of opioid administration, is often a con-
cal care unit stays, shorter hospital stays, and half as cern. However, the incidence of true opioid-induced
many complications as patients receiving standard respiratory depression is low in most patients.
anesthesia and analgesia.5 In some cases, a respiratory rate as low as 10 breaths/
This method is especially benecial for critically min may not be signicant if the patient is still
ill patients after thoracic, upper abdominal, or breathing deeply.
peripheral vascular surgery; postoperative patients
with a history of obesity or pulmonary disease; and RED FLAG! Patients most at risk for respiratory
patients with rib fractures or orthopedic trauma. depression are elderly people who have not recently
Contraindications to epidural analgesia include sys- used opioids and patients with coexisting pulmonary,
temic infection or sepsis, bleeding disorders, and renal, or hepatic disease.
increased intracranial pressure (ICP).
With epidural analgesia, opioids are adminis- If serious respiratory depression does occur, an
tered through a catheter inserted in the spinal canal opioid antagonist can be administered to reverse

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Relieving Pain and Providing Comfort C H A P T E R 5 39

the adverse effects of the opioid. Antagonists are to minimize noise and disruptions during normal
titrated to effect, which means reversing the overse- sleeping hours and to create a pattern of light that
dation and respiratory depression, not reversing mimics normal daynight patterns. Earphones, with
analgesia. This usually occurs within 1 to 2 minutes. music of the patients choosing, and earplugs have
After administering an antagonist, the nurse also been recommended for use in the critical care
continues to observe the patient closely for overseda- unit.8
tion and respiratory depression because the half-life
of antagonists is shorter than that of most opioids. Distraction
Distraction helps patients direct their attention
Sedatives and Anxiolytics away from the source of pain or discomfort toward
Acute pain is frequently accompanied by anxiety, something more pleasant. Initiating a conversation
which can increase the patients perception of pain. with the patient during an uncomfortable proce-
When treating acute pain, anxiolytics and hypnotics dure, watching television, and visiting with family
can be used to complement analgesia and improve are all excellent sources of distraction.
the patients overall comfort.
Anxiolytics Relaxation Techniques
Anxiolytic medications (eg, benzodiazepines) con- Relaxation exercises involve repetitive focus on a
trol anxiety and muscle spasms and produce amne- word, phrase, prayer, or muscular activity, and a
sia for uncomfortable procedures. Because these conscious effort to reject other intruding thoughts.
medications have no analgesic effect (except for con- Most relaxation methods require a quiet environ-
trolling pain caused by muscle spasm), an analgesic ment, a comfortable position, a passive attitude, and
must be administered concomitantly to relieve pain. concentration.
If an opioid and benzodiazepine are used together, Breathing exercises have been used with much
the doses of both medications are usually reduced success in critically ill patients. The quieting reex is
because of their synergistic effects. The patient a breathing technique that requires only 6 seconds
must also be closely monitored for oversedation and to complete, calms the sympathetic nervous system,
respiratory depression. and gives the patient a sense of control over stress
An advantage of benzodiazepines is that they are and anxiety. The nurse teaches the patient to per-
reversible agents. If respiratory depression occurs form the following steps frequently during the day:
because of benzodiazepine administration, benzodi-
azepine-specic reversal agents can be administered 1. Inhale an easy, natural breath.
intravenously. These drugs are given reverse the 2. Think alert mind, calm body.
sedative and respiratory depressant effects without 3. Exhale, allowing the jaw, tongue, and shoulders to
reversing opioid analgesics. go loose.
Critically ill patients who are receiving repeated 4. Allow a feeling of warmth and looseness to go
doses or continuous infusions of benzodiazepines down through the body and out through the
are given a break from sedation at least once per day. toes.
Administration should be interrupted until the patient
is fully awake. This helps prevent oversedation, which Touch
can inhibit weaning from mechanical ventilation. Touch has a positive effect on perceptual and cog-
Hypnotics nitive abilities and can inuence physiological
With appropriate airway and ventilatory manage- parameters, such as respiration and blood ow.
ment, hypnotics can be an ideal agent for patients Additionally, touch has played a major part in
requiring sedation during painful procedures. promoting and maintaining reality orientation in
Because of their ultrashort half-life, they are revers- patients prone to confusion about time, place, and
ible simply by discontinuing the infusion, and personal identication. Nursing touch may be most
patients awaken within a few minutes. They also helpful in situations in which people experience
can be used as a continuous infusion for mechani- fear, anxiety, depression, or isolation.
cally ventilated patients who require deep, pro-
longed sedation. The Older Patient. Older patients often have
an increased need for meaningful touch during
episodes of crisis.
Nonpharmacological Comfort Measures
Research has shown that the combination of non-
pharmacological and pharmacological interven- Massage
tions provides better pain control, with less use of Supercial massage initiates the relaxation response
opioid analgesics, decreased incidence of anxiety, and has been shown to increase the amount of sleep
and increased patient satisfaction.6,7 in critical care patients.9 Hands, feet, and shoulders
are good sites for massage in critically ill patients,
Environmental Modification because the back is less accessible. Family members
Environmental modications can help to minimize who wish to provide comfort to a critically ill loved
anxiety and agitation. Care should be preplanned one can be taught the technique of massage.

Morton_Chap05.indd 39 2/4/2012 2:31:43 PM

40 P A R T T W O Essential Interventions in Critical Care

2. Puntillo KA, Morris AB, Thompson CL, et al.: Pain behav-

CA SE STUDY iors observed during six common procedures: Results from
Thunder Project II. Crit Care Med 32(2):421427, 2004
M r. B., a 28-year-old man, is admitted to 3. National Cancer Institute: Pain (PDQ). Retrieved September
1, 2007, from
the critical care unit. with multiple orthopedic and supportivecare/pain/HealthProfessional/page1
abdominal injuries sustained in a motorcycle 4. Jacobi J, Fraser G, Coursin D, et al.: Clinical practice guide-
accident. During his third day in the critical care lines for the sustained use of sedatives and analgesics in the
unit., he continues to describe his pain as intoler- critically ill adult. Crit Care Med 30(1):119141, 2002
5. Yeager MP, Glass DD, Neff RK, et al.: Epidural anesthesia
able and says it is not relieved by the combination and analgesia in high-risk surgical patients. Anesthesiology
of oxycodone and acetaminophen that he receives 66(6):729736, 1987
every 4 hours. He is grimacing and continuously 6. Weintraub M, Mamtani R, Micozzi M: Complimentary
asking for more medication before the scheduled and Integrative Medicine in Pain Management. Springer
Publishing, 2008
dosage interval. The medical resident is frustrated 7. Khatta M. A complimentary approach to pain management.
by Mr. B.s frequent requests and has advised Topics Adv Pract Nurs 7(1), 2007
the nurses to be conservative in medicating him 8. Schartz F. Pilot study of patients in postoperative cardiac
because of his history of drug and alcohol abuse. surgery. Music Med 1(1):7074, 2009
9. Mitchinson A, et al. Acute postoperative pain management
1. What might be major concerns of the nurse car- using massage as an adjuvant therapy: a randomized trial.
ing for Mr. B.? Arch Surg 142(12):11581167, 2007
2. How could the nurse advocate for Mr. B.?
3. How could the nurse determine whether Mr. B. is
seeking drugs for illicit purposes rather than for Want to know more? A wide variety of resources to enhance your learn-
relief of pain? ing and understanding of this chapter are available on . Visit
4. What approach could the nurse take to convince to access chapter review
the medical resident to consider a different anal- questions and more!
gesic regimen?

1. International Association for the Study of Pain: Pain
Terminology. Retrieved August 28, 2007, from http://www.
=/ CM/HTMLDisplay.cfm&ContentID=3088#Pain

Morton_Chap05.indd 40 2/4/2012 2:31:43 PM

End-of-Life and Palliative Care

Based on the content in this chapter, the reader should be able to:
1 Describe how the integration of palliative care principles into critical care is
essential to providing end-of-life care in the critical care setting.
2 Identify common symptoms experienced at the end of life and appropriate
measures to address them.
3 Explain the role of advance directives in facilitating end-of-life care.
4 Explain how effective communication among caregivers, patients, and family
members can facilitate end-of-life care.
5 Explain aspects of family-centered care that are important during the end-of-
life period.
6 Identify strategies caregivers can use for managing their own grief.

T echnology, urgency, uncertainty, and conict are

common in critical care practice. These characteristics

Symptom management
Advanced care planning
may inhibit or fragment a coordinated effort that aims Family-centered care
to provide good end-of-life care.1 Critical care nurses Emotional, psychological, social, and spiritual care
play an important role in recognizing opportunities for Facilitating communication
interventions that support patients, families, and other Awareness of ethical issues
staff members during the difcult transition period Caring for the caregiver
between life and death. Being with patients and fam-
In critical care nursing, it is vital to take an inter-
ilies in addition to doing things to them enables criti-
disciplinary approach to incorporating these core
cal care nurses to provide the holistic care that is central
palliative care principles into the patients daily plan
to nursing.1
of care. Incorporating palliative care services into
The introduction of palliative care principles into
critical care leads to improved symptom manage-
critical care practice can provide a framework to
ment, enhanced family support, reduced lengths of
address end-of-life issues. Palliative care improves
hospital stays, increased discharges to home with
the quality of death and dying for patients and
hospice referrals, and reduced costs.3 The American
their families by addressing aspects of care that
Association of Critical-Care Nurses protocols for
are unrelated to disease-specic treatments, cure,
critical care practice in palliative and end-of-life care
or rehabilitation. According to the World Health
provide a good overview of core issues and clinical
Organization,2 palliative care includes the following
recommendations for critical care nurses.4
interdisciplinary core principles:

Morton_Chap06.indd 41 2/4/2012 2:32:19 PM

42 P A R T T W O Essential Interventions in Critical Care

Symptom Management symptomatic relief can also be provided by sur-

gery (to relieve the obstruction) or placement of a
Common symptoms at the end of life include the nasogastric tube or draining percutaneous endo-
following. scopic gastrostomy tube.

Pain. The underlying disease pathology, proce- Assessing for the presence of symptoms and work-
dures, and interventions are all sources of pain in ing collaboratively to intervene and provide relief is
the dying patient. The assessment and manage- crucial in providing good end-of-life care. If symp-
ment of pain is discussed in Chapter 5. toms are intractable and cannot be relieved despite
Dyspnea. Causes of dyspnea include the underly- appropriate interventions, end-of-life (terminal)
ing disease pathology; anxiety; and environmental sedation may be considered. End-of-life sedation is
issues (eg, feeling crowded). Common interven- used when the patient is experiencing unbearable
tions used for dyspnea include oxygen, opioids, and unmanageable pain or other symptoms and is
and anxiolytics. Nonpharmacological interven- approaching the last hours or days of life.5 The goal
tions such as reducing the room temperature (but of end-of-life sedation is to produce a level of obtun-
not chilling the patient), reducing the number of dation sufcient to relieve suffering without hasten-
people in the room at one time, keeping an unob- ing death.5 Before end-of-life sedation is considered,
structed line of sight between the patient and the specialists in other disciplines (eg, pain, palliative
outside environment, and using a fan to blow air care, social services, chaplaincy services, mental
gently across the patients face have all been found health) are consulted to verify that all therapies have
to be effective in decreasing dyspnea. been attempted without success.
Anxiety and agitation. Anxiety can be related
to any number of physical, emotional, psycho-
logical, social, practical, and spiritual issues. Advanced Care Planning
Nonpharmacological interventions may include
counseling, taking care of practical matters (eg, Advanced care planning involves making the nec-
arranging for the care of a pet), and facilitating essary arrangements so that a persons preferences
resolution of spiritual concerns (eg, arranging for for end-of-life care are known and can be followed
a visit from a clergy member). If medication is should the person become unable to make deci-
needed, short- or long-acting benzodiazepines and sions or communicate her wishes regarding care at
antidepressants may be helpful. Additional inter- a later time.
ventions for anxiety are discussed in Chapter 2,
Box 2-1. Advance Directives
Depression. It is a myth that depression is nor-
mal at the end of life. If feelings of depression Advance directives are written or oral instructions
persist, appropriate treatment (eg, supportive psy- about future medical care that are to be followed in
chotherapy, cognitive-behavioral therapy, antide- the event that the person loses the capacity to make
pressants) must be initiated. decisions. Advance directives can be revised, orally
Delirium. Delirium is an acute change in aware- or in writing, at any time. Each state regulates the
ness or cognitive status that may manifest as use of advance directives differently.
agitation, withdrawal, confusion, inappropri- Types of advance directives include living wills
ate behavior, disorientation, or hallucinations. and durable powers of attorney for healthcare (used
Terminal delirium is common in patients near to specify a person, called a healthcare proxy, sur-
death and may manifest as daynight reversal. rogate decision maker, or healthcare agent, who is
Management of delirium during the end-of-life authorized to make decisions on behalf of the patient
care is focused more on symptom control and in the event that the patient cannot make decisions
relief of the patients and familys distress than on for himself or herself). The designation of a person
diagnosis and treatment of the underlying cause as a healthcare proxy must be in written form and
of the delirium. Benzodiazepines or neurolep- should always be up to date. The proxy should know
tics (eg, haloperidol) may be used for symptom the preferences of the patient and be able to commu-
control. nicate and adhere to those preferences.
Nausea and vomiting. Causes of nausea and When a patient arrives on the unit, the nurse
vomiting may include physiological factors (eg, determines if the patient has made an advance direc-
intestinal obstruction, constipation, pancreatitis, tive, and if so, obtains a copy to place in the patients
metabolic disturbances, increased intracranial chart. If the patient does not have an advanced
pressure); emotional factors; treatment-related directive but is currently able to make autonomous
factors (eg, chemotherapy); and vestibular distur- decisions, the nurse seeks to determine the patients
bances. A careful assessment of the source of nau- wishes regarding end-of-life care. If the patient is
sea and vomiting is important in determining the unable to make decisions or communicate, then the
appropriate management. Many classes of drugs next of kin is used as the proxy for healthcare deci-
are used to provide symptomatic relief. If intesti- sions. The order for determining next of kin is legal
nal obstruction is causing nausea and vomiting, guardian, spouse, adult children, parents, adult

Morton_Chap06.indd 42 2/4/2012 2:32:21 PM

End-of-Life and Palliative Care C H A P T E R 6 43

siblings, other adult relatives, and close friends who the familys mind, the opposite of everything is
are familiar with the patients activities and beliefs. nothing. It is also important to clearly dene terms
to ensure understanding and avoid ambiguous lan-
guage. For example, to the nurse everything might
Do Not Resuscitate and Do Not Attempt include aggressive interventions, whereas to a fam-
Resuscitation Orders ily member everything may include only those
interventions that provide comfort and pain relief.
The standard of care for patients who experience car-
A seven-step approach has been suggested to help
diac or respiratory arrest is to initiate cardiopulmo-
negotiate goals in caring for patients5:
nary resuscitation (CPR). The immediate intervention
to preserve life without the express consent of the 1. Create the proper setting. Sit down, ensure pri-
patient is supported by the principle of benecence. vacy, and allow adequate time.
However, patients can request that resuscitation not 2. Determine what the patient and family know. Clarify
be attempted, especially when death is imminent the current situation and the context in which deci-
and inevitable. Do not resuscitate (DNR) and do not sions about goals of care should be made.
attempt resuscitation (DNAR) orders are orders placed 3. Explore what the patient and family are expect-
by a physician, most often with the consent of the ing or hoping for. Understanding these hopes and
patient or the healthcare proxy, to alert caregivers that expectations will assist the nurse in tailoring com-
if the patient experiences cardiac or respiratory arrest, munication and reorienting families to what is or
no attempts to restore cardiac or pulmonary function might be possible.
should occur. The order is written, signed, and dated 4. Suggest realistic goals. To assist with decision
by the responsible physician and is reviewed periodi- making, share your knowledge about the patients
cally (eg, every 24 to 72 hours) per facility policy. illness, its natural course, the experience of
patients in similar circumstances, and the effects
RED FLAG! It is important to recognize that that contemporary healthcare may have. Work
DNR and DNAR orders do not mean do not give through unreasonable or unrealistic expectations.
appropriate care. Although resuscitation efforts 5. Respond empathically to the emotions that may
should not be initiated for a patient with a DNR or arise.
DNAR order, the patient should continue to receive 6. Make a plan and follow through with it.
appropriate medical and nursing care throughout the 7. Review and revise the goals and treatments as
duration of the hospitalization. appropriate.

RED FLAG! If an arrest occurs in a situation in

which a formal DNR decision has not been made Delivering Bad News
and written, the presumption of the medical and Critical care nurses must develop effective strategies
nursing staffs should be in favor of life, and a code for delivering bad news. Bad news can range from
should be called. A slow code (one in which the reporting that a patient is not responding positively
nurse takes excessive time to call the code, or the to an intervention to telling a family member that a
healthcare team takes an excessive time to respond patient has died. Keeping an honest and open line
to it) is never permissible. of communication is essential to preserve the trust
of the patient and family. Because nurses are at the
bedside 24 hours a day, communicating with fami-
Communication and End-of-Life Care lies early that a patient is not doing well may help
avoid a surprise announcement of the patients
Communication among the healthcare team, the death. Bad news should be phrased in a way that
patient, and family is an important aspect of caregiv- clearly indicates that the patient is not doing well
ing in critical care, especially at the end of life. Good but the healthcare team is doing its best to help the
communication facilitates a better understanding of patient. If discussions regarding withholding or
how to care for the patient and family and fosters withdrawing life-sustaining measures become nec-
an environment that supports the physical and psy- essary, the family may be more receptive because
chosocial needs of the patient, family, and providers. they are more aware of the situation.
Notifying the family members that the patient
Establishing Treatment Goals and has died is a special case of delivering bad news.
Priorities Measures such as being prepared to answer ques-
tions about the patients death, using the persons
Establishing treatment goals and priorities is essen- name (instead of the patient or the deceased),
tial to facilitating decision making with regard and being available to provide support can have
to care. The way in which options are presented a positive impact on how the family members
can inuence the decisions the patient and family remember the last moments of the patients life.
make. For example, if a nurse asks Do you want Becoming comfortable with the wording of the
the healthcare team to do everything for your loved message (eg, by practicing phrases before they are
one? it sets the family up for a yes answer. In needed) allows the nurse to focus on the family and

Morton_Chap06.indd 43 2/4/2012 2:32:21 PM

44 P A R T T W O Essential Interventions in Critical Care

their reaction to the message, instead of the message Withholding or Withdrawing Life-
itself and how that message is delivered.
Sustaining Measures
When it becomes clear to the family and healthcare
Family-Centered Care providers that additional treatment will not be
benecial, the decision may be made to withdraw
Serious illness affects not only the patient but also life-support methods (eg, mechanical ventilation,
the family. hemodialysis, tube feeding). The healthcare system
requires that patients and their proxy decision mak-
Visitation ers be active in making decisions about healthcare
treatment. However, at times, the healthcare team
To the greatest extent possible, families should be tries to place the responsibility for making a cru-
free to visit a patient who is near death. The ability cial decision, such as withdrawing treatment, on
to see, touch, and communicate with the patient is the family. It is important to remember that fam-
reassuring for both the patient and family. During ily members are not healthcare professionals. Even
this period of closure, cultural or spiritual ceremo- when family members are healthcare professionals,
nies may also take place. The nurse seeks to facilitate they are family members rst and healthcare profes-
visitation while taking into consideration the physi- sionals second, and they may make decisions based
cal and emotional needs of the patient, as well as the more on their relationship with the patient than
patients wishes. For example, the nurse must also on sound medical or nursing decisions. The best
be alert to signs from the patient (eg, agitation) that approach is to help the family understand the ben-
a particular family member is unwelcome. If there ets and drawbacks of continuing treatment and to
is tension among certain family members, a visiting make the decision jointly. When the decision is made
schedule may need to be established to allow family to withdraw a therapy, measures are taken to reduce
members to see the patient without crossing paths. the suffering of the patient and to minimize family
members distress. For example opioids or sedatives
Bereavement Care may be administered to the patient, and the alarms
on equipment may be silenced to allow the family to
The death of a patient can affect family members focus on the patient rather than the technology.
in different ways. Previous experiences with death,
coping skills, cultural and spiritual beliefs, and the
circumstances surrounding the death inuence the Brain Death
grief experience. Bereavement support includes
providing family members with information about All states have laws addressing the denition of death
bereavement support services available through the in the state. It is important that the nurse know the
facility, as well as information about how to make legal denition of death in any state where he or she
arrangements after the death and who can be con- is practicing. A brain dead patient (ie, one who has
tacted at the facility if questions arise. experienced the irreversible loss of all brain func-
It is important to do everything possible to allow tion) is legally dead, and there is no legal duty to
the family sufcient time to go through their leave- continue to treat him or her. It is not necessary to
taking rituals. Not allowing family members the obtain court approval to discontinue life support on
chance to say goodbye can complicate the grieving a patient who is brain-dead. Furthermore, although
process and negatively inuence how the family it can be desirable to obtain family permission to
remembers the experience of losing their loved one. discontinue treatment of a brain-dead patient, there
is no legal requirement. However, before terminat-
ing life support, physicians and nurses should be
Legal and Ethical Issues in End-of-Life sure that organs are not intended for transplanta-
tion purposes.
Principle of Double Effect Organ and Tissue Donation
The principle of double effect involves actions that Organs and tissues can be procured after cardiac
have two effects, one good and one bad.6 This prin- death or brain death. Both federal law and the Joint
ciple often applies with the administration of pain Commission require facilities to have written pro-
medications to patients who are dying. Opioids are tocols regarding organ and tissue donation, and
used to relieve pain and other symptoms of suffer- that family members be given the chance to autho-
ing (ie, the good effect). However, opioids also may rize donation of the patients tissues and organs.7
cause respiratory and cardiovascular depression When organ or tissue procurement is a possibility,
that may hasten death (ie, the bad effect). If the pri- it is important that all family members are given
mary intention is to relieve pain and suffering with the information they need to make a decision with
the recognition that it may hasten death, it is mor- which they are comfortable and that their grief is
ally and legally permissible to administer the opioid. respected.

Morton_Chap06.indd 44 2/4/2012 2:32:22 PM

End-of-Life and Palliative Care C H A P T E R 6 45

Caring for the Caregiver References

1. Nelson J, et al.: Integrating palliative care in the ICU.
Some deaths affect the nurse more signicantly than 13(2):8994, 2011
others. The death of a child, the death of a friend 2. End of Life Care Strategies: Core competencies. Department
or colleague, mass casualties, or a particularly hor- of Health and NHS End of Life Care Program. July (2008)
3. Campbell ML: Palliative care consultation in the intensive
ric, traumatic death can have a profound effect on care unit. Crit Care Med 34(11 Suppl):S355S358, 2006
the nurse. Nurses may delay attending to their own 4. Medina J, Puntillo KA: AACN Protocols for Practice:
grief because the demands of the unit and the needs Palliative Care and End-of-Life Issues in Critical Care.
of the family members may take precedence. It is Sudbury, MA: Jones & Bartlett, 2006
important for nurses to recognize their grief and 5. Emanuel L, von Gunten C, Ferris F, et al. (eds): The
Education in Palliative and End-of-Life Care (EPEC)
take appropriate measures to address it. Self-care Curriculum: The EPEC Project. Chicago: Author, 2003.
strategies include: 6. Matzo M, Witt Sherman D: Societal and Professional Issues
in Palliative Care. In Palliative Care Nursing: Quality Care to
Asking for temporary relief from care the End of Life. Springer Publishing, 2009
responsibilities 7. Campbell ML, Zalenski R: The emergency department. In
Reecting on feelings after the event Ferrell BR, Coyle N (eds): Textbook of Palliative Care, 2nd
Discussing the experience with a colleague, friend, ed. New York, NY: Oxford University Press, 2006, pp 861869
or nurse leader
Focusing on what was done right
Maintaining physical health (eg, through regu- Want to know more? A wide variety of resources to enhance your learn-
lar exercise, proper nutrition, adequate rest, and ing and understanding of this chapter are available on . Visit
stress-relieving activities) to access chapter review
questions and more!

M rs. M. is a 35-year-old woman who was in
a motor vehicle collision. She sustained a severe
brain injury (subdural hematoma and diffuse axonal
injury), bilateral pulmonary contusions, and a liver
laceration. By hospital day 3, she has received 30
units of packed red blood cells and is beginning
to exhibit signs of organ dysfunction (eg, elevated
creatinine and blood urea nitrogen levels, coagu-
lopathy). She remains unresponsive. The primary
physician is at the bedside and wants to discuss
the options for future care with the family. The
physician raises the subjects of initiating a do-
not-resuscitate (DNR) order and withdrawing life
1. What are the nurses responsibilities toward
the family following the conversation with the
2. If the family decides to initiate a do-not-resusci-
tate (DNR) order, to remove life support, or both,
what are the major goals in caring for Mrs. M.?

Morton_Chap06.indd 45 2/4/2012 2:32:22 PM

Providing Nutritional Support,

7 Fluids, and Electrolytes

Based on the content in this chapter, the reader should be able to:
1 Explain how the physiological stressors of illness and injury alter the bodys
needs for energy.
2 Describe data obtained during assessment of the patients nutritional status.
3 Describe the nurses role in providing enteral nutrition.
4 Describe the nurses role in providing parenteral nutrition.
5 Describe the nurses role in ensuring fluid balance.
6 Describe the nurses role in the acute management of electrolyte imbalances.

Physiological stressors, such as illness and injury,

alter the bodys metabolic and energy demands.
glycogen or fatty acids (triglycerides). Because there
is no pathway for converting fatty acids back to glu-
Patients can experience considerable weight loss cose, fatty acids are used directly as a fuel source
(>10 kg) during and after a stay in the critical care or are converted to ketones by the liver. After pro-
unit. This unintentional weight loss may deplete longed starvation, the body adapts to preserve vital
vital nutrient reserves, which may predispose the proteins by using ketones, rather than glucose, as
patient to malnutrition. Malnutrition from starva- energy. Ketoacidosis occurs when ketone produc-
tion alone can usually be corrected by replacing tion exceeds utilization.
body stores of essential nutrients. However, malnu- The pancreatic hormones insulin and glucagon
trition resulting from critical illness and disease pro- have opposing functions in metabolism. Insulin
cesses that alter metabolism is not as easily rectied helps transport glucose for storage into the cells
and can have serious consequences for the hospital- and tissues, prevents fat breakdown, and increases
ized patient (Box 7-1). Early identication of nutri- protein synthesis. Glucagon stimulates glycoge-
tional deciencies and appropriate intervention can nolysis (glycogen breakdown) and gluconeogen-
lessen morbidity and mortality risks in critically ill esis (glucose synthesis from other sources such as
patients. proteins), and it increases lipolysis (fat breakdown
Metabolism has two parts: anabolism and catab- and mobilization). The catecholamines epinephrine
olism. Anabolism builds up and repairs the body, and norepinephrine, which are released from the
which requires energy. Catabolism breaks down adrenal medulla in times of stress, also play a role
food and body tissues to liberate energy. Glucose in glycogenolysis. Once glucose and glycogen stores
is the obligatory fuel of the body. The liver, which have been exhausted (usually within 8 to 12 hours),
has the ability to both store and synthesize glucose, hepatic gluconeogenesis increases dramatically
regulates glucose entry into the circulatory system. to meet metabolic demands in response to gluca-
The liver converts and stores excess glucose as either gon and the glucocorticoid hormone cortisol. If


Morton_Chap07.indd 46 2/4/2012 2:33:00 PM

Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 47

ICU nurses are responsible for obtaining an initial

BOX 7-1 Consequences of Malnutrition for
dry weight (ie, the patients weight before uids
the Hospitalized Patient
are administered), as well as daily weight measure-
Delayed wound healing ments, vital signs, intake and output measurements,
Increased complications and laboratory data. In addition, the nurse must
Immunosuppression monitor for clinical signs of dehydration (ie, thirst,
Increased length of hospitalization dry mucous membranes, tachycardia, poor skin tur-
Organ impairment gor), and uid excess (ie, peripheral edema, adventi-
Increased morbidity and mortality tious lung sounds). Early detection and subsequent
interventions may prevent the occurrence of exces-
sive uid shifts and cardiac compromise.
An important factor that inuences nutritional
status is nitrogen balance, a sensitive indicator of
catabolic processes continue without the support of the bodys gain or loss of protein. An adult is in
energy, amino acids, and essential nutrients, exist- nitrogen balance when the nitrogen intake equals
ing body stores become depleted and malnutrition the nitrogen output (in urine, feces, and perspira-
may develop. tion). A positive nitrogen balance exists when nitro-
All tissues require protein to maintain struc- gen intake exceeds nitrogen output and indicates
ture and facilitate wound healing. If protein intake tissue growth (such as occurs during recovery from
is inadequate, the body becomes catabolic, seek- surgery) and rebuilding of wasted tissue. A negative
ing protein from skeletal muscle and vital organs. nitrogen balance indicates that the tissue is break-
Proteincalorie malnutrition is typically caused ing down faster than it is being replaced.
by acute, life-threatening conditions (eg, surgery,
trauma, sepsis) and is due to depletion of fat, muscle
wasting, and micronutrient deciencies from acute Nutritional Support
and chronic illness. Clinical signs of protein-calorie
malnutrition include generalized edema (the result Goals for nutritional support may include:
of extracellular uid shifts caused by low-protein Prevention and treatment of macronutrient and
oncotic pressures in the intravascular space), hair micronutrient deciencies
loss, skin breakdown, poor wound healing and sur- Maintenance of uid and electrolyte balance
gical wound dehiscence. Laboratory data reveal Reduction in patient morbidity and mortality
low serum albumin levels, and treatment requires
aggressive repletion of protein stores. In patients unable to meet their nutritional needs
with oral intake, nutritional supplementation may
RED FLAG! Protein-calorie malnutrition is much be delivered by either enteral or parenteral routes.
easier to prevent than to treat.
Enteral Nutrition
Nutritional Assessment Enteral nutrition refers to any form of nutrition
delivered to the gastrointestinal tract through a
A critically ill patients nutritional status may fall feeding tube placed into the stomach or the small
anywhere on a continuum ranging from optimal intestine. Enteral nutrition is considered when the
nutrition to malnutrition. Nutritional disturbances patient cannot or should not eat or intake is insuf-
can be subtle and are frequently nonspecic. The cient or unreliable.
nurse, registered dietician or nutritionist, and other For patients with an intact gastrointestinal tract,
members of the nutritional support team work col- the enteral route is the preferred method of nutri-
laboratively to assess and manage the patients nutri- tional support (If the gut works, use it.). The gas-
tional status. The nutritional assessment includes: trointestinal mucosa depends on nutrient delivery
and adequate blood ow to prevent atrophy, thereby
A history, including questions aimed at under-
maintaining the absorptive, barrier, and immuno-
standing factors that can affect the patients food
logical functions of the intestine. Gut-associated
intake and the patients usual eating habits and
lymphoid tissue (GALT) lines the gastrointestinal
tract and is associated with maintenance of the
Physical examination (Table 7-1)
immunological function of the mucosa. Without
Anthropometric measurements (ie, height,
food, the gastrointestinal mucosa atrophies, the
weight, body mass index [BMI], triceps skin-
tissue available to absorb nutrients decreases,
fold thickness, and midarm and arm muscle
and GALT is impaired. Bacterial translocation
(ie, the entry of resident gastrointestinal bacteria and
Laboratory studies (Table 7-2)
endotoxins into the systemic circulation) can trig-
Serial weight measurement is perhaps the single ger immune and inammatory responses, leading
most important indicator of nutritional status and to infection, sepsis, and multisystem organ failure.1
is the evaluation that the nurse performs most often. In addition to helping to preserve gastrointestinal

Morton_Chap07.indd 47 2/4/2012 2:33:02 PM

48 P A R T T W O Essential Interventions in Critical Care

TA B L E 7 - 1 Physical Assessment Interpretation in Nutritional Disorders

Body System or Region Sign or Symptom Implications

General Weakness and fatigue Anemia or electrolyte imbalance, decreased calorie
Weight loss intake, increased calorie use, or inadequate
nutrient intake or absorption
Skin, hair, and nails Dry, flaky skin Vitamin A, vitamin B complex, or linoleic acid
Dry skin with poor turgor Dehydration
Rough, scaly skin with bumps Vitamin A deficiency
Petechiae or ecchymoses Vitamin C or K deficiency
Sore that will not heal Protein, vitamin C, or zinc deficiency
Thinning, dry hair Protein deficiency
Spoon-shaped, brittle, or rigid nails Iron deficiency
Eyes Night blindness; corneal swelling, Vitamin A deficiency
softening, or dryness; Bitots spots
(gray triangular patches on the
Red conjunctiva Riboflavin deficiency
Throat and mouth Cracks at the corner of mouth Riboflavin or niacin deficiency
Magenta tongue Riboflavin deficiency
Beefy, red tongue Vitamin B12 deficiency
Soft, spongy, bleeding gums Vitamin C deficiency
Swollen neck (goiter) Iodine deficiency
Cardiovascular Edema Protein deficiency
Tachycardia, hypotension Fluid volume deficit
Gastrointestinal Ascites Protein deficiency
Musculoskeletal Bone pain and bow leg Vitamin D or calcium deficiency
Muscle wasting Protein, carbohydrate, and fat deficiency
Neurological Altered mental status Dehydration and thiamine or vitamin B12 deficiency
Paresthesia Vitamin B12, pyridoxine, or thiamine deficiency

From Nutrition Made Incredibly Easy. Philadelphia, PA: Lippincott Williams & Wilkins, Springhouse, 2006.

tract function, enteral feeding is easier, safer, and postoperatively, bowel sounds may not be detected
less costly to administer than parenteral nutrition. for 3 to 5 days owing to gastric atony. The small
Contraindications to enteral nutrition are given in intestine is less prone to ileus than the stomach or
Box 7-2. the colon and retains its absorptive and digestive
A common misconception is that enteral feedings capabilities, making it possible to accept enteral
should not be started if bowel sounds are absent. feedings immediately after surgery or trauma.2
Bowel sounds are an indication of large intesti- The ultimate goal is for the patient to resume
nal motility, not of absorption. After injury and adequate oral intake. Enteral feeding may be

TA B L E 7 - 2 Laboratory Studies to Evaluate Nutritional Status

Study Clinical Significance

Hemoglobin Helps identify anemia, protein deficiency, excessive blood loss, hydration status (elevated with
dehydration; decreased with overhydration)
Hematocrit Decreased value with overhydration and increased with dehydration; blood loss; poor dietary
intake of iron, protein, certain vitamins
Albumin Decreased with protein deficiency; blood loss secondary to burns; malnutrition; liver/renal
disease; heart failure; major surgery; infections; cancer
Elevated with dehydration
Total protein Decreased with overhydration, malnutrition, liver disease
Prealbumin Decreased in malnutrition in critically ill patients and those with chronic disease
Transferrin Reflects current protein status; a more sensitive indicator of visceral protein stores
Elevated in pregnancy or iron deficiency
Decreased in acute or chronic infection, cirrhosis, renal disease, cancer
Retinol-binding protein Decreased in overhydration and liver disease
Total lymphocyte count May indicate malnutrition when no other cause of elevated lymphocyte count apparent; may
point to infection, leukemia, or tissue necrosis

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Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 49

BOX 7-2 Contraindications to Enteral

Absolute Contraindications Nasoduodenal
Mechanical obstruction
Relative Contraindications
Severe hemorrhagic pancreatitis
Necrotizing enterocolitis
Prolonged ileus
Severe diarrhea
Protracted vomiting
Enteric stulas
Intestinal dysmotility
Intestinal ischemia

discontinued when the patient can drink enough to
maintain hydration and eat enough to meet at least
two thirds of her nutritional requirements.

Enteral Feeding Tubes

The expected duration of nutritional support, the
placement technique, and the patients overall con-
dition, aspiration risk, and gastrointestinal tract
function are considered when deciding on which
type of feeding tube to place. F I G U R E 7 - 1 Enteral feeding routes.
Nasoenteral Feeding Tubes
Nasoenteral tubes are inserted through the nose or
mouth and advanced through the esophagus into Because a nasoenteral tube may shift position,
the stomach (nasogastric tube), duodenum (naso- ongoing assessment of tube placement is required.
duodenal tube), or jejunum (nasojejunal tube) (Fig. After conrming proper positioning radiographi-
7-1). A nasoenteric tube is indicated for short-term cally, the tubes exit site from the nose or mouth
use (ie, less than 4 to 6 weeks). The small diam- is marked and documented to facilitate ongoing
eter of the nasoenteral tube may help prevent reux assessment. An increase in the external length of
and lessen the risk for aspiration because there is the tubing can signal that the tubes distal tip has
less compromise of the lower esophageal sphinc- dislocated upward in the gastrointestinal tract (eg,
ter. When placed past the pylorus, nasoduodenal from the intestine into the stomach or esopha-
and nasojejunal tubes also carry a reduced risk for gus, or from the stomach into the esophagus).
aspiration and regurgitation because of the barrier Measuring the pH and observing the appearance
provided by the pyloric sphincter. Potential compli- of uid withdrawn from the tube may also be used
cations associated with nasoenteral tubes include to evaluate tube placement, although this method
sinusitis, epistaxis, erosion of the nasal septum or is not 100% reliable (Table 7-3, p. 51). Injecting air
esophagus, otitis, vocal cord paralysis, and distal into the tube and auscultating the gastric bubble,
esophageal strictures. although commonly used, is also not 100% accu-
Nasoenteral tubes can be accidentally placed rate and should not be relied on alone to deter-
in the trachea or bronchial tree. Patients with a mine tube location.
decreased level of consciousness, poor cough or gag
reex, or an inability to cooperate are at increased RED FLAG! If at any time tube location is in
risk for pulmonary intubation. Before initiating question, the nurse holds the tube feeding and
tube feeding with a nasoenteral tube, proper tube requests an order for an abdominal radiograph to
placement must be conrmed by an abdominal confirm placement.
Enterostomal Feeding Tubes
RED FLAG! Nasoenteral feeding tubes are If therapy is expected to last a month or more,
contraindicated in patients with basilar skull a more permanent enterostomal device can be
fractures because of the risk for passing the tube inserted through the abdomen into the stom-
through the cribiform fracture and into the brain. For ach (gastrostomy) or jejunum (jejunostomy) (see
these patients, enteral feeding tubes must be placed Fig. 7-1). Various techniques may be used to place
orally. enterostomal feeding tubes:

Morton_Chap07.indd 49 2/4/2012 2:33:03 PM

50 P A R T T W O Essential Interventions in Critical Care

or in the endoscopy suite using minimal seda-

EVIDENCE-BASED PRACTICE GUIDELINES tion. Because the endoscope is passed through
Verification of Feeding Tube Placement the mouth and upper gastrointestinal tract, the
patient must have an intact oropharynx and an
PROBLEM: Erroneous placement of a feeding tube can
unobstructed esophagus. In addition, the patient
cause serious and even fatal complications.
must not have any conditions that would result in
EVIDENCE-BASED PRACTICE GUIDELINES an inability to bring the gastric wall into apposi-
tion with the abdomen. Prior abdominal surgeries,
1. Use a variety of bedside methods to predict tube location ascites, hepatomegaly, and obesity may impede
during the insertion procedure, including observation for gastric transillumination and preclude percutane-
signs of respiratory distress, capnography, measurement ous endoscopic tube placement. Advantages of per-
of aspirate pH, and observation of aspirate. (level B) cutaneous endoscopy include earlier feeding after
2. Recognize that auscultatory (air bolus) and water bubbling tube placement, increased comfort, decreased cost,
methods of verifying tube location are unreliable. (level B) and decreased recovery time. Complications are
3. Obtain radiographic confirmation of correct placement infrequent but include wound infection related to
of any blindly inserted tube prior to initiating feedings or bacterial contamination by oral ora during inser-
medication administration. The radiograph should visual- tion, necrotizing fasciitis, peritonitis, and aspira-
ize the entire course of the feeding tube in the gastroin- tion. Pneumoperitoneum is common following
testinal tract and should be read by a radiologist to avoid tube placement by percutaneous endoscopy but
errors in interpretation. (level A) is not clinically signicant unless accompanied by
4. Mark and document the tubes exit site from the nose or signs and symptoms of peritonitis.
mouth immediately after radiographic confirmation of cor- Surgery. The gastrostomy or jejunostomy tube
rect tube placement. (level A) is inserted through an incision in the abdominal
5. Check tube location at 4-hour intervals after feedings are wall under general anesthesia. Disadvantages of
initiated. (level B) surgical placement include the need for general
Observe for a change in length of the external portion of anesthesia, increased recovery time, decreased
the feeding tube. comfort, and increased cost.
Review routine chest and abdominal x-ray reports to look Laparoscopy. A laparoscopically placed gastros-
for notations about tube location. tomy tube also requires general anesthesia or
Observe changes in volume of aspirate from the feeding IV conscious sedation. Laparoscopic placement
tube. is usually used for patients with head, neck, or
Measure pH of feeding tube aspirates if feedings are esophageal cancer. It is less invasive, less painful,
interrupted for more than a few hours. and usually involves fewer complications than a
Obtain an x-ray to confirm tube position if there is doubt surgical gastrostomy.
about the tubes location. Fluoroscopy. Direct percutaneous catheter inser-
tion of a gastrostomy tube under uoroscopy is
KEY indicated for patients with high-grade pharyngeal
Level A: Meta-analysis of quantitative studies or metasynthesis of or esophageal obstruction. Disadvantages of uo-
qualitative studies with results that consistently support a specific roscopic placement include the inability to detect
action, intervention, or treatment mucosal disease, the potential for prolonged expo-
Level B: Well-designed, controlled studies with results that consis- sure to radiation, the need to transport the patient
tently support a specific action, intervention, or treatment to a uoroscopy suite, and increased cost.
Level C: Qualitative studies, descriptive or correlational studies,
Enterostomal tubes are secured to the abdominal
integrative review, systematic reviews, or randomized controlled
trials with inconsistent results
wall to prevent dislodgment or migration of the
tube and to prevent tension on the tubing (Fig. 7-2).
Level D: Peer-reviewed professional organizational standards with
Buried bumper syndrome can occur if the reten-
clinical studies to support recommendations
tion device is too tight and becomes imbedded in
Level E: Multiple case reports, theory-based evidence from expert the tissue, leading to mucosal or skin erosion.
opinions, or peer-reviewed professional organizational standards
In-and-out play on the tubing is checked; it should
without clinical studies to support recommendations
be able to move 1/4 inch to prevent erosion of gas-
Level M: Manufacturers recommendations only tric or abdominal tissue. The length of the external
Adapted from American Association of Critical-Care Nurses (AACN) Prac- tubing is documented to monitor for migration of
tice Alert, revised 12/2009. the tubing.
Serosanguineous drainage may be expected for
7 to 10 days after insertion. The skin around the
insertion site and the retention device is assessed
Percutaneous endoscopy may be used to place at least daily for skin breakdown, erythema, or
gastrostomy or jejunostomy tubes. Placement is drainage. To avoid maceration, the site is kept
through an abdominal incision using direct endo- clean and dry and lifting or adjusting the tube is
scopic visualization. Percutaneous endoscopic avoided for several days after the initial insertion.
tube placement may be performed at the bedside When drainage is present, the amount of dressing

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Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 51

TA B L E 7- 3 Characteristics of Aspirate From Enteral Feeding Tubes

Source of Aspirate Aspirate pH Aspirate Appearance Clinical Significance

Stomach 5 or less Grassy green or clear and colorless Normal if tube is supposed to terminate
with off-white to tan mucus shreds in stomach
Abnormal if tube is supposed to
terminate in the intestine
Small bowel 6 or greater Bile-stained (ranging in color Normal if tube is supposed to terminate
from light to golden yellow or in the intestine
brownish-green); thicker and more Abnormal if tube is supposed to
translucent than fluid withdrawn terminate in stomach
from a gastric tube
Tracheobronchial tree 6 or greater Similar to fluid obtained during Abnormal
tracheal suctioning
Pleural space 6 or greater Straw-colored and watery, possibly Abnormal

between the external retention device and the When initiating enteral tube feedings, most clini-
skin is limited to avoid pulling the internal reten- cians recommend beginning with an isotonic formula
tion device taut against the gastric or intestinal at a slow rate (eg, 20 to 30 mL/h), and increasing the
mucosa. Cleansing the site with soap and water is rate incrementally until the goal rate is achieved.1
adequate. The tissue usually heals within a month. Dilution of formula may help in tolerance but is not
If an enterostomal tube becomes accidentally recommended because this may increase the time
dislodged, the physician must be notied imme- needed to meet the nutritional requirements.1
diately so that the tube can be reinserted quickly Methods of administering enteral feedings include
before the tract closes. the following.
Bolus feedings, considered the most natural physi-
Providing Enteral Nutrition ologically, entail using a syringe to administer a
Numerous formulas are available for enteral nutri- large volume of formula (eg, up to 400 mL) over 5
tion, with many designed to assist in the man- to 10 minutes, ve to six times a day. Alternatively,
agement of specic disease processes (Table 7-4). 300 to 400 mL of formula may be administered by
Enteral formula selection is based on the patients slow gravity drip over a period of 30 to 60 minutes,
clinical status, nutrient requirements, uid and elec- four to six times a day (this is termed bolus inter-
trolyte restrictions, and gastrointestinal function; the mittent feeding). Bolus feedings allow for increased
location of enteral access; the expected duration of patient mobility because the patient is free from a
enteral feeding; and cost. All enteral formulas con- mechanical device between feedings. The stomach
tain proteins, carbohydrates, fats, vitamins, miner- is the preferred site for bolus feedings because the
als, trace elements, and water. stomach and pyloric sphincter regulate the outow
of formula from the stomach. However, because of
high residuals, bolus feedings are usually not well
tolerated and are often accompanied by nausea,
Plug-in adapter bloating, cramping, diarrhea, or aspiration. The risk
Tubing clamp for osmotic diarrhea is decreased with bolus inter-
mittent feeding.
Continuous feedings are administered over
24 hours using a feeding pump to ensure a
constant ow rate. Continuous feeding is the
External retention device
preferred method when the feeding tube is placed
in the intestines because delivery to the intestines
that is too rapid may lead to dumping syndrome
(osmotic diarrhea, abdominal distention, cramps,
Internal retention device
hyperperistalsis, lightheadedness, diaphoresis, and
palpitations). The small intestine can usually toler-
Mushroom ate feedings at a rate of 150 mL/h. Continuous feed-
catheter tip ings are best suited for critically ill patients because
Stomach wall they allow more time for nutrients to be absorbed
in the intestine and may act prophylactically to
F I G U R E 7 - 2 Percutaneous endoscopic gastrostomy (PEG) tube. prevent stress ulcers and metabolic complications.

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52 P A R T T W O Essential Interventions in Critical Care

TA B L E 7 - 4 Types of Enteral Formulas

Formula Description Comments

Polymeric Isotonic formulas that can provide enough protein, Pancreatic enzymes required for
carbohydrate, fat, vitamins, trace elements, and digestion of carbohydrates and
minerals to prevent nutritional deficiencies proteins
Carbohydrates supplied as oligosaccharides
and polysaccharides
Proteins supplied as intact proteins (eg, meat,
whey, milk, or soy proteins)
Supply 12 kcal/mL
Peptide (elemental) Proteins supplied as dipeptides, tripeptides, Used when digestion is impaired
or oligopeptides and free amino acids (from (eg, pancreatic insufficiency,
hydrolysis of whey, milk, or soy protein) radiation enteritis, Crohns disease,
short bowel syndrome secondary to
surgical resection)
Modular Contain individual nutrient components Added to other formulas to meet the
(eg, protein, carbohydrate, fat) patients individualized needs
Immunonutrition Contain addition nutrients purported to enhance Immune-enhancing benefits have not
(immune-enhancing) immune function (eg, glutamine, arginine, been proven
omega-3-polyunsaturated fatty acids)

RED FLAG! Tube feeding should be held if the Precipitation of medications, pill fragments, or
patient demonstrates overt signs of regurgitation, coagulation of formula may cause obstruction of
vomiting, or aspiration. the feeding tube. To avoid clogging, the feeding
tube is ushed with tepid water every 4 to 6 hours
The nurse checks gastric residual volumes every during continuous feeds, before and after medica-
4 to 6 hours during continuous feedings and before tion administration, after checking residuals, and
initiating intermittent feedings. Food normally passes when turning off feedings. Obstructions are cleared
through the stomach at a rate of 2 to 10 mL/min; by ushing the tube with warm water using a large
however, gastric emptying is delayed or absent in piston syringe and a gentle pushpull motion.
many critically ill patients. To allow time for normal Pancreatic enzymes have been effective in unclog-
gastric emptying and reduce the risk for aspiration, it ging a tube when water is unsuccessful, as long as
is common to hold the feeding for 1 to 2 hours if the the enzymes are activated before instillation.4
residual volume is greater than 250 mL. The residual
volume should be rechecked every 1 to 2 hours until RED FLAG! A stylet should never be used to unclog
it is less than 200 to 250 mL from a nasogastric tube a tube because of the risk for rupturing the tube
or less than 100 mL from a gastrostomy tube. The and perforating the esophagus, stomach, or small
residuals should be replaced and not discarded. intestine.
Withholding feedings based on a single high
residual volume measurement can be problematic.3 Complications of Enteral Nutrition
A high residual volume should raise suspicion of Although enteral nutrition is associated with fewer
intolerance, but one high value does not mean complications than parenteral nutrition, complica-
feeding failure, and automatic cessation of feeding tions may still occur (Box 7-3). Many of these com-
can delay the patients ability to meet his nutritional plications can be prevented by closely observing
goals. When evaluating residual volumes, the residuals and watching for signs and symptoms of
following points should be kept in mind: intolerance to the enteral feedings. Two major com-
There is no concensus about what constitutes a plications associated with enteral nutrition include
high residual volume. Amounts ranging from diarrhea and aspiration.
100 to 400 mL may be considered high. Diarrhea
High infusion rates result in higher residual Diarrhea in a patient receiving enteral feeding has a
volumes. myriad of causes:
It is difcult to determine whether gastric contents
have been completely removed, so the measured Medications (eg, antibiotics)
residual volume may be less than the actual resid- Bacterial overgrowth (eg, due to reduced motility,
ual volume. acid suppression)
High residual volumes do not always correlate Formula composition (eg, intolerance to lactose,
with an increased risk for aspiration, and low fat, or osmolality)
residual volumes do not preclude aspiration.2 High infusion rates

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Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 53

Maintaining endotracheal cuff pressures at 20 to

BOX 7-3 Complications of Enteral Nutrition
30 cm H2O and performing subglottic suctioning
prior to deating the cuff
Nausea RED FLAG! Signs of pulmonary aspiration include
Vomiting a low-grade fever, coughing, shortness of breath,
Bloating rhonchi during or after enteral feeding infusions, and
Abdominal discomfort tracheal or oral secretions with a sweet formula odor.
Fluid and electrolyte imbalance
Parenteral Nutrition
Hypoglycemia (if feedings are abruptly terminated) Parenteral nutrition is indicated when oral or enteral
Aspiration nutrition is not possible or when absorption or func-
tion of the gastrointestinal tract is not sufcient to
meet the nutritional needs of the patient. There are
Hypoalbuminemia two types of parenteral nutrition:
Contamination of the formula or administration set Peripheral parenteral nutrition (PPN) is infused
Measures such as reducing the infusion rate, using into a small peripheral vein and is often used for
a peptide-based formula that is easier to digest or a short-term nutrition support or as a supplement
ber-containing formula to bulk stools, and giving during transitional phases to enteral or oral nutri-
an absorbing product (eg, Metamucil), may resolve tion. Because of the risk for phlebitis, concen-
the diarrhea. The risk for diarrhea caused by con- trations of PPN formulas must not exceed 900
tamination of the formula or administration set can mOsm/L.
be reduced by: Total parenteral nutrition (TPN), also known as
central parenteral nutrition, is infused through a
Minimizing breaks in the system large central vein. The TPN formula is highly con-
Using formula in closed, prelled, ready-to-hang centrated. The greater blood volumes in large cen-
containers tral veins facilitate dilution and dispersion of the
Hanging no more than 4 hours of formula at one highly osmotic formula.
time and using any open formula within 24 hours
Discarding expired formula Formula Composition
Changing the administration set daily, and rinsing
TPN delivers all daily required nutrients to the
between bolus feedings
patient in the form of macronutrients (carbohy-
Using good handwashing technique and wearing
drates, lipids, and amino acids) and micronutrients
gloves when administering feedings or handling
(electrolytes, vitamins, and trace minerals). When
the equipment
all three macronutrients are combined together
Aspiration in one TPN bag, the admixture is referred to as a
Aspiration of formula can result in hypoxia or pneu- 3 in 1. Sometimes lipids are infused separately.
monia. Many critically ill patients have multiple risk TPN formulation is based on the specic needs of
factors for aspiration, in addition to enteral feeding each patient; standard formulas are no longer widely
(eg, endotracheal intubation, mechanical ventila- prescribed. While preparing the TPN formula, the
tion, altered level of consciousness). In patients with pharmacist can also add medications.
endotracheal tubes who are receiving enteral nutri-
tion, the incidence of aspiration is as high as 50%
The primary energy source is carbohydrates. The
to 75%.2 Intermittent feedings allow the restoration
most common and preferred source of carbohy-
of gastric pH, which can minimize gastric bacterial
drates is dextrose (D-glucose) because it is readily
colonization and the risk for aspiration pneumonia.
metabolized, stimulates the secretion of insulin,
Other measures to reduce the risk for aspiration in
and is usually well tolerated in large quantities. The
patients who are receiving enteral nutrition include:
amount of dextrose prescribed in TPN is based on
Maintaining the head of the bed at a 30- to metabolic needs and contributes the most to the
45-degree angle, unless medically contraindicated osmolality (concentration) of the TPN solution.
(if elevating the head of the bed is contraindicated, Once the patients metabolic needs are met, amino
a reverse Trendelenburg position may be used acids can be used for protein synthesis rather than
unless medically contraindicated) solely as an energy source.
Discontinuing feedings at least 30 minutes before Excessive dextrose concentrations can lead to
any procedure for which the patient must lay at hyperglycemia, requiring the use of insulin. In
Checking residuals frequently, and assessing for addition, because carbon dioxide is an end product
signs of feeding intolerance (through subjective of carbohydrate metabolism, excessive dextrose
reports, if the patient is awake and alert, and concentrations can lead to carbon dioxide reten-
abdominal examination to assess bowel sounds tion and respiratory acidosis, which in turn lead
and changes in abdominal girth) to an increased minute ventilation and work of

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54 P A R T T W O Essential Interventions in Critical Care

breathing, making weaning from mechanical ven- Micronutrients

tilation difcult. Vitamins. Standard aqueous multivitamin prepa-
rations created for TPN provide high levels of thi-
Lipids amine, pyridoxine, ascorbic acid, and folic acid.
Lipid emulsions contain essential fatty acids from Concentrations of vitamins in TPN formulas are
safower and soybean vegetable oils. Egg yolk usually increased over standard U.S. Recommended
phospholipids are used as emulsiers, so it is Dietary Allowance requirements because in TPN,
important to check the patients food allergy his- many vitamins are destroyed (by exposure to light
tory before administration. Before infusion, lipid- and oxygen), lost (due to adherence to plastic tubing
containing TPN solutions must be inspected for and bags), or excreted in the urine before the body
separation. Loss of emulsion can be identied by can use them. Hypermetabolic conditions of critical
yellow-brown marbling of the entire solution or illness can exacerbate deciencies (eg, of vitamin
as layering of oil at the surface of the TPN bag. K), necessitating additional monitoring and poten-
Emulsions that have separated are not safe for tially supplementation. Patients with liver or kidney
infusion and must be returned to the pharmacy disease may require lower doses of certain vitamins.
for replacement. Lipid emulsions provide an Minerals. Trace minerals are required to maintain
excellent medium for bacterial growth, so exces- biochemical homeostasis. Most commercial mix-
sive manipulation and prolonged hang times are tures contain chromium, copper, manganese, sele-
avoided. nium, and zinc.
Lipid emulsions are isotonic and available in Electrolytes. Most electrolyte standard mixtures
10%, 20%, and 30% concentrations, providing 1.1, contain sodium, potassium, calcium, magnesium,
2.0, and 2.9 kcal/mL, respectively. Higher concentra- phosphorus, chloride, and acetate. Depending on
tions provide a greater concentration of calories in the patients underlying disease process and physi-
less total uid volume, an important consideration cal assessment ndings, specic electrolyte concen-
for many patients. In situations in which hypergly- trations can be adjusted daily in the TPN solution.
cemia has become problematic, dextrose concen-
trations and volumes may be reduced, and unless RED FLAG! Electrolyte supplements or medications
contraindicated, lipid concentrations and volumes should never be added to the TPN bag after the
can be increased. pharmacist has formulated it. Doing so compromises
Baseline and weekly triglyceride trends are the sterility of the solution and may cause the
used to monitor lipid tolerance. Triglyceride levels solution to precipitate.
exceeding 400 mg/dL suggest impaired lipid clear-
ance and an increased risk for pancreatitis; in this Providing Parenteral Nutrition
situation, lipid emulsions should be held until lev-
TPN is usually administered into a central venous
els return to normal. Lipid concentrations may
catheter. If TPN is expected to be needed for more
need to be adjusted for patients who are receiving
than a few weeks, a more permanent device (eg, a
lipids from sources other than TPN (eg, continuous
subcutaneously tunneled Hickman catheter, Port-
infusion of propofol, a sedative delivered as a lipid
a-Cath, or peripherally inserted central catheter
[PICC]) can be placed. Radiologic conrmation of
RED FLAG! Adverse reactions to lipids include fever, catheter tip placement is required before the initial
chills, chest or back tightness, dyspnea, tachycardia, infusion. Per facility protocol, the nurse changes
headache, nausea, and vomiting. If such reactions the TPN solution bag and tubing (usually every
occur, the infusion should be stopped immediately 24 hours) and redresses the catheter insertion site
and the reaction reported to the physician and using either a sterile transparent or gauze dressing
pharmacist. (usually every 24 to 72 hours).
When administering, use a lumen devoted to
Amino Acids the TPN only. Infusing TPN along with other IV
In TPN, protein is provided as a mixture of essen- therapies (eg, uids, medications, blood products)
tial and nonessential crystalline amino acids in into the same lumen carries a high risk for for-
concentrations that supply approximately 15% to mula contamination and precipitation, and should
20% of daily caloric needs. Patients with burns, be avoided. Typically, the solution is infused at
wounds, draining stulas, renal failure, or hepatic a constant rate over a 24-hour period to achieve
failure may need frequent adjustments in the maximal assimilation of the nutrients and to pre-
amount of amino acids they receive. For patients vent hyperglycemia or hypoglycemia. During TPN
with renal disease, solutions with a higher concen- administration, the patient is at risk for hyperglyce-
tration of essential amino acids are available. For mia and insulin is often administered to maintain
patients with hepatic failure or hypercatabolic con- glucose control. Once the TPN infusion is discon-
ditions, formulas with branched-chain amino acids tinued, insulin requirements become notably less
may be used. Branched-chain amino acids spare or nonexistent. If new TPN solution is temporar-
the breakdown of other muscle proteins to use as ily unavailable, administration of 10% dextrose in
energy, possibly reducing the incidence of hepatic water (D10W) is recommended to prevent rebound
encephalopathy. hypoglycemia.

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Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 55

RED FLAG! If a solution is behind schedule, the Refeeding Syndrome

infusion rate should not be increased to make up Refeeding syndrome, characterized by rapid shifts
time because this may cause sudden metabolic in electrolytes, glucose, and volume status within
fluctuations and fluid overload. hours to days of nutrition implementation, is one
of the most critical complications that occurs with
Tapering TPN is often initiated once the patient the initiation of TPN. Rapid refeeding, excessive
is able to safely resume (and tolerate) enteral or dextrose infusion, severe proteincalorie malnutri-
oral nutrition sufcient to meet approximately 50% tion, and conditions such as chronic alcoholism
to 75% of his nutritional needs. A calorie count is and anorexia nervosa increase the patients risk for
essential to ensure that the patients nutritional developing refeeding syndrome.
needs are being met. Before TPN is discontinued, In refeeding syndrome, parenterally delivered glu-
the infusion rate is decreased by half for 30 to 60 cose loads stimulate insulin release, which in turn
minutes to allow a plasma glucose response and stimulates intracellular uptake of phosphorus, glu-
prevent rebound hypoglycemia. Checking blood glu- cose, and other electrolytes for anabolic processes.
cose for 30 to 60 minutes after discontinuation facil- Despite relatively normal serum phosphorus levels
itates identication and management of immediate on standard laboratory reports, intracellular stores
glucose abnormalities. are markedly depleted in malnourished catabolic
patients. Severe hypophosphatemia (<1 mg/dL)
Complications of Parenteral Nutrition can lead to neuromuscular, respiratory, and cardiac
Complications of parenteral nutrition are summa- dysfunction. Low serum levels of potassium, magne-
rized in Box 7-4. Two major complications include sium, and calcium can precipitate cardiac dysrhyth-
hyperglycemia and refeeding syndrome. mias. The increased intravascular uid volumes
associated with parenteral nutrition can strain the
Hyperglycemia heart, possibly inducing heart failure and myocar-
Although hyperglycemia can be caused by either dial damage.
enteral or parenteral feedings, it is more common Prevention of refeeding syndrome includes reple-
in patients receiving parenteral nutrition. Even tion of phosphorus, potassium, magnesium, and
slightly elevated blood glucose levels can impair calcium before TPN initiation, limiting the initial
lymphocyte function, leading to immunosuppres- concentration of dextrose in the TPN solution, and
sion and increased risk for infection. If the renal titrating total volume and rate to evaluate for uid
threshold for glucose reabsorption is exceeded, overload and potential cardiac decompensation.
osmotic diuresis can occur, resulting in dehydration Daily monitoring of phosphorous, potassium, and
and electrolyte imbalances. To manage hypergly- magnesium is recommended. Weight-based phos-
cemia, the pharmacist may add insulin to the TPN phorus repletion algorithms have been shown to be
solution. Alternatively, insulin may be administered highly efcacious in correcting hypophosphatemia
by continuous infusion during TPN administration, during nutrition support therapy.5
or subcutaneously at regular intervals or according
to sliding scales.
RED FLAG! Many patients receiving parenteral or Fluids
enteral nutrition are also on insulin drips. To prevent
a dangerous hypoglycemic episode from occurring, Critically ill patients often have uid imbal-
the nurse must stop the insulin drip any time the ances related to their primary underlying disease.
nutrition is interrupted. Assessment of uid balance and careful manage-
ment are mainstays of patient care in the critical
care setting. The most sensitive indices of changes
in body water content are serial weights and intake
BOX 7-4 Complications of Parenteral and output patterns.
Weight. Admission weight is compared with that
Hepatic dysfunction (eg, hepatic steatosis, extrahe- obtained in the history. Of note is whether the
patic cholestasis, cholelithiasis) weight has changed signicantly over the past 1 to
Gastrointestinal atrophy 2 weeks. One liter of uid equals 1 kg of body weight,
Metabolic complications (eg, hyperglycemia, hypo- equivalent to 2.2 lb. An increase in weight does not
glycemia, hypophosphatemia, hypokalemia, hypo- specify where the weight is gained. For example, a
magnesemia, hypocalcemia) patient may have depleted intravascular volume yet
Refeeding syndrome show an increase in weight because of third-spac-
Local infection at the catheter insertion site ing of uid (ie, movement of uid to the intersti-
Systemic bloodstream infection and sepsis tial space). Rapid daily gains and losses of weight
Mechanical complications related to catheter inser- usually are associated with changes in uid volume
tion (eg, vascular trauma, pneumothorax, thrombo- and not nutritional factors. Critically ill patients
sis, venous air embolism) often experience unmeasured insensible losses
(eg, through ventilation, fever, and wounds).

Morton_Chap07.indd 55 2/4/2012 2:33:06 PM

56 P A R T T W O Essential Interventions in Critical Care

Intake and output. The nurse monitors the Maintenance Fluids

critically ill patients intake and output every
Under normal conditions, the average healthy
1 to 2 hours. The intake and output values are
adult requires about 2.5 L/d. This volume replaces
summed to provide an overall balance at the end
uids lost through the feces, the respiratory tract,
of a 24-hour period. Accurate intake and output
sweating, and urine. When determining the rate of
is important in care of a critically ill patient.
administration of maintenance uid, factors such
In the event that renal function decreases, this
as the patients medical history and age must be
information may aid in the diagnosis and pos-
sible prevention of prerenal azotemia or acute
renal failure.
Replacement Fluids
The type of uid given to a critically ill patient
Fluid Volume Deficit depends on the type of uid lost. When blood is
lost, as in trauma or surgery, blood products may
When uid loss exceeds intake, a uid volume be administered. When intravascular volume is
decit exists. A uid volume decit is a physio- depleted, as in diarrhea, isotonic solutions may be
logical situation in which uids are lost in an iso- administered. The depletion of extravascular uids
tonic fashion (both uid and electrolytes are lost (dehydration) may require replacement with hypo-
together). Dehydration is the loss of water alone, tonic solutions. The rate of administration depends
resulting in a hyperosmolar state. Although a uid on the patients medical history and amount of vol-
volume decit and dehydration can coexist, this ume lost.
discussion is limited strictly to disorders of uid
volume decit. Crystalloids
Fluid volume decits can occur from: Crystalloid solutions (Box 7-5) are prepared with
a specified balance of water and electrolytes.
Fever. As much as 2,500 mL of uid can be lost in Crystalloids are classified as hypotonic (osmolarity
a 24-hour period from a patient with a body tem- < 250 mEq/L), isotonic (osmolarity approximately
perature of 40C (104F) and a respiratory rate of 310 mEq/L), or hypertonic (osmolarity > 376
40 breaths/min. mEq/L). When pure dextrose solutions such as
Hyperventilation Either from disease or use of 5% dextrose in water (D 5W) are administered,
nonhumidied oxygen delivery systems, can result the dextrose is metabolized, resulting in the
in substantial uid loss. administration of free water. When given intra-
Gastrointestinal tract. Losses can occur as a venously, free water decreases the plasma osmo-
result of vomiting, nasogastric suction, diarrhea, larity, thereby promoting the movement of water
or enterocutaneous drainage or stulas. evenly into all body compartments. Free water,
Third-spacing can result from pleural or perito- which is hypotonic, does not stay in the vascular
neal effusions; edema from liver, renal, or hepatic space.
disease; or diffuse capillary leak. Normal (0.9%) saline is an isotonic solution.
Burns. Both evaporative and transudative losses Approximately one third of the uid administered
through burned skin can result in very large losses remains in the vascular space, and the remaining
of uid daily. uid moves into the extracellular space or is lost
Renal losses. Renal losses are seen in the through the renal system. When hypertonic solu-
diuretic phase of acute tubular necrosis, as a tions are administered (such as 3% or 7.5% saline),
result of excessive diuretic administration, the hypertonicity pulls uid from the extravascular
and in patients with cerebral salt wasting syn- space to the vascular space, increasing the intravas-
drome. Renal losses also may occur as a result cular volume.
of solute diuresis from high-protein or high-
saline enteral and parenteral nutrition and Colloids
from administration of osmotic agents (eg, Colloids are high-molecular-weight substances that
mannitol, radiocontrast). Fluid can also be lost do not cross the capillary membrane under normal
during metabolic alkalosis, in which compen- conditions (Table 7-5). The starches dextran and
satory urinary bicarbonate excretion obligates hetastarch and the protein albumin differ from each
renal sodium excretion, frequently resulting in other only slightly but exert similar oncotic pressure.
volume depletion.
Fluid Volume Excess
RED FLAG! Elderly patients are at particular risk
for a fluid volume deficit because of the multisystem Fluid volume excess occurs when there is retention
changes associated with aging. of sodium, resulting in the reabsorption of water.
Electrolytes typically remain unchanged when there
To correct a uid volume decit, it is necessary to is an increase in total body water and electrolytes
treat the underlying cause and replace the lost uid. increase in parallel. Many critically ill patients may
Several types of uids, which have different physi- have mixed disturbances with manifestations of the
ological effects, are available. confounding compensatory mechanisms. Causes

Morton_Chap07.indd 56 2/4/2012 2:33:07 PM

Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 57

BOX 7-5 Common Crystalloid Solutions

5% Dextrose in water (D5W): no electrolytes, 50 g Often used to treat hypernatremia (because this solu-
dextrose tion contains a small amount of sodium, it dilutes the
Supplies about 170 cal/L and free water to aid in renal plasma sodium while not allowing the level to drop
excretion of solutes too rapidly)
Should not be used in excessive volumes in patients 3% or 7.5% Saline
with increased antidiuretic hormone (ADH) activity or Grossly hypertonic solution used to treat severe hypo-
to replace uids in hypovolemic patients natremia or to decrease intracranial pressure (ICP);
0.9% NaCl (isotonic saline): Na+ 154 mEq/L, Cl 154 may also be used to resuscitate trauma patients
mEq/L Used only in settings where the patient can be closely
Isotonic uid commonly used to expand the extracel- monitored
lular uid in presence of hypovolemia Lactated Ringers solution: Na+ 130 mEq/L, K+ 4
Because of relatively high chloride content, it can be mEq/L, Ca2+ 3 mEq/L, Cl 109 mEq/L, lactate (metabo-
used to treat mild metabolic alkalosis lized to bicarbonate) 28 mEq/L
0.45% NaCl ( strength saline): Na+ 77 mEq/L, Cl 77 Approximately isotonic solution that contains multiple
mEq/L electrolytes in about same concentrations as found in
A hypotonic solution that provides sodium, chloride, plasma (note that this solution is lacking magnesium
and free water (sodium and chloride provided in uid and phosphate)
allow kidneys to select and retain needed amounts) Used in the treatment of hypovolemia, burns, and
Free water desirable as aid to kidneys in elimination uid lost as bile or diarrhea
of solutes Useful in treating mild metabolic acidosis

0.33% NaCl (1/3 strength saline): Na+ 56 mEq/L, Cl

56 mEq/L
A hypotonic solution that provides sodium, chloride,
and free water

Adapted from Metheny NM: Fluid and Electrolyte Balance: Nursing Considerations. Philadelphia, PA:
Lippincott Williams & Wilkins, 2000, p 181, with permission.

TA B LE 7- 5 Common Colloid Solutions

Solution Contents Indications Comments

Albumin Available in two Used as volume expander Cost is approximately 2530 times more than
concentrations: 5%: in treatment of shock for crystalloid solutions.
oncotically similar to May be useful in treating Increased interstitial oncotic pressure in
plasma 25%: hypertonic burns and third-spacing disease states in which there is increased
Both 5% and 25% solutions shifts capillary leaking (eg, burns, sepsis) may
contain about 130160 occur; this may result in increased vascular
mEq/L of sodium loss of fluid.
Use caution with rapid administration; watch
for volume overload.
Hetastarch Synthetic colloid made from May be used to expand Plasma volume expansion effects decrease
starch (6%) and added to plasma volume when over 2436 h.
sodium chloride solution volume is lost from Starch is eliminated by kidneys and liver;
hemorrhage, trauma, therefore, use with caution in patients with
burns, and sepsis liver and kidney impairment.
Mild, transient coagulopathies may occur.
Transient rise in serum amylase may occur.
Dextran Glucose polysaccharide May be used to expand Has been associated with greater risk
substance, available as plasma volume when for allergic reaction than albumin or
low-molecular-weight volume is lost from hetastarch.
dextran (dextran 40) or hemorrhage, trauma, Interference with blood cross-matching may
high-molecular-weight burns, and sepsis occur.
dextran (dextran 70) May cause coagulopathy; has more profound
No electrolyte content effect on coagulation than hetastarch.

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58 P A R T T W O Essential Interventions in Critical Care

of uid volume excess include overadministration Electrolytes

of uids; heart, kidney, or liver failure; excessive
sodium intake; and medications (eg, steroids, des- Electrolyte disorders commonly occur in critically
mopressin acetate [DDAVP]). ill patients, typically in combination with other con-
Management of uid volume excess is directed ditions. Management of the underlying problem
toward correction of the underlying disorder. ensures long-term restoration of balance. However,
Diuretics are the mainstay of treatment for acute acute management of electrolyte disorders is often
resolution of uid volume excess. Sodium restriction required to maintain cellular integrity. Common
reduces the amount of water reabsorption and can causes and interventions for electrolyte imbalances
contribute to acute correction of volume overload. are summarized in Table 7-6.

TA B L E 7 - 6 Electrolyte Imbalances: Common Causes and Interventions

Selected Medical Conditions

Electrolyte Associated With Disturbance Collaborative Interventions
Hyponatremia Heart failure Review medication profile and patient
Liver failure history.
Kidney failure Monitor for sites of fluid losses or gains.
Hyperlipidemia Monitor fluid balance and for signs and
Hypoproteinemia symptoms of electrolyte disturbance.
Syndrome of inappropriate antidiuretic hormone (SIADH) Attempt to manage underlying cause.
Gastrointestinal loss Correction of imbalance may require
Adrenal insufficiency sodium replacement (3% saline)
Thiazide diuretics or water restriction, depending on
Drugs: nonsteroidal anti-inflammatory drugs (NSAIDs), underlying cause.
tricyclic antidepressants, selective serotonin reuptake
inhibitor (SSRIs), chlorpropamide, omeprazole
Tumors associated with ectopic excessive antidiuretic
hormone (ADH) production: oat cell carcinoma,
leukemia, lymphoma
Pulmonary disorders: pneumonia, acute asthma
Hypernatremia Profound dehydration usually in patients not able to Monitor patients at particular risk for
ask for water (eg, debilitated elderly or children), in hypernatremia, including debilitated or
those with impaired thirst regulation (eg, elderly), or elderly patients, acutely or critically ill
in those with heatstroke children, and patients receiving tube
Hypertonic tube feedings without water supplementation Monitor laboratory values closely in patients
Increased insensible water loss (eg, excessive sweating, with insensible fluid losses and in those
second- and third-degree burns, hyperventilation) receiving parenteral administration of
Excessive administration of sodium-containing fluids sodium-containing fluids.
(3% saline, sodium bicarbonate) Administer therapeutic medications,
Diabetes insipidus including vasopressin, desmopressin
Hyperaldosteronism, Cushings syndrome acetate (DDAVP).
Administer hypotonic fluids (1/2 saline to
free water, D5W).
Hypokalemia Gastrointestinal loss: diarrhea, laxatives, gastric suction Monitor laboratory values closely
Renal loss: potassium-losing diuretics, hyperaldosteronism, in patients at particular risk for
osmotic diuresis, steroids, some antibiotics hypokalemia.
Intracellular shifts: alkalosis, excessive secretion or Pay particular attention to potassium
administration of insulin, hyperalimentation level in patients receiving digoxin.
Poor intake: anorexia nervosa, alcoholism, debilitation Administer potassium either PO or IV.
Monitor magnesium levels in patients who
are refractory to potassium replacement.
Hyperkalemia Pseudohyperkalemia: prolonged tight application Ensure that minimal negative pressure is
of tourniquet; fist clenching and unclenching used to obtain all laboratory samples,
immediately before or during blood draws; particularly when drawn through
hemolysis of blood sample small-gauge needles.
Restrict potassium-sparing diuretics.

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Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 59

TA B LE 7- 6 Electrolyte Imbalances: Common Causes and Interventions (continued)

Selected Medical Conditions

Electrolyte Associated With Disturbance Collaborative Interventions
Decreased potassium excretion: oliguric renal failure, Promote excretion: sodium polystyrene
potassium-sparing diuretics, hypoaldosteronism sulfonate PO or per rectum, dialysis,
High potassium intake: improper use of oral potassium potassium-losing diuretics (eg,
supplements; rapid IV potassium administration furosemide)
Extracellular shifts: acidosis, crush injuries, tumor cell Emergency management measures:
lysis after chemotherapy calcium IV, sodium bicarbonate, IV
insulin with glucose, 2-adrenergic
Hypocalcemia Surgical hypoparathyroidism Monitor for signs and symptoms
Primary hypoparathyroidism associated with low calcium,
Malabsorption (alcoholism) especially for seizures, and stridor.
Acute pancreatitis Administer calcium IV for acute
Excessive administration of citrated blood replacement.
Alkalotic states Ensure adequate dietary intake for
Drugs (loop diuretics, mithramycin, calcitonin) patients at particular risk.
Medullary carcinoma of thyroid
Hypercalcemia Hyperparathyroidism Administer bisphosphonates, such
Malignant neoplastic disease as etidronate or mithramycin,
Drugs (thiazide diuretics, lithium, theophylline) especially when disorder is related to
Prolonged immobilization malignancy.
Dehydration Administer diuretics, such as loop
diuretics, to promote renal excretion.
Provide fluid replacement with 0.9% saline.
Hypomagnesemia Inadequate intake: starvation, TPN without adequate Monitor for hypokalemia in patients with
Mg2+ supplementation, chronic alcoholism low magnesium because kidneys are
Increased GI loss: diarrhea, laxatives, fistulas, not able to conserve potassium when
nasogastric tube suction, vomiting magnesium level is low.
Increased renal loss: drugs (loop and thiazide Administer magnesium IV for acute
diuretics, mannitol, amphotericin B), diuresis replacement.
(uncontrolled diabetes mellitus, hypoaldosteronism) Administer PO preparations for long-term
Changes in magnesium distribution: pancreatitis, replacement.
burns, insulin, blood products
Hypermagnesemia Renal failure Avoid administration of magnesium-
Excessive intake of magnesium-containing containing compounds to patients in
compounds (eg, antacids, mineral supplements, renal failure.
laxatives) In extreme cases, dialysis may be
Hypophosphatemia Refeeding syndrome Ensure nutritional intake.
Alcoholism Monitor phosphorus for the first few days
Phosphate-binding antacids after initiation of enteral or parenteral
Respiratory alkalosis nutrition.
Administration of exogenous insulin IV Administer by oral supplementation
Burns (Neutra-Phos capsules) or IV.
Hyperphosphatemia Renal failure Avoid administration of phosphorus to
Chemotherapy patients in renal failure.
Excessive administration of phosphate compounds Administer calcium acetate.
Administer IV fluids to promote renal
In severe cases, administration of high
levels of glucose with insulin may help
shift phosphorus intracellularly.

ADH, antidiuretic hormone; AIDS, acquired immunodeficiency syndrome; DDAVP, desmopressin acetate;
NSAID, nonsteroidal anti-inflammatory drug; SIADH, syndrome of inappropriate antidiuretic hormone; SSRI,
selective serotonin reuptake inhibitor.

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60 P A R T T W O Essential Interventions in Critical Care

Sodium BOX 7-7 Nursing Considerations for

Sodium is the major extracellular cation. It is a Intravenous Calcium Replacement
major contributor of serum osmolarity and con- Dilution
trols movement of water. Low serum sodium usu- Calcium can be delivered as calcium gluconate (4.5
ally indicates water intake in excess of sodium and mEq of elemental Ca2+) or calcium chloride (13.5
is characterized by an increase in body weight. It mEq of elemental Ca2+).
may also be due to a renal loss of sodium with a Calcium can be irritating to veins. If peripheral
normal intravascular volume. High serum sodium administration is required, calcium gluconate is rec-
usually indicates water loss in excess of sodium and ommended because damage can occur to surround-
is reected in weight loss. ing soft tissues.
Potassium Administer by slow IV push through central vein or
Potassium is the major intracellular cation. Potassium administer by mixing with compatible IV uids.
plays a key role in neuromuscular functioning and Administer slowly (over 1 to 2 hours) for patients
maintaining the myocardial resting potential. Both receiving digoxin.
high and low levels may result in alterations in the
cardiac rhythm. Because of the narrow range of
extracellular potassium balance, renal function is
essential to regulation of potassium. In critically ill
patients, disorders of potassium are common and
have numerous causes. Box 7-6 presents nursing Almost all (99%) of the calcium in the body is con-
considerations in potassium replacement. tained in the bone. The remaining 1% is intravascu-
lar, either bound to albumin or in an ionized (free)
form. The primary function of calcium is promotion
BOX 7-6 Nursing Considerations for of the neuromuscular impulse. Several clotting fac-
Intravenous Potassium Replacement tors also depend on calcium. Hypocalcemia in the
critically ill has numerous causes. Nursing consider-
Dilution ations for calcium replacement are given in Box 7-7.
Do not administer undiluted potassium directly IV. Many critically ill patients have low albumin,
Keep all vials of undiluted potassium away from which will result in a low serum calcium level. This
patient care area. laboratory nding does not necessarily mean that
Dilution of potassium depends on the amount of the patients ionized calcium (ie, readily available
uid the patient can tolerate. Highly concentrated calcium) is low. It is necessary to either assess ion-
potassium solutions can cause irritation, pain, and ized calcium (if available) or to correct the serum
sclerosing of vein. calcium for the albumin level, using the following
Typical concentrations of potassium are 10 to 40 formula:
mEq/100 mL. Premixed bags are available. Corrected calcium = [0.8 (normal albumin
patients albumin)] + serum
Peripheral IV Administration
In collaboration with prescribing provider, consider
the addition of a small volume of lidocaine to mini- Magnesium
mize pain.
Most of the magnesium in the body is in the skel-
Administer in central vein if available.
etal system and in the intracellular space. About 1%
For mild to moderate hypokalemia, rates of 10 to 20
circulates in the intravascular space. Magnesium is
mEq/h are recommended.
a catalyst for hundreds of enzymatic reactions and
Rates >40 mEq/h are not recommended.
plays a role in neurotransmission and cardiac con-
Use infusion pump to administer replacement.
traction. Magnesium is primarily excreted by the
Monitoring kidneys. Nursing considerations for magnesium
Monitor urinary output, blood urea nitrogen, and replacement are summarized in Box 7-8.
creatinine in patients receiving potassium replace-
ment. Patients with impaired renal function or Phosphorus
oliguric renal failure may experience transient
hyperkalemia. Consider smaller replacement dosages Phosphorus is the major intracellular anion. The
and periodic reevaluation. source of adenosine triphosphate (ATP), phospho-
When rate of administration exceeds 10 mEq/h, rus is critical to many life-sustaining processes, such
monitoring of cardiac rhythm is recommended. as muscle contraction, neuromuscular impulse con-
Assess magnesium level because correction of potas- duction, and the regulation of several intracellular
sium may be refractory to potassium replacement and extracellular electrolyte balances. Nursing con-
with concurrent hypomagnesemia. siderations for phosphorus replacement are sum-
marized in Box 7-9.

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Providing Nutritional Support, Fluids, and Electrolytes C H A P T E R 7 61

BOX 7-8 Nursing Considerations for BOX 7-9 Nursing Considerations for
Intravenous Magnesium Replacement Intravenous Phosphorus Replacement

Administration Phosphorus IV replacement is available as sodium

Administer with caution to patients with renal fail- or potassium phosphate. Phosphorus is dosed in mil-
ure because magnesium is primarily excreted by the limoles, whereas sodium and potassium are dosed in
kidneys. milliequivalents.
During emergencies, such as torsades de pointes, Administer sodium phosphate for patients with renal
magnesium may be injected directly. failure.
In mild to moderate hypomagnesemia, a rate of infu- Do not administer with calcium.
sion of 1 to 2 g over 1 hour is advisable. Administer over several hours, typically 15 to 30
Monitoring mmol phosphorus over 4 to 6 hours.
Monitor for hypotension or ushing during
Monitor deep tendon reexes periodically during

CASE STUDY References

1. McClave S, Martindale R, Varek V, et al.: Guidelines of
Mr. P. is a 62-year-old executive who is status parenteral and enteral nutrition. American Society for
Parenteral and Enteral Nutrition and Society of Critical
post cerebrovascular accident with severe dyspha- Care Medicine. J Parenter Enteral Nutr 33(3):277316, 2009.
gia. He has a medical history of gastroesophageal 2. A guide to enteral access procedures and enteral nutrition.
reflux disease, coronary artery disease, hyperten- Nat Rev Gastroenterol Hepatol Medscape Nurses, 2009.
sion, hypercholesterolemia, and type 2 diabetes 3. Montejo J, Minambres E, Bordeje L: Residual volume dur-
mellitus. He is currently prescribed pantoprazole, ing enteral nutrition in ICU patients: The REGANE study.
Intensive Care Med 36:13861393, 2010.
40 mg daily; aspirin, 81 mg daily; clopidogrel, 75 mg 4. Williams N: Medication administration through enteral
daily; metoprolol, 50 mg twice daily; simvastatin, feeding tubes. Am J Health-Syst Pharm 65(24):23472357,
20 mg daily; and 15 units Lantus insulin subcu- 2008.
taneously at bedtime. Because of Mr. P.s severe 5. Marino P, Sutin K. The ICU Book. Lippincott Williams &
Wilkins, 2008.
dysphagia, swallowing studies and calorie counts
are ordered to determine whether he will be able
to resume safe and adequate oral nutrition. In the
meantime, to ensure that Mr. P.s nutritional needs Want to know more? A wide variety of resources to enhance your learn-
are met, he is receiving enteral nutrition 400 mL ing and understanding of this chapter are available on . Visit
every 4 hours through a small-bore nasogastric tube. to access chapter review
Physical examination reveals a nontender, non- questions and more!
distended, obese abdomen with positive bowel
sounds. However, before the instillation of a sched-
uled feeding, the gastric residual volume is found
to be 300 mL. Subsequently, the nurse decides
to hold the enteral feedings for the remainder of
the day. The following morning, Mr. P. resumes his
scheduled enteral bolus feeds of 400 mL every
4 hours, and he is found to have minimal gastric
residuals. However, Mr. P. now reports abdominal
cramps, bloating, and diarrhea after each bolus
feeding; abdominal examination reveals positive
bowel sounds with mild abdominal distention.
Because of these multiple issues, the nurse recom-
mends to the physician that a central line be placed
and that Mr. P. be started on total parenteral nutrition
(TPN) to meet his long-term nutritional requirements.
1. Initially the nurse held the enteral tube feedings
based on the residual volume measurement. Was
this an appropriate action to take? Why or why not?
2. What was the most likely etiology of the patients
diarrhea? What interventions are needed, if any?
3. Is total parenteral nutrition (TPN) appropriate for this
patient? Why or why not?

Morton_Chap07.indd 61 2/4/2012 2:33:07 PM

Dysrhythmia Interpretation

8 and Management

Based on the content in this chapter, the reader should be able to:
1 Describe the major clinical uses of the 12-lead electrocardiogram (ECG) and
interpret a rhythm strip.
2 Explain the major features of a cardiac monitoring system.
3 Describe the causes, clinical significance, ECG appearance, and management
of major types of dysrhythmias.
4 Describe nursing considerations specific to antidysrhythmic agents.
5 Describe the indications for electrical cardioversion.
6 Describe the critical care nurses role in caring for a patient undergoing
radiofrequency ablation.
7 Describe the critical care nurses role in caring for a patient undergoing cardiac
8 Explain the major features of an implantable cardioverterdefibrillator (ICD).

Standard 12-Lead Electrocardiogram system, and ventricles. During the cardiac cycle, the
following waveforms and intervals are produced on
An electrocardiogram (ECG) is a graphic recording the ECG surface tracing (see Fig. 8-1):
of the hearts electrical activity. The paper consists of P wave: The P wave is a small, usually upright and
horizontal and vertical lines, each 1 mm apart. The rounded deection representing depolarization of
horizontal lines denote time measurements. When the the atria. It normally is seen before the QRS com-
paper is run at a sweep speed of 25 mm/s, each small plex at a consistent interval.
square measured horizontally is equal to 0.04 second, PR interval: The PR interval represents the time
and each large square (ve small squares) equals from the onset of atrial depolarization until the
0.2 second. Height (voltage) is measured by counting onset of ventricular depolarization. Included in
the lines vertically. Each small square measured verti- the interval is the brief delay at the AV node that
cally is 1 mm, and each large square is 5 mm (Fig. 8-1). allows time for atrial contraction before the ven-
tricles are depolarized. The interval is measured
Waveforms and Intervals from the beginning of the P wave to the begin-
ning of the QRS complex. A normal PR interval is
The hearts normal route of depolarization moves 0.12 to 0.2 second.
from the sinoatrial (SA) node and atria, downward QRS complex: The QRS complex represents ven-
through the atrioventricular (AV) node, HisPurkinje tricular depolarization. A normal QRS complex is


Morton_Chap08.indd 62 2/4/2012 2:34:01 PM

Dysrhythmia Interpretation and Management C H A P T E R 8 63


QT interval: The QT interval is the period from the
0.5 mV (5 mm) beginning of ventricular depolarization to the end
of ventricular repolarization. The QT interval is
Q-T Interval measured from the beginning of the QRS complex
to the end of the T wave.
Isoelectric Line
P-R Interval Views (Leads)
Negative Positive Deflection

S-T Interval
A standard 12-lead ECG produces 12 electrical
views of the heart using 10 electrodes (Fig. 8-3).
T For the limb leads, the recording device alternates
U the combination of electrodes that are active dur-
ing recording of electrical signals from the heart
Q S (Fig. 8-4). This produces six standard views (leads)

QRS Interval that are recorded in the hearts frontal plane: I,

HORIZONTAL II, III, augmented voltage of the right arm (aVR),
augmented voltage of the left arm (aVL), and aug-
F I G U R E 8 - 1 The waveforms and intervals of the electrocardiogram mented voltage of the left foot (aVF). The six pre-
(ECG) represent the electrical impulse as it traverses the conduc- cordial leads (V1, V2, V3, V4, V5, and V6) are arranged
tion system, resulting in depolarization and repolarization of the
across the left side of the anterior chest to record
electrical activity in the hearts horizontal plane
(see Fig. 8-3). Additional horizontal plane leads
0.06 to 0.11 second in width (Fig. 8-2). Atrial repo- may be recorded by placing precordial electrodes
larization, which occurs during the QRS complex, on the right side of the chest to view right ventricu-
is not represented by a wave on the ECG. lar activity or the back of the chest to view left ven-
ST segment: The ST segment is the portion of tricular posterior wall activity (see Fig. 8-3). The
the tracing from the end of the QRS complex to positive electrode acts as a camera, providing a
the beginning of the T wave. It represents the time view of the heart from that perspective (Table 8-1).
from the end of ventricular depolarization to the The appearance of the intervals and waveforms on
beginning of ventricular repolarization. Normally, the ECG varies slightly according to which lead is
it is isoelectric (ie, the ST segment joins the QRS being viewed (Table 8-2).
complex at the baseline). ST segments may be ele-
vated or depressed in acute myocardial injury or RED FLAG! Proper placement of the electrodes is
ischemia (see Chapter 14). very important. Misplacement of an electrode by
T wave: The T wave is the deection representing as little as one intercostal space can cause QRS
ventricular repolarization and appears after the morphology to change, leading to misdiagnoses.
QRS complex.
U wave: A U wave is a small, usually positive Uses of the 12-Lead Electrocardiogram
deection after the T wave that is typically seen
only in hypokalemia. In addition to being used to detect dysrhythmias,
the 12-lead ECG is used to determine the electrical
axis of the heart; detect atrial or ventricular enlarge-
ment; and detect patterns of ischemia, injury, or

Detection of Dysrhythmias
The 12-lead ECG provides a visual representation of
the major events of the cardiac cycle, and therefore
is useful for detecting dysrhythmias and estimating
atrial and ventricular rates (Box 8-1). A systematic
approach to assessing a rhythm strip is given in
Box 8-2 on page 66. It is important to take the time
to complete each step because many dysrhythmias
are not as they rst appear. Specic dysrhythmias are
discussed in more detail later in this chapter. Because
of the effects of electrolytes on the electrical impulse
of the heart, ECG changes may also raise suspicion
for serum electrolyte imbalances (Table 8-3, p. 66).

F I G U R E 8 - 2 Configurations of the QRS complex. A Q wave is a neg- Determination of Electrical Axis

ative deflection before an R wave, an R wave is a positive deflec- Electrical axis refers to the general direction of the
tion, and an S wave is a negative deflection after an R wave. wave of excitation as it moves through the heart.

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64 P A R T T W O Essential Interventions in Critical Care

Supplemental Right Precordial Leads

Midclavicular line
Anterior axillary line
Midaxillary line


Horizontal plane V5R V3R
of V4 V6 V4R

V1 V 2 V 4 V 6


V7 V8 V9
Posterior view


ECG machine
ECG strip

F I G U R E 8 - 3 Electrocardiogram (ECG) electrode placement. The standard left precordial leads are V1
through V6. The right precordial leads, placed across the right side of the chest, are the mirror opposite of
the left leads. The posterior leads (V7 through V9) are placed on the back to the left of the spine on the same
horizontal line as V6.

In the normal heart, the ow of electrical forces is

downward and to the left, a pattern known as nor-
mal axis. Because the ventricles make up the larg-
est muscle mass of the heart and therefore make the
most signicant contribution to the determination
of the direction of the ow of forces, the QRS com-
plex is examined in leads I and aVF to determine
the electrical axis (Fig. 8-5, p. 67).The direction of
the ow of forces in the heart can shift to the left
Lead I
or to the right as a result of an anatomical shift of
the heart (eg, in very obese patients and in patients
R L with large abdominal tumors or abdominal ascites),

TA B LE 8 -1 Electrocardiographic Leads and


Corresponding Views of the Heart

Lead II Lead III
Placement of
Lead Positive Electrode View of the Heart
II, III, aVF Left leg Inferior
I, aVL, V5, and V6 Left arm, chest Left lateral
F I G U R E 8 - 4 Frontal plane leads: standard limb leads, I, II, III, plus V1 through V4 Chest (left side) Anteroseptal
augmented leads aVR, aVL, and aVF. This allows an examination of V4R through V6R Chest (right side) Right ventricle
electrical conduction across a variety of planes (eg, left arm to leg, V7 through V9 Chest Posterior
right arm to left arm).

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Dysrhythmia Interpretation and Management C H A P T E R 8 65

TA B LE 8- 2 The Normal 12-Lead Electrocardiogram (ECG)

Waveform or Interval
Lead P Q R S ST T
I Upright Small, 0.04 s, or Dominant Less than R or none Isoelectric +1 to 0.5 Upright
none mm
II Upright Small or none Dominant Less than R or none +1 to 0.5 mm Upright
III Upright Small or none None to dominant None to dominant +1 to 0.5 mm Upright
Flat Flat
Diphasic Diphasic
Inverted Inverted
aVR Inverted Small, none, or Small or none Dominant +1 to 0.5 mm Inverted
aVL Upright Small, none, or Small, none, or dominant Small, none, or dominant +1 to 0.5 mm Upright
Flat Flat
Diphasic Diphasic
Inverted Inverted
aVF Upright Small or none Small, none, or dominant None to dominant +1 to 0.5 mm Upright
Flat Dominant
V1 Upright None Small Deep 0 to +3 mm Inverted
Flat May be QS Flat
Diphasic Upright
V2 Upright None 0 to +3 mm Upright
V3 Upright Small or none 0 to +3 mm Upright
V4 Upright Small or none +1 to 0.5 mm Upright
V5 Upright Small +1 to 0.5 mm Upright
V6 Upright Small Tall Small or none +1 to 0.5 mm Upright

BOX 8-1 Estimating Heart Rate Using the Electrocardiogram (ECG)

Method 1. This method works for regular or irregular


rhythms. Count the number of QRS complexes in a





6-second strip and multiply by 10 (to estimate the
ventricular rate). Count the number of P waves in a
6-second strip and multiply by 10 (to estimate the
atrial rate).
Method 2. If the rhythm is regular, divide 300 by the
number of large boxes on the ECG paper between two
R waves (ventricular rate) and between two P waves
(atrial rate).
Method 3. Find a QRS complex that falls directly on
a dark line of the ECG paper. This dark line becomes
the reference point, and the next six dark lines of the
paper are labeled 300, 150, 100, 75, 60, and 50.
The QRS complex immediately after the reference
point is used to estimate ventricular rate (eg, in the
gure above, the ventricular rate is approximately 85
beats/min). The same method can be used for estimat-
ing atrial rate by using the P waves.

RED FLAG! Estimating the heart rate using

the ECG strip or cardiac monitor should never be
substituted for determining the heart rate by
palpating the pulse. In some situations, electrical
activity can occur without contraction. Therefore,
palpation of the pulse is a more accurate method
of determining heart rate.

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66 P A R T T W O Essential Interventions in Critical Care

BOX 8-2 Assessing a Rhythm Strip

1. Determine the atrial and ventricular heart 4. Measure the PR interval.

rates. Is it normal?
Are they within normal limits? Is it the same throughout the strip, or does it vary?
If not, is there a relationship between the two If it varies, is there a pattern to the variation?
(ie, one a multiple of the other)? 5. Evaluate the QRS complex.
2. Examine the rhythm to see if it is regular. Is it normal in width, or is it wide?
Is there an equal amount of time between each QRS Are all complexes of the same conguration?
complex (RR interval)? 6. Examine the ST segment.
Is there an equal amount of time between each Is it isoelectric, elevated, or depressed?
P wave (PP interval)? 7. Identify the rhythm and determine its clinical
Are the PP and RR intervals the same? signicance.
3. Look for the P waves. Is the patient symptomatic? (Check skin,
Are they present? neurological status, renal function, coronary circu-
Are they upright? lation, and hemodynamic status or blood pressure.)
Is there one or more P waves for each QRS Is the dysrhythmia life threatening?
complex? What is the clinical context?
Do all P waves have the same conguration? Is the dysrhythmia new or chronic?

conduction defects (eg, left or right bundle branch suggestive of right ventricular hypertrophy includes
block), ventricular enlargement (left or right), or right atrial enlargement and right axis deviation. In
myocardial infarction (eg, inferior wall or anterior addition, the normal QRS complex pattern across
wall). the precordial leads is reversed. Normally, R waves
are small in V1 and gradually grow tall by V6. With
Enlargement Patterns right ventricular hypertrophy, the R wave is tall in
Enlargement of a cardiac chamber may involve V1 and progresses to small by V6. Precordial S waves
hypertrophy of the muscle or dilation of the cham- persist rather than gradually disappear.
ber. The term ventricular hypertrophy is com- Left ventricular hypertrophy, often seen in
monly used to describe ventricular changes because chronic systemic hypertension or aortic stenosis,
hypertrophy is the most frequent cause of ventricu- can be detected on the ECG by adding the deepest
lar enlargement. However, the term atrial enlarge- S wave in either lead V1 or V2 to the tallest R wave
ment is often used (instead of the more specic in either lead V5 or V6. If the sum is 35 mm or more
atrial hypertrophy) to describe atrial changes and the patient is older than 35 years of age, left ven-
because atrial changes on the ECG may result from tricular hypertrophy is suspected. In addition, the
a variety of causes. T waves in leads V5 and V6 may be asymmetrically
inverted, and a left axis shift is likely.
Ventricular Hypertrophy
Right ventricular hypertrophy, often seen in chronic Atrial Enlargement
pulmonary conditions, may exist without clear evi- When the atria enlarge, changes are seen in the
dence on the ECG because the left ventricle nor- P wave because the P wave represents atrial depo-
mally is larger than the right and can mask changes larization (Fig. 8-6). Right atrial enlargement (P pul-
in the size of the right ventricle. ECG evidence monale) often has an underlying pulmonary cause

TA B L E 8 - 3 Electrocardiographic Changes Associated With Electrolyte Imbalances

Electrolyte Imbalance Possible Electrocardiographic Findings Possible Resultant Dysrhythmias
Hyperkalemia Tall, narrow, peaked T waves; flat, wide P waves; Sinus bradycardia; sinoatrial block;
widening of the QRS complex junctional rhythm; idioventricular rhythm;
ventricular tachycardia; ventricular
Hypokalemia Prominent U waves; ST-segment depression; Premature ventricular beats;
T-wave flattening or inversion supraventricular tachycardia; ventricular
tachycardia; ventricular fibrillation
Hypercalcemia Shortened QT interval Premature ventricular contractions (PVCs)
Hypocalcemia Lengthened QT interval; T-wave flattening or Ventricular tachycardia

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Dysrhythmia Interpretation and Management C H A P T E R 8 67

T-wave inversions. Acute patterns of injury are

I aVF 90 aVF
noted by ST-segment elevations. The presence of
I signicant Q waves indicates a myocardial infarc-
Extreme Left tion. A more detailed discussion of patterns of
right axis axis ischemia, injury, and infarction is provided in
deviation deviation Chapter 14.
+180 0 Lead I
Right Normal
axis axis
deviation Cardiac Monitoring
I Cardiac monitoring is used when it is necessary
aVF +90 I aVF to monitor continuously a patients heart rate and
Lead aVF rhythm. All monitoring systems have three basic
F I G U R E 8 - 5 The electrical axis of the heart is determined by exam-
components: electrodes, a monitoring cable, and
ining the direction of the QRS complex (negative or positive) in a display screen (cardiac monitor). Electrodes are
leads I and aVF. placed on the patients chest to receive the electrical
current from the cardiac muscle tissue. The electri-
cal signal is then carried by the monitoring cable to
and is often seen in association with right ventricu- the cardiac monitor.
lar hypertrophy. It is noted on the ECG by the pres- Cardiac monitoring systems may incorporate sev-
ence of tall, pointed P waves in leads II, III, and aVF. eral advanced features, such as
The P wave in lead V1 may show a diphasic wave Computer systems that store, analyze, and trend
with an initial upstroke that is larger than the down- monitored data, facilitating retrieval of informa-
stroke (see Fig. 8-6B). Left atrial enlargement (P tion to aid in diagnosis and to track trends in the
mitrale) is often associated with mitral valve steno- patients status
sis. It is noted on the ECG by the presence of broad, Automatic chart documentation (the ECG recorder
notched P waves in leads I, II, and aVL. The P wave is activated by alarms or at preset intervals)
in lead V1 may show a diphasic wave with a terminal Expanded alarm systems
downstroke that is larger than the initial upstroke Multilead or 12-lead ECG displays to facilitate
(see Fig. 8-6C). complex dysrhythmia interpretation
ST-segment analysis for monitoring ischemic
Ischemia, Injury, and Infarction Patterns events1
The 12-lead ECG can be useful in detecting myo- QT-interval monitoring2
cardial ischemia, injury, or infarction. Ischemia is Wireless communication devices that provide data
seen on the ECG as ST-segment depressions and and alarms and can be carried by the nurse

lead II lead II lead II

lead V1 lead V1 lead V1

F I G U R E 8 - 6 Atrial enlargement patterns. A: The normal P wave in leads II and V1. B: Right atrial enlarge-
ment. Note the tall, pointed P wave in lead II and the increased amplitude of the early, right atrial component
of the P wave in V1. C: Left atrial enlargement. Note the broad, notched P wave in lead II and the increased
amplitude and duration of the P wave in V1.

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68 P A R T T W O Essential Interventions in Critical Care

monitoring cable. Information is displayed and

EVIDENCE-BASED PRACTICE GUIDELINES recorded at the bedside and at a central station
ST-Segment Monitoring simultaneously. Because patient mobility is lim-
ited, hard-wire monitoring systems can only be
PROBLEM: Research demonstrates that monitoring for
used for patients who are on bedrest or conned
ST-segment changes in multiple leads, preferably 12
to the bedside.
leads, substantially improves the chance of identifying
Telemetry monitoring systems do not require a
ischemic events, including silent (asymptomatic) ischemia.
direct wire connection between the patient and
EVIDENCE-BASED PRACTICE GUIDELINES the cardiac monitor. Electrodes are connected by a
short monitoring cable to a small battery-operated
1. If 12-lead electrocardiography is available, ST-segment transmitter, which sends radiofrequency signals to
monitoring should be performed using all 12 leads. (level V) a receiver that picks up and displays the signal on
2. If 12-lead electrocardiography is not available, leads a monitor either at the bedside or at a central sta-
for ST-segment monitoring are selected based on the tion. Although telemetry monitoring systems allow
patients needs and risk for ischemia. for more patient mobility, because the patient is
Patients with acute coronary syndrome (ACS) and a known mobile, stable ECG tracings often are more dif-
ST fingerprint (ie, a pattern of ST-segment elevation, cult to obtain.
depression, or both that is unique to the patient based on the
site of coronary occlusion, obtained during a known ischemic Some hard-wire systems have built-in telemetry
event): Use the lead that best displays the patients ST finger- capability so that patients may be switched easily
print when monitoring. (level V) from one system to another as monitoring needs
Patients with ACS but no known ST fingerprint: Use leads III change.
and V3. (level IV) Commonly used cardiac monitoring systems
Patients without definitive ACS, but in whom ACS is sus- include a three-electrode system and a ve-electrode
pected or being ruled out: Use leads III and V5. system (Fig. 8-7). The three-electrode system allows
Noncardiac patients undergoing surgical procedures: Use lead monitoring of leads I, II, or III with only a single
V5 (useful for identifying demand-related ischemia). (level IV) lead viewed on the monitor at one time (single-
3. Once proper lead placement has been determined, mark channel recording) (Fig. 8-8). The three-electrode
the skin electrode placement with indelible ink. Do not system can also be used to obtain a modied version
alter the location of the skin electrodes during monitor- of any of the six chest leads, referred to as MCL1
ing because this can cause false-positive ST-segment through MCL6. Five-electrode systems allow moni-
changes. (level II) toring of any of the 12 leads, with two or more leads
4. Set the ST alarm parameter 1 to 2 mm above and below viewed on the monitor simultaneously (multichan-
the patients baseline ST segment. (level II) nel recording). Lead selection depends on the clini-
5. Evaluate the ST segment with the patient in the supine cal situation (Table 8-4, p. 70). Often, multichannel
position. (level IV) recording is desirable.
6. Recognize that ST depression or elevation of 1 to 2 mm Troubleshooting cardiac monitoring problems is
that lasts for 1 minute or more can be clinically significant summarized in Box 8-3 on page 70.
and requires further assessment. (level II)

KEY Common Dysrhythmias

Level I: Manufacturers recommendations only
Level II: Theory based, no research data to support recommenda-
Dysrhythmias Originating at the Sinus
tions, but recommendations from expert consensus group may Node
Box 8-4 on page 71 summarizes and compares ECG
Level III: Laboratory data, no clinical data to support
characteristics of sinus rhythms.
Level IV: Limited clinical studies to support recommendations
Sinus Tachycardia
Level V: Clinical studies in more than one or two patient populations
and situations to support recommendations
In sinus tachycardia, the sinus node initiates an
impulse at a rate of 100 beats/min (up to 160 to 180
Level VI: Clinical studies in a variety of patient populations and situ-
beats/min). Stress, exercise, stimulants (eg, caffeine,
ations to support recommendations
nicotine), clinical conditions (eg, fever, anemia,
Adapted from American Association of Critical-Care Nurses (AACN) Prac- hyperthyroidism, hypoxemia, heart failure, shock),
tice Alert, revised 5/2009. and medications (eg, atropine, epinephrine, dopa-
mine) can cause sinus tachycardia. The rapid rate
of sinus tachycardia increases oxygen demands on
There are two types of cardiac monitoring systems: the myocardium and decreases the lling time of
the ventricles, and if allowed to persist, may worsen
Hard-wire monitoring systems, commonly used underlying conditions such as heart failure or
in critical care units, require the patient to be ischemia. Treatment is directed at eliminating the
linked directly to the cardiac monitor via the underlying cause.

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Dysrhythmia Interpretation and Management C H A P T E R 8 69



F I G U R E 8 - 7 Cardiac monitoring. A: Three-electrode monitoring system. Leads placed in this position allow
the nurse to monitor leads I, II, and III. The left leg electrode must be placed below the level of the heart.
B: Five-electrode monitoring system. Using a five-electrode system allows the nurse to monitor any of the
12 leads of the electrocardiogram (ECG). The chest electrode must be moved to the appropriate chest loca-
tion when monitoring the precordial leads. C, chest; LA, left arm; LL, left leg; RA, right arm, RL, right leg.

Sinus Bradycardia
In sinus bradycardia, the sinus node initiates
impulses at a rate of less than 60 beats/min. Sinus
bradycardia is present in both healthy and diseased
hearts. It may be associated with sleep, severe pain,
inferior wall myocardial infarction, acute spinal
cord injury, and certain drugs (eg, digoxin, -adren-
ergic blockers, verapamil, diltiazem). In people with
healthy hearts, slow heart rates are tolerated well.
However, in those with severe heart disease, the
heart may not be able to compensate for a slow rate
by increasing the stroke volume. In this situation,
sinus bradycardia leads to a low cardiac output. No
treatment is indicated unless symptoms are present.
Lead I
If the pulse is very slow and the patient is symptom-
atic, appropriate measures include atropine or car-
diac pacing.

Sinus Dysrhythmia
Sinus dysrhythmia is caused by an irregularity
in sinus node discharge, often in association with
phases of the respiratory cycle (ie, the sinus node
rate gradually increases with inspiration and gradu-
Lead II Lead III ally decreases with expiration). On the ECG, the RR
intervals (from the shortest to the longest) vary by
more than 0.12 second. Sinus dysrhythmia is often
normal, especially in young people with lower heart
rates. It also occurs after enhancement of vagal
tone (eg, with digoxin or morphine). Symptoms
are uncommon unless there are excessively long
F I G U R E 8 - 8 Leads I, II, or III may be viewed with a three-electrode pauses between heartbeats; usually no treatment is
system. required.

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70 P A R T T W O Essential Interventions in Critical Care

TA B L E 8 - 4 Suggested Monitoring Lead Selection

Lead Rationale for Use
II Produces large, upright visible P waves and QRS complexes for determining underlying rhythm
V1 or MCL1 Helpful for detecting right bundle branch block and to differentiate ventricular ectopy from supraventricular
rhythm aberrantly conducted in the ventricles
V6 or MCL6 Helpful for detecting left bundle branch block and to differentiate ventricular ectopy from supraventricular
rhythm aberrantly conducted in the ventricles
III, aVF, V1 Produce visible P waves; useful in detecting atrial dysrhythmias
I Useful in patients with respiratory distress
Less affected by chest motion compared with other leads due to the lead placement
II, III, aVF Helpful in detecting ischemia, injury, and infarction in the inferior wall left ventricle
I, aVL, V5, V6 Helpful in detecting ischemia, injury, and infarction in the lateral wall left ventricle
V1 through V4 Helpful in detecting ischemia, injury, and infarction in the septal and anterior wall left ventricle

Sinus Arrest and Sinoatrial Block AV node or the ventricles) takes over or when sinus
node function returns. In SA block, the sinus node
In sinus arrest, the sinus node fails to form a dis-
res, but the impulse is delayed or blocked from
charge, producing pauses of varying lengths because
exiting the sinus node. SA block often is difcult to
of the absence of atrial depolarization (P wave). The
differentiate from sinus arrest on the ECG.
pause ends either when another pacemaker (eg, the

BOX 8-3 Troubleshooting Cardiac Monitoring Problems

Excessive Triggering of Heart Rate Alarms Are the electrode wires rmly attached to the
Is the highlow alarm set too close to the patients electrodes?
heart rate? Are the electrode wire connectors loose or worn?
Is the monitor sensitivity level set too high or too low? Have the electrodes been applied properly?
Is the patient cable securely inserted into the monitor Are the electrodes properly located and in rm skin
receptacle? contact?
Are the lead wires or connections damaged? Is the patient cable damaged?
Has the monitoring lead been properly selected?
Wandering or Irregular Baseline
Were the electrodes applied properly?
Is there excessive cable movement? This can be
Are the R and T waves the same height, causing both
reduced by clipping to the patients clothing.
waveforms to be sensed?
Is the power cord on or near the monitor cable?
Is the baseline unstable, or is there excessive cable or
Is there excessive movement by the patient? Are there
lead wire movement?
muscle tremors from anxiety or shivering?
Baseline but No Electrocardiogram (ECG) Trace Is site selection correct?
Is the size (gain or sensitivity) control properly Were proper skin preparation and application proce-
adjusted? dures followed?
Is an appropriate lead selector being used on the Are the electrodes still moist?
Low-Amplitude Complexes
Is the patient cable fully inserted into the ECG
Is size control adjusted properly?
Were the electrodes applied properly?
Are the electrode wires fully inserted into the patient
Is there dried gel on the electrodes?
Change electrode sites. Check 12-lead ECG for lead with
Are the electrode wires rmly attached to the
highest amplitude, and attempt to simulate that lead.
If none of the preceding steps remedies the problem,
Are the electrode wires damaged?
the weak signal may be the patients normal complex.
Is the patient cable damaged?
Call for service if the trace is still absent. Sixty-Cycle Interference
Is the battery dead (for telemetry system)? Is the monitor size control set too high?
Are there nearby electrical devices in use, especially
Intermittent Trace
poorly grounded ones?
Is the patient cable fully inserted into the monitor
Were the electrodes applied properly?
Is there dried gel on the electrodes?
Are the electrode wires fully inserted into the patient
Are lead wires or connections damaged?

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Dysrhythmia Interpretation and Management C H A P T E R 8 71

BOX 8-4 Dysrhythmias Originating at the Sinus Node

Normal Sinus
Rhythm Sinus Tachycardia Sinus Bradycardia Sinus Dysrhythmia

Rate 60 to 100 beats/min Greater than 100 beats/min Less than 60 beats/min 60 to 100 beats/min
Rhythm Regular Regular Regular Irregular
P waves Present, one per QRS Present, one per QRS Present, one per QRS Present, one per QRS
PR interval Less than 0.20 s, equal Less than 0.20 s, equal Less than 0.20 s, equal Less than 0.20 s, equal
QRS complex Less than 0.12 s Less than 0.12 s Less than 0.12 s Less than 0.12 s

Normal sinus rhythm Sinus tachycardia

Sinus bradycardia Sinus arrhythmia

Both dysrhythmias may result from disruption of Management entails control of the rapid atrial dys-
the sinus node by infarction, degenerative brotic rhythmias with drug therapy and, in some cases,
changes, drugs (eg, digoxin, -adrenergic blockers, control of very slow heart rates with implantation of
calcium channel blockers), or excessive vagal stim- a permanent pacemaker.
ulation. These rhythms usually are transient and
insignicant unless a lower pacemaker fails to take Atrial Dysrhythmias
over to pace the ventricles. Treatment to increase the
ventricular rate is indicated if the patient is symp- Premature Atrial Contraction
tomatic. In the presence of serious hemodynamic A premature atrial contraction (PAC) occurs when
compromise, a pacemaker may be required. an ectopic atrial impulse discharges prematurely
and, in most cases, is conducted in a normal fashion
Sick Sinus Syndrome to the ventricles. On the ECG tracing, the P wave is
Sick sinus syndrome is a chronic form of sinus node premature and may even be buried in the preced-
disease. Patients exhibit severe degrees of sinus node ing T wave; it often differs in conguration from the
depression, including marked sinus bradycardia, SA sinus P wave (Fig. 8-10). The QRS complex usually
block, or sinus arrest. Often, rapid atrial dysrhyth- is of normal conguration. A short pause, usually
mias, such as atrial utter or brillation (tachycar- less than compensatory, is present. (A pause is
diabradycardia syndrome), coexist and alternate considered fully compensatory if the cycles of the
with periods of sinus node depression (Fig. 8-9). normal and premature beats equal the time of two
normal heart cycles.) Patients may have the sensa-
tion of a pause or skip in a heartbeat when PACs
are present.
PACs may occur in healthy people as a result
of emotions or stimulants (eg, tobacco, alcohol,
caffeine). PACs also may be associated with rheu-
matic heart disease, ischemic heart disease, mitral
stenosis, heart failure, hypokalemia, hypomagne-
semia, medications, and hyperthyroidism. In some
F I G U R E 8 - 9 Sick sinus syndrome. Atrial fibrillation is followed by patients, PACs are indicative of increasing atrial
atrial standstill. A sinus escape beat is seen at the end of the strip. irritability and are a precursor to atrial tachycardia,

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72 P A R T T W O Essential Interventions in Critical Care

Premature P wave

F I G U R E 8 - 1 0 Premature atrial contraction (PAC).

F I G U R E 8 - 1 1 Paroxysmal supraventricular tachycardia (PSVT),

atrial brillation, or atrial utter. Treatment, if indi- which begins with a premature atrial contraction (PAC).
cated, is aimed at identifying and addressing the
underlying cause.
These patients may develop dyspnea, angina pecto-
Paroxysmal Supraventricular Tachycardia ris, and heart failure as ventricular lling time, and
Paroxysmal supraventricular tachycardia (PSVT) is thus cardiac output, is decreased.
a rapid atrial rhythm occurring at a rate of 150 to A vagal maneuver (eg, carotid sinus massage)
250 beats/min (Fig. 8-11). PSVT is also known as AV may be used to terminate the PSVT. If vagal stimu-
nodal reentrant tachycardia because the mechanism lation is unsuccessful, IV adenosine may be given.
most commonly responsible for this dysrhythmia is Cardioversion or overdrive pacing (ie, using a pace-
a reentrant circuit at the level of the AV node. The maker to pace the heart at a rate faster than the
tachycardia begins abruptly, usually with a PAC, patients intrinsic rate to suppress the tachycardia)
and it ends abruptly. The rhythm is regular, and the may be required if drug therapy is unsuccessful.
paroxysms may last from a few seconds to several Long-term prophylactic therapy may be indicated.
hours or even days. P waves may precede the QRS
complex but also may be hidden in the T waves at Atrial Flutter
faster rates. The P waves may be negative in leads II, Atrial utter is a rapid atrial ectopic rhythm in
III, and aVF because of retrograde conduction from which the atria re at rates of 250 to 350 beats/ min
the AV node to the atria. The QRS complex usually (Fig. 8-12). The AV node, which functions as a gate-
is normal unless there is an underlying intraven- keeper, may allow only every second, third, or
tricular conduction problem. PSVT must be differ- fourth atrial stimulus to proceed to the ventricles,
entiated from other supraventricular narrow QRS resulting in what is known as a 2:1, 3:1, or 4:1 ut-
complex tachycardias (Table 8-5). ter block. The rapid and regular atrial rate produces
Like PACs, PSVT often occurs in adults with sawtooth or picket-fence P waves on the ECG. It
healthy hearts in response to emotions or stimu- is usual for a utter wave to be partially concealed
lants. Patients without underlying heart disease may in the QRS complex or T wave. The QRS complex
experience palpitations and some light-headedness, exhibits a normal conguration except when aber-
depending on the rate and duration of the PSVT. rant conduction is present. When the ventricular
Rheumatic heart disease, acute myocardial infarc- rate is rapid, the diagnosis of atrial utter may be
tion, and digoxin toxicity may also produce PSVT. difcult. Vagal maneuvers or administration of

TA B L E 8 - 5 Differential Diagnosis of Narrow QRS Tachycardia

Type of
Supraventricular Response to
Tachycardia Onset Atrial Rate Ventricular Rate RR Interval Carotid Massage
Sinus tachycardia Gradual 100180 beats/min Same as sinus rate Regular Gradual slowing
Paroxysmal Abrupt 150250 beats/min Usually same as atrial Regular, except May convert to
supraventricular rate; block seen with at onset and normal sinus
tachycardia digoxin toxicity and termination rhythm
(PSVT) AV node disease
Atrial flutter Abrupt 250350 beats/min Occurs with 2:1, Regular or Abrupt slowing
3:1, 4:1, or varied regularly of ventricular
ventricular response irregular response; flutter
waves remain
Atrial fibrillation Abrupt 400650 beats/min Depends on ability of Irregularly Abrupt slowing
AV node to conduct irregular of ventricular
atrial impulse; response;
decreased with drug fibrillation waves
therapy remain

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Dysrhythmia Interpretation and Management C H A P T E R 8 73

response and the formation of emboli. If the ven-

tricular rate is too fast, end-diastolic lling time
is decreased, and cardiac output is compromised.
A ventricular rate that is too slow can also decrease
cardiac output. Patients are at risk for the forma-
tion of mural thrombi in the brillating atrium and
embolic events (eg, stroke, myocardial infarction,
F I G U R E 8 - 1 2 Atrial flutter. P waves show a characteristic saw- pulmonary embolus). The treatment principles for
toothed pattern. atrial brillation are the same as those for atrial
adenosine increase the degree of AV block and allow
recognition of utter waves. Junctional Dysrhythmias
Atrial utter often is seen in the presence of
underlying cardiac disease, including coronary Junctional (Nodal) Rhythm
artery disease (CAD), right-sided heart failure, and A junctional (nodal) rhythm originates in the AV
rheumatic heart disease. Treatment goals are to rees- node. When the SA node fails to re, the AV node
tablish sinus rhythm or, when the ventricular rate is usually takes control, but the rate is slower. The
rapid, to achieve ventricular rate control. Drugs may rate of a junctional rhythm ranges between 40 and
be selected to slow the conduction of the impulses 60 beats/min. The P wave in the dysrhythmia can
through the AV node or to achieve pharmacological have one of three possible congurations:
conversion of the rhythm. If pharmacological con-
version is not successful, electrical cardioversion 1. The AV node res, and the wave of depolarization
can be used. If the patient has been experiencing travels backward (retrograde conduction) into the
atrial utter for more than 72 hours, anticoagula- atria. The impulse from the AV node then moves
tion may be needed before pharmacological or elec- forward into the ventricle. On the ECG, the P
trical conversion of the rhythm is attempted. Other wave appears as an inverted wave before a normal
therapies that may be indicated for the long-term QRS complex (Fig. 8-14A).
management of atrial utter include ablation, pac- 2. The retrograde conduction into the atria occurs at
ing, and use of an implantable cardioverterdebril- the same time as the forward conduction into the
lator (ICD). ventricles. The resulting rhythm strip shows an
absent P wave with a normal QRS complex (see
Atrial Fibrillation Fig. 8-14B). In reality, the P wave is not absent; it
is buried inside the QRS complex.
Atrial brillation is a rapid atrial ectopic rhythm, 3. Forward conduction into the ventricles precedes
occurring with atrial rates of 350 to 500 beats/min retrograde conduction into the atria. On the ECG,
(Fig. 8-13). It is characterized by chaotic atrial activ- a normal QRS complex is followed by an inverted
ity with small, quivering brillatory waves. As in P wave (see Fig. 8-14C).
atrial utter, the ventricular rate and rhythm depend
on the ability of the AV junction to function as a A junctional rhythm may be the result of hypoxia,
gatekeeper. The ventricular rhythm is characteristi- hyperkalemia, myocardial infarction, heart failure,
cally irregular. valvular disease, drugs (digoxin, -adrenergic
Although atrial brillation may occur as a tran- blockers, calcium channel blockers), or any cause
sient dysrhythmia in healthy young people, the of SA node dysfunction. Patients with a junctional
presence of chronic atrial brillation is usually asso- rhythm may develop hypotension, decreased car-
ciated with atrial muscle disease or atrial distention diac output, and decreased perfusion as a result of
together with disease of the sinus node. This rhythm the slower rate. The benet of AV synchrony and
commonly occurs in heart failure, ischemic or rheu- the atrial kick (which provides 20% of the cardiac
matic heart disease, congenital heart disease, pul- output) is lost when the atria are stimulated with or
monary disease, and after open heart surgery. after ventricular depolarization.
The immediate clinical concern in patients Symptomatic patients may require immediate
with atrial brillation is the rate of the ventricular treatment, which is directed at the underlying cause.
Interventions are also directed toward improving
the heart rate (eg, through the use of atropine or
cardiac pacing) and improving cardiac output.

Premature Junctional Contractions

A premature junctional contraction (PJC) is an
ectopic impulse initiated at the AV junction that
F I G U R E 8 - 1 3 Atrial fibrillation. Characteristic atrial fibrillatory waves occurs prematurely, before the next sinus impulse
seen with a variable ventricular response. (Fig. 8-15). As in all rhythms originating in the AV

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74 P A R T T W O Essential Interventions in Critical Care

F I G U R E 8 - 1 4 Junctional rhythm. A: A junctional rhythm in which the inverted P wave appears before a nor-
mal QRS complex. B: A junctional rhythm in which the inverted P wave is buried inside the QRS complex. C:
A junctional rhythm in which the inverted P wave follows the QRS complex.

junction, the QRS complex is narrow (less than 0.12 Ventricular Dysrhythmias
second), reecting normal AV conduction. Rarely,
the QRS complex may be wide if the impulse is Premature Ventricular Contractions
conducted aberrantly. The atria are depolarized in a A premature ventricular contraction (PVC) is an
retrograde fashion before, during, or after ventricu- ectopic beat originating prematurely at the level of
lar excitation, producing inverted P waves that may the ventricles. Because the beat originates in the
occur before, during, or after the QRS complex. As ventricles, there is no atrial electrical activity, and
with PACs, PJCs may occur in healthy people or thus no P waves on the ECG (Fig. 8-16A). Rather
in those with underlying heart disease. Ischemia than traveling through the normal ventricular
or infarction may activate an ectopic focus in the conduction system, the ventricular depolarization
AV junction, as may stimulants or pharmacological spreads more slowly through the Purkinje system,
agents (eg, digoxin). Although usually asymptom- producing a wide QRS complex with a T wave
atic, patients may experience a feeling of a skipped that is opposite in direction to the QRS complex.
beat. Treatment for PJCs is not necessary. A compensatory pause often follows the premature
beat as the heart awaits the next stimulus from the
RED FLAG! Frequent PJCs may indicate sinus node.
increasing irritability and may be a precursor to a Premature ventricular beats can be described by
junctional rhythm. their frequency (number of PVCs per minute) and
pattern. Ventricular bigeminy is a PVC that occurs
after each sinus beat (see Fig. 8-16A). Ventricular
trigeminy is a PVC occurring after two consecutive
sinus beats. When PVCs originate from one ven-
tricular site, each of the PVCs has the same congu-
ration and is referred to as uniform. When PVCs
originate from more than one ventricular site, two
or more shapes of the QRS complex appear and the
PVC is said to be multiform (see Fig. 8-16B). Two
PVCs in a row are a couplet (see Fig. 8-16C). Three
in a row are a triplet, and constitute a short run of
F I G U R E 8 - 1 5 Premature junctional contraction. ventricular tachycardia (see Fig. 8-16D).

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Dysrhythmia Interpretation and Management C H A P T E R 8 75

F I G U R E 8 - 1 6 Various forms and patterns of premature ventricular contractions (PVCs). A: Ventricular bigem-
iny. (Every other beat is a PVC.) B: Multiformed PVCs. C: Couplet (two PVCs in a row). D: Triplet, constituting
a run of ventricular tachycardia. The rhythm then converts to sinus rhythm with first-degree heart block.

The most common of all ectopic beats, PVCs can irritation by a wire or catheter). Because of their
occur with or without heart disease in any age group. association with ventricular myocardial irritability,
They are especially common in people with myocar- PVCs may lead to ventricular tachycardia or ventric-
dial disease (ischemia or infarction) or with myo- ular brillation in some patients. In patients with
cardial irritability (eg, as a result of hypokalemia, serious heart disease, numerous and multiformed
increased levels of catecholamines, or mechanical PVCs worsen the prognosis.

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76 P A R T T W O Essential Interventions in Critical Care

Infrequent, isolated PVCs require no treatment.

Multiple or consecutive PVCs may be managed with
antidysrhythmic agents. In the emergency setting,
amiodarone and lidocaine are the drugs of choice.
Other antidysrhythmic agents are available for
chronic therapy. Treatment of the underlying cause F I G U R E 8 - 1 8 Torsades de pointes.
(eg, hypokalemia, digoxin toxicity) may also correct
the dysrhythmia. Torsades de Pointes
Torsades de pointes (twisting of the points) is a
RED FLAG! PVCs approaching the preceding specic type of ventricular tachycardia (Fig. 8-18).
T wave (R-on-T phenomenon) are of clinical concern. The dysrhythmia is characterized by large, bizarre,
The T wave represents ventricular repolarization. If polymorphous, or multiformed QRS complexes of
stimulation occurs during this vulnerable period, varying amplitude and direction, frequently varying
ventricular fibrillation and sudden death may result from beat to beat and resembling torsion around
(see figure below). an isoelectric line (hence the name, twisting of
the points). The rate of the tachycardia is 100 to
180 beats/min but can be as fast as 200 to 300 beats/
min. The rhythm is highly unstable; it may terminate
in ventricular brillation or revert to sinus rhythm.
Torsades de pointes is most likely to develop in
patients with myocardial disease when the refrac-
tory period (ie, the QT interval) is prolonged, such
as in severe bradycardia, drug therapy (especially
with type IA antidysrhythmic agents), and electro-
lyte disturbances (eg, hypokalemia, hypocalcemia).
Other factors that can precipitate this dysrhythmia
include familial QT-interval prolongation, central
Ventricular Tachycardia nervous system disorders, and hypothermia.
Ventricular tachycardia is dened as three or more
PVCs in a row. Ventricular tachycardia is recog- RED FLAG! In patients who are at high risk
nized by wide, bizarre QRS complexes occurring for torsades de pointes, dysrhythmia monitoring
in a fairly regular rhythm at a rate greater than should include measurement of the QT interval and
100 beats/min (Fig. 8-17). P waves, if seen, are not calculation of the QTc (ie, the QT interval corrected
related to the QRS complex. Ventricular tachycardia for heart rate) using a consistent lead.2
may be a short, nonsustained rhythm or longer and
sustained. Dysrhythmia progression depends on the Treatment focuses on shortening the refractory
underlying heart disease. period by administering IV magnesium sulfate or
Ventricular tachycardia is a common complica- initiating overdrive pacing. Emergency cardiover-
tion of myocardial infarction. Other causes are the sion or debrillation is indicated if the dysrhythmia
same as those described for PVCs. Signs and symp- does not revert spontaneously to sinus rhythm.
toms of hemodynamic compromise (eg, ischemic
chest pain, hypotension, pulmonary edema, loss of Ventricular Fibrillation
consciousness) may be seen if the tachycardia is sus- Ventricular brillation is rapid, irregular, and inef-
tained. The patient may or may not have a pulse and fectual depolarizations of the ventricle. On ECG,
cardiac output. only irregular oscillations of the baseline are appar-
If the patient is hemodynamically stable, amio- ent; these may be either coarse or ne in appearance
darone may be administered intravenously. If the (Fig. 8-19). Loss of consciousness occurs within
patient becomes unstable, synchronized cardiover- seconds. There is no pulse and no cardiac output.
sion (or in emergency situations, unsynchronized Causes of ventricular brillation include myocardial
debrillation) is indicated. Long-term treatment for ischemia and infarction, catheter manipulation in
this dysrhythmia may involve the use of an ICD. the ventricles, electrocution, terminal rhythms in
circulatory failure, and conditions that prolong the
RED FLAG! Ventricular tachycardia is often a refractory period (QT interval).
precursor to ventricular fibrillation.
RED FLAG! Ventricular fibrillation is fatal if
rapid defibrillation is not instituted immediately. If
there is no response to defibrillation, support with
cardiopulmonary resuscitation (CPR) and drugs is

Accelerated Idioventricular Rhythm

Accelerated idioventricular rhythm (AIVR) occurs
F I G U R E 8 - 1 7 Ventricular tachycardia. when the ventricular pacemaker cells increase their

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Dysrhythmia Interpretation and Management C H A P T E R 8 77

(eg, digoxin, -adrenergic blockers, calcium

channel blockers); CAD; infectious disease; and
congenital lesions. First-degree block is of no
hemodynamic consequence but is an indicator of
a potential AV conduction system disturbance and
may progress to second- or third-degree AV block.
Management entails monitoring the PR interval
closely for further block, and exploring underlying
causes (eg, drug effect).
F I G U R E 8 - 1 9 Ventricular fibrillation.

Second-Degree Atrioventricular BlockMobitz I

rate beyond their normal rate of 20 to 40 beats/ (Wenckebach)
min. AIVR is characterized by wide QRS complexes Mobitz type I (Wenckebach) block occurs when
occurring regularly at a rate of 50 to 100 beats/min AV conduction is delayed progressively with each
(Fig. 8-20). When the idioventricular rate exceeds sinus impulse until eventually the impulse is com-
the sinus rate, the ventricular pacemaker becomes pletely blocked from reaching the ventricles. The
the primary pacemaker. AIVR may last for a few cycle then repeats itself. Of the two types of sec-
beats or may be sustained. Typically, AIVR is seen ond-degree block, Mobitz type I is the more com-
with acute myocardial infarction, often in the set- mon. A Mobitz type I block usually is associated
ting of coronary artery reperfusion after throm- with block above the bundle of His; therefore,
bolytic therapy. It may occur less commonly as a any medication or disease process that affects the
result of ischemia or digoxin toxicity. Patients usu- AV node (eg, digoxin, myocarditis, inferior wall
ally are asymptomatic. Adequate cardiac output can myocardial infarction) may produce this type of
be maintained, and degeneration into ventricular second-degree block. Patients with a Mobitz type
tachycardia is rare. If a patient is hemodynamically I block rarely are symptomatic because the ven-
compromised, the sinus rate is increased with atro- tricular rate usually is adequate. The block often
pine or atrial pacing to suppress the AIVR. is temporary, and if it progresses to third-degree
block, a junctional pacemaker at a rate of 40 to
60 beats/min usually takes over to pace the ventri-
Atrioventricular Blocks cles. No treatment is required except patient mon-
Atrioventricular (AV) blocks occur when the sinus- itoring and discontinuation of pharmacotherapy,
initiated beat is delayed or completely blocked from if a drug is the offending agent.
activating the ventricles. The block may occur at the
AV node, the bundle of His, or the bundle branches. Second-Degree Atrioventricular BlockMobitz II
In rst- and second-degree AV block, the block is Mobitz type II block is an intermittent block in AV
incomplete; some or all of the impulses eventu- conduction, usually in or below the bundle of His.
ally are conducted to the ventricles. In third-degree This type of block is seen in the setting of an ante-
(complete) heart block, none of the sinus-initiated rior wall myocardial infarction and various diseases
impulses are conducted. Box 8-5 summarizes the of the conducting tissue, such as brotic disease.
ECG characteristics of heart blocks. A Mobitz type II block is potentially more dangerous
than a Mobitz type I block. Mobitz type II block often
First-Degree Atrioventricular Block is permanent, and it may deteriorate rapidly to third-
In rst-degree block, AV conduction (repre- degree heart block with a slow ventricular response of
sented by the PR interval) is prolonged and equal 20 to 40 beats/min. Constant monitoring and obser-
in length per beat. All impulses eventually are vation for progression to third-degree heart block are
conducted to the ventricles. First-degree block required. Medications (eg, atropine) or cardiac pac-
occurs in people of all ages and in healthy and ing may be required if the patient becomes symptom-
diseased hearts. Causes may include medications atic or if the block occurs in the setting of an acute
anterior wall myocardial infarction. Permanent
pacing often is indicated for long-term management.

Third-Degree (Complete) Atrioventricular Block

In third-degree (complete) heart block, the sinus
node continues to re normally, but the impulses do
not reach the ventricles. The ventricles are stimu-
lated by pacemaker cells either in the junction (at
F I G U R E 8 - 2 0 Accelerated idioventricular rhythm (AIVR). a rate of 40 to 60 beats/min) or in the ventricles
The first three beats are of ventricular origin. The fourth beat (arrow) (at a rate of 20 to 40 beats/min), depending on the
represents a fusion beat. The subsequent two beats are of sinus level of the AV block. The causes of complete heart
origin. block are the same as for lesser degrees of AV block.

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78 P A R T T W O Essential Interventions in Critical Care

BOX 8-5 Heart Block Rhythms

Second-Degree Second-Degree
First-Degree Heart BlockMobitz Heart Block Third-Degree Heart
Heart Block Type I (Wenckebach) Mobitz Type II Block

Rate Usually 60 to Usually 60 to 100 beats/ May be slow depending Rate determined by
100 beats/min min on number of ventricular focus,
blocked P waves usually very slow
Rhythm Regular Irregular due to dropped Often regular but May be regular or irregular
QRS depends on pattern ventricular focus;
of block; PP interval PP and RR intervals
regular regular
P waves Present, one per Present, one per QRS Present, more than one Present, more than one P
QRS (1:1) until QRS is missed P wave per QRS wave per QRS; P waves
(2:1, 3:1, or 4:1 no relationship to QRS
block) complexes
PR interval Greater than Progressively gets longer May be normal or May be normal or
0.20 s, equal until QRS is missed; prolonged, equal prolonged, unequal
throughout; pattern repeats throughout (fixed) throughout (variable)
QRS complex Less than 0.12 s Less than 0.12 s Usually greater than Greater than 0.12 s
0.12 s (due to BBB)

First-degree heart block

P waves

Second-degree heart block (Mobitz type I)

Second-degree heart block (Mobitz type II)

Third-degree (complete) heart block

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Dysrhythmia Interpretation and Management C H A P T E R 8 79

Complete heart block is often poorly tolerated. If the

rhythm is ventricular in origin, the rate is slow, and
the pacemaker site is unreliable. The patient may
be symptomatic because of a low cardiac output. A
pacemaker site high in the bundle of His may pro-
vide an adequate rate to sustain cardiac output and
is more dependable. A temporary pacing wire is usu-
ally inserted immediately, and when the patient is
stabilized, a permanent pacemaker is implanted.
Bundle Branch Block
A bundle branch block develops when there is a
block in one of the major branches of the intraven- A
tricular conduction system. The right ventricle has
a single bundle branch and the left ventricle has
two bundle branches. The impulse travels along
the unaffected bundle and activates one ventricle
normally. However, because the impulse must then
travel outside the normal conduction system to
reach the other ventricle, depolarization of the other
ventricle is delayed. The right and left ventricles are
thus depolarized sequentially instead of simulta-
neously. The abnormal activation produces a wide
QRS complex (representing the increased time it
takes for ventricular depolarization) with two peaks
(indicating that depolarization of the two ventricles
was not simultaneous). B
A bundle branch block is determined by view- F I G U R E 8 - 2 1 Bundle branch block. A: V1 tracing showing the wide
ing the 12-lead ECG. In right bundle branch block, QRS complex and double-peaked R wave characteristic of right
depolarization of the right ventricle is delayed, bundle branch block. B: A V6 tracing showing the wide QRS complex
which alters the conguration of the QRS complex and double-peaked R wave characteristic of left bundle branch block.
in the right-sided chest leads, V1 and V2. Normally,
these leads have a small, single-peaked R-wave and
deep S-wave conguration. A right bundle branch disease in the older patient is a common cause of
block is evidenced by an RSR' conguration in V1 left bundle branch block.
(Fig. 8-21A) If the initial peak of the QRS complex The patient is monitored for involvement of the
is smaller than the second peak, the pattern would other bundles or for progression to complete heart
be described as rSR'. Likewise, if the initial peak block. Progression of block may be very slow or
of the QRS complex is taller than the second peak, rapid, depending on the clinical setting. A tempo-
the pattern is described as an RSR'. Whenever ven- rary pacemaker may be inserted until a permanent
tricular depolarization is abnormal, so is ventricular pacemaker can be placed, if indicated.
repolarization. As a result, ST-segment and T-wave
abnormalities may be seen in leads V1 and V2 for
patients with a right bundle branch block. Management of Dysrhythmias
A left bundle branch block changes the QRS com-
plex pattern in the left-sided chest leads, V5 and V6. Pharmacotherapy
Normally, these leads have a tall, single-peaked R wave Antidysrhythmic drugs are used to restore the
and a small or absent S wave. Instead, the double- heart to a regular rhythm. The therapeutic window
peaked RSR' pattern is noted (see Fig. 8-21B). In addi- is small, and these drugs may have a toxic effect,
tion, V1 shows a small R wave with a widened S wave, especially when used in combination with other
indicating delayed conduction through the ventricles. antidysrhythmic agents. Many antidysrhythmics
As in right bundle branch block, the ST segments and are classied by their effect on the cardiac action
T waves may be abnormal in leads V5 and V6. potentialwhether they block -adrenoreceptors or
The most common causes of bundle branch block sodium, potassium, or calcium channels (Table 8-6).
are myocardial infarction, hypertension, heart fail- Table 8-7 summarizes antidysrhythmic drugs that
ure, and cardiomyopathy. Right bundle branch are commonly used in critical care settings.
block may be found in healthy people with no clini-
cal evidence of heart disease, in patients with con- Class I Antidysrhythmics (Sodium Channel
genital lesions involving the septum, and in patients
with right ventricular hypertrophy. Left bundle Blockers)
branch block is usually associated with some type of Because many class I antidysrhythmics may cause
underlying heart disease. Long-term cardiovascular life-threatening dysrhythmias and often interact

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80 P A R T T W O Essential Interventions in Critical Care

TA B L E 8 - 6 Classification of Antidysrhythmic Medications

Class Action Examples
IA Inhibits fast sodium channel, decreases automaticity, depresses phase 0, and prolongs Quinidine
the action potential duration Procainamide
IB Inhibits fast sodium channel, depresses phase 0 slightly, and shortens action potential Lidocaine
duration Mexiletine
IC Inhibits fast sodium channel, depresses phase 0 markedly, slows HisPurkinje Flecainide
conduction profoundly leading to a prolonged QRS duration Moricizine
II Depresses phase 4 depolarization, blocks sympathetic stimulation of the conduction Esmolol
system Propranolol
Sotalol (plus class III effects)
III Blocks potassium channel, prolongs phase 3 repolarization, prolongs action potential Amiodarone
duration Sotalol
IV Inhibits inward calcium channel, depresses phase 4 depolarization, lengthens Verapamil
repolarization in phases 1 and 2 Diltiazem

TA B L E 8 - 7 Selected Antidysrhythmic Medications

Drug Antidysrhythmic Indications Major Adverse Effects

Class I
Procainamide Ventricular tachycardia, ventricular fibrillation, supraventricular Hypotension with IV use, asystole, ventricular
tachycardias, atrial fibrillation, atrial flutter fibrillation, heart block, torsades de pointes
Lidocaine Ventricular tachycardia, ventricular fibrillation Bradycardia, hypotension, tremors, dizziness,
tinnitus, convulsions, mental status changes
Flecainide Atrial fibrillation and paroxysmal supraventricular tachycardia Ventricular dysrhythmias, palpitations,
(PSVT) in patients without structural heart disease; dizziness, dyspnea, headache, fatigue,
ventricular tachycardia nausea
Class II
Esmolol Supraventricular tachycardias including atrial fibrillation and Hypotension, heart block, bronchospasm
atrial flutter; noncompensatory sinus tachycardia
Propranolol Supraventricular tachycardias; ventricular dysrhythmias; Hypotension, heart block, bradycardia, heart
digoxin-induced tachydysrhythmias; premature ventricular failure, bronchospasm, gastrointestinal
contractions (PVCs) upset
Sotalol Ventricular tachycardia, ventricular fibrillation, maintenance Bradycardia, AV block, heart failure,
of normal sinus rhythm in patients with symptomatic atrial bronchospasm, gastric pain
fibrillation or atrial flutter
Class III
Ibutilide Atrial fibrillation, atrial flutter Hypotension, torsades de pointes, ventricular
tachycardia, bundle branch block,
Dofetilide Atrial fibrillation, atrial flutter; maintenance of normal sinus Torsades de pointes, bradycardia
rhythm after conversion
Amiodarone Ventricular fibrillation, ventricular tachycardia, pulseless Heart block, cardiac arrest, bradycardia,
ventricular tachycardia, atrial fibrillation, atrial flutter; wide- hypotension, ventricular tachycardia
complex tachycardia, and preexcited atrial fibrillation
Class IV
Verapamil PSVT, ventricular rate control in atrial fibrillation, atrial flutter Hypotension, heart block, heart failure,
Diltiazem Ventricular rate control in atrial fibrillation, atrial flutter; PVST Bradycardia, heart block, hypotension
Adenosine PSVT; idiopathic ventricular tachycardia; evaluation of Bradycardia, heart block, asystole, chest pain
ventricular tachycardia, supraventricular tachycardia,
latent preexcitation
Atropine Symptomatic sinus bradycardia, AV block, asystole, Palpitations, tachycardia
bradycardic pulseless electrical activity
Digoxin Ventricular rate control in atrial fibrillation Heart block, bradycardia, digoxin toxicity
Magnesium sulfate Torsades de pointes; refractory ventricular tachycardia and Hypotension, nausea, depressed reflexes, and
ventricular fibrillation; life-threatening dysrhythmias caused flushing
by digoxin toxicity

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Dysrhythmia Interpretation and Management C H A P T E R 8 81

with other drugs commonly used for cardiovascular supraventricular tachycardia, and treat rare forms
disease, these agents are used only in select cases. In of idiopathic ventricular tachycardia. The half-life of
general, research data do not support the effective- adenosine is less than 10 seconds; therefore, adverse
ness of class I antidysrhythmics. effects (which include a brief period of asystole) are
Class II Antidysrhythmics (b-Adrenergic
Blockers) Magnesium Sulfate
This class of drugs has a broad spectrum of activ- Magnesium sulfate is the drug of choice for treat-
ity and an established safety record and is currently ing torsades de pointes. Magnesium is also used for
the best class of antidysrhythmics for general use. refractory ventricular tachycardia and ventricular
Acebutolol, esmolol, propranolol, and sotalol are brillation, as well as for life-threatening dysrhyth-
approved to treat dysrhythmias. mias caused by digoxin toxicity. Its mechanism of
action is unclear; however, it has calcium channel
Class III Antidysrhythmic Drugs (Potassium blocking properties and inhibits sodium and potas-
sium channels.
Channel Blockers)
Amiodarone is indicated for the treatment of ven- Atropine
tricular tachycardia, atrial brillation, and atrial
Atropine reduces the effects of vagal stimulation,
utter. The advanced cardiac life support (ACLS)
thus increasing heart rate and improving cardiac
algorithms include amiodarone as a rst-line
function. It is a rst-line drug used to treat symp-
option for treating ventricular brillation, pulse-
tomatic bradycardia and slowed conduction at the
less ventricular tachycardia, wide-complex tachy-
AV node.
cardia (either supraventricular or ventricular),
and atrial brillation.3 Limitations of amiodarone RED FLAG! It is important not to increase
include its variable onset of action, intolerable the heart rate excessively in patients with ischemic
adverse effects, dangerous drug interactions, and heart disease because doing so may increase
life-threatening complications associated with myocardial oxygen consumption and worsen
chronic therapy. ischemia.
Ibutilide and dofetilide are indicated for atrial
brillation and atrial utter. Ibutilide inhibits Digoxin
potassium current and enhances sodium current,
prolonging repolarization. Dofetilide blocks the Digoxin is a mild positive inotrope with antidys-
rapid potassium current channel, prolonging the rhythmic and bradycardic actions. It is primarily
action potential duration and refractory period. indicated for patients with both heart failure and
Although these agents may cause a prolonged chronic atrial brillation. It may also be used to con-
QT interval and torsades de pointes, they have trol a rapid ventricular rate associated with atrial
fewer systemic adverse effects than other class III brillation or atrial utter and in combination with
agents. calcium channel blockers or -adrenergic blockers
for patients without heart failure. Because of its nar-
row therapeutic window, toxicity is common and is
Class IV Antidysrhythmics (Calcium Channel frequently associated with serious dysrhythmias.
Blockers) Other signs and symptoms of toxicity include palpi-
Class IV agents are primarily indicated for the tations, syncope, gastrointestinal upset, and neuro-
treatment of supraventricular tachycardia. In logic changes.
general, calcium channel blockers are only used
when -adrenergic blockers are contraindicated or Electrical Cardioversion
maximal dosage has been reached without effect.
Adverse effects include hypotension, decreased In electrical cardioversion, a debrillator is used
myocardial contractility (except with diltiazem), to deliver a shock that is synchronized with ven-
and bradycardia. tricular depolarization by detecting the patients
R wave; this minimizes the risk for causing ven-
tricular brillation, which can occur if a shock is
Adenosine delivered during ventricular repolarization (on the
Adenosine is a rst-line antidysrhythmic that effec- T wave). Cardioversion is indicated to convert sus-
tively converts narrow-complex PSVT to normal tained supraventricular or ventricular tachydys-
sinus rhythm by slowing conduction through the rhythmias to sinus rhythm, especially when the
AV node. This agent is effective in terminating patient is hemodynamically unstable. It may be used
dysrhythmias caused by reentry involving the SA electively for recent-onset dysrhythmias that do not
and AV nodes; however, it does not convert atrial respond to antidysrhythmic agents.
brillation, atrial utter, or ventricular tachycar- Although recommendations are made for the
dia to sinus rhythm. Adenosine is also used to dif- amount of joules needed to convert various rhythms
ferentiate between ventricular tachycardia and (Table 8-8), the actual energy needed may vary

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82 P A R T T W O Essential Interventions in Critical Care

heart in sinus rhythm and any abnormal sequence

TA B L E 8 - 8 Energy Requirements for Cardioversion of activation during an induced dysrhythmia. The
recordings are used to create a map that is used
Energy Requirements
Dysrhythmia in Joules (J)a to guide the placement of the ablating catheter by
identifying the focus of the dysrhythmia or the loca-
Monomorphic ventricular 100360 tion of an accessory pathway. When the appropriate
tachycardia with a pulse site is identied, an ablating catheter is positioned
Atrial flutter 50 in the targeted area of the heart and the radiofre-
Atrial fibrillation 200 initially quency current is applied. Elimination of the target
site is evaluated by examining the ECG and IC-EGM
Energy requirements given are for a monophasic defibrillator. Energy
requirements for a biphasic defibrillator vary but are usually less.
tracings and conrmed when the dysrhythmia is no
longer inducible on a postprocedure EPS.

depending on the duration of the dysrhythmia, Cardiac Pacing

transthoracic impedance, and the type of debrilla- Cardiac pacing is most commonly indicated for con-
tor (ie, monophasic or biphasic). Monophasic de- ditions that result in failure of the heart to initiate
brillators deliver a current of electricity that travels or conduct an intrinsic electrical impulse at a rate
in a single direction between the two paddles that adequate to maintain perfusion (eg, dysrhythmias,
are placed on the patients chest, whereas biphasic atherosclerotic heart disease, acute myocardial
debrillators deliver a current of electricity that infarction). Cardiac pacing can be used to treat bra-
travels back and forth between the two paddles, thus dydysrhythmias and tachydysrhythmias. Common
requiring fewer joules. terms associated with cardiac pacing are dened in
Precautions and relative contraindications for Box 8-6.
cardioversion are listed in Table 8-9. The patient
should have nothing by mouth before the proce- Types of Pacing Systems
dure and receive sedation. After conversion to sinus
Pacing systems consist of a pulse generator and one
rhythm, antidysrhythmic therapy may be initiated
to three leads with electrodes. The electrodes at the
for rhythm maintenance.
distal end of the lead provide sensing and pacing of
the heart muscle. Cardiac pacing may be permanent
Radiofrequency Ablation or temporary.
In radiofrequency ablation, a percutaneous catheter Permanent Pacing Systems
is inserted through a vein or artery and positioned in Box 8-7 summarizes indications for permanent
the heart to deliver radiofrequency energy to a local- cardiac pacing. Most permanent pulse genera-
ized area of the myocardium, creating a small area tors are inserted in a subcutaneous pocket in the
of irreversible tissue injury. The localized area of pectoral region below the clavicle (Fig. 8-22). The
damage prevents the dysrhythmia by eliminating its pulse generator for a permanent pacemaker is a
point of origination (ie, its focus) or by interrupting lithium iodide battery, which lasts for about 6 to
its conduction (accessory pathway). Radiofrequency 12 years. The permanent pacemaker lead is typi-
ablation is used to treat tachydysrhythmias (eg, cally inserted either through a subclavian vein
PSVT, AV nodal reentrant tachycardia, atrial bril- or a cephalic vein through the chest wall (see
lation, or utter).4 Fig. 8-22). The lead is then positioned with uo-
Before ablation, the patient undergoes an elec- roscopic guidance and afxed in the right atrial
trophysiological study (EPS). During the EPS, cath- appendage or in the apex of the right ventricle, or
eters are placed in the heart to record intracardiac in both locations. A third lead may be inserted in
electrograms (IC-EGMs). The test provides informa- a coronary sinus branch to stimulate the left ven-
tion about the sequence of electrical activation of the tricle for biventricular pacing.

TA B L E 8 - 9 Precautions and Relative Contraindications to Cardioversion

Condition Complications
Digoxin toxicity Ventricular irritability, asystole
Hypokalemia Ventricular irritability/fibrillation
Atrial fibrillation with slow ventricular response Postcardioversion asystole
Atrial fibrillation of unknown duration with inadequate Thromboembolization
Pacemaker dependency Rise in thresholds with loss of capture
Low-amplitude R wave Synchronization on T wave leading to ventricular fibrillation

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Dysrhythmia Interpretation and Management C H A P T E R 8 83

BOX 8.6 Clinical Terminology Related to Pacemakers

Active xation lead: A pacing lead with some design at Overdrive pacing: A method of suppressing tachy-
the lead tip (corkscrew, coil) that allows the tip to be cardia by pacing the heart at a rate faster than the
embedded in heart tissue, thus decreasing the likeli- patients intrinsic rate
hood of dislodgment Oversensing: Inhibition of the pacemaker by events
Asynchronous pacing: A pacemaker that res at a other than those that the pacemaker was intended to
xed rate regardless of the intrinsic activity of the sense (eg, electromagnetic interference, tall T waves)
heart Pacing threshold: The minimal electrical stimulation
Bipolar lead: A pacing lead containing two electrodes. required to initiate atrial or ventricular depolariza-
One electrode is at the tip of the lead and provides tion consistently; expressed as milliamperage (mA) in
stimulation to the heart. A second electrode is several temporary pacing systems and voltage (V) in perma-
millimeters proximal to the tip and completes the nent pacing systems
electrical circuit. Both electrodes provide sensing of Passive xation lead: A pacing lead that lodges in the
the intrinsic cardiac activity. trabeculae of the heart without actually penetrating
Capture: The depolarization of a cardiac chamber in the cardiac wall
response to a pacing stimulus Rate-responsive (rate-adaptive, rate-modulated) pac-
Chronotropic incompetence: Inability of the sinus ing: A pacemaker that alters pacing rate in response
node to accelerate in response to exercise to detected changes in the bodys metabolic demand
Demand pacing (inhibited pacing): A pacemaker Sensing: The ability of the pacemaker to detect intrin-
that withholds its pacing stimulus when sensing an sic cardiac activity and respond appropriately; how
adequate intrinsic heart rate the pacemaker responds depends on the programmed
Dual-chamber pacing (physiological pacing): Pacing mode of pacing
in both the atria and the ventricles to articially Sensing threshold: The minimal atrial or ventricular
restore atrioventricular (AV) synchrony intracardiac signal amplitude required to inhibit or
Electromagnetic interference: Electrical or magnetic trigger a demand pacemaker
energy that can interfere with or disrupt the function Situational vasovagal syncope: Syncope associated
of the pulse generator with bradycardia by vagal stimulation during cough-
Milliamperage (mA): The unit of measure used for ing, micturition, or severe pain
the electrical stimulus (output) generated by the Triggered: A response to sensing in which the pacemaker
pacemaker res a stimulus in response to intrinsic cardiac activity
Multisite pacing: The ability to stimulate more than Undersensing: Failure of the pacemaker to sense the
one site in a chamber (eg, right ventricle and left ven- hearts intrinsic activity, resulting in inappropriate
tricle stimulation in biventricular pacing) ring of the pacemaker

Temporary Pacing Systems Transvenous Pacing. A transvenous pacing sys-

Temporary pacing is used both emergently (eg, to tem consists of an external pulse generator and a
correct life-threatening situations such as asystole, temporary transvenous pacing lead. The temporary
complete heart block, severe bradydysrhythmias, transvenous lead system usually includes a bipo-
and cardiac arrest) and electively (eg, to evaluate lar catheter. The bipolar catheter has a negative
the need for permanent pacing, after cardiac sur- distal electrode and a positive proximal electrode
gery, or for overdrive pacing of tachydysrhythmias). that attach to the negative and positive generator
Temporary pacing systems may be transvenous, epi- terminals, respectively, on the pulse generator. The
cardial, transcutaneous, or transthoracic.

Subclavian vein

Cephalic vein
BOX 8-7 Indications for Permanent Cardiac
Second-degree atrioventricular (AV) blockMobitz II vein
Third-degree (complete) heart block
Bilateral bundle branch blocks
Symptomatic bradydysrhythmias
Sick sinus syndrome Pacemaker
Prophylaxis during open heart surgery
Tachydysrhythmias F I G U R E 8 - 2 2 Transvenous installation of a permanent pacemaker.
Bifascicular LBBB For dual-chamber pacing, a separate pacing wire would be in the

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84 P A R T T W O Essential Interventions in Critical Care

catheter is introduced into the brachial, internal or accomplished by thoracotomy or through a subxi-
external jugular, subclavian, or femoral vein. The phoid incision. Epicardial pacing is often used as a
subclavian and internal jugular sites promote cathe- temporary adjunct during and after open heart sur-
ter stability and allow patient mobility. The catheter gery. After attaching the pacing wires to the epicar-
is threaded through a sheath in the vein, and the tip dium, the proximal end is brought outside through
is placed in contact with the endocardial surface of the chest incision and either connected to a tempo-
the right ventricular apex for stability and reliabil- rary pacemaker generator or capped and then con-
ity.5 For atrial pacing, an atrial bipolar catheter is nected if the need for pacing arises. The wires are
placed in the right atrial appendage. extracted without reopening the incision, even after
After catheter placement, the sheath is attached scar tissue has formed over the tips.
to a continuous drip (if it will be used for drawing
Transcutaneous Pacing. Transcutaneous pac-
blood or administering drugs). To maintain sterility,
ing involves placing large gelled electrode patches
a sterile protective sleeve over the catheter can be
directly on the chest wall, anteriorly to the left of
used before insertion and then connected to the end
the sternum, and posteriorly on the patients back
of the sheath after satisfactory position is conrmed.
(Fig 8-23). It may be used as a bridge (temporary
The insertion site is covered with a biopatch and a
measure) until either a transvenous or permanent
self-adhesive, semipermeable transparent dressing.
pacemaker can be placed. Indications for transcu-
Nursing care of a patient with a temporary transve-
taneous pacing include symptomatic bradycardia
nous pacemaker is summarized in Box 8-8.
(unresponsive to drug therapy), new Mobitz type
Epicardial Pacing. In epicardial pacing, the pac- II heart block, and new third-degree (complete)
ing electrodes are placed directly on the outer sur- heart block. Transcutaneous pacing may also be
face of the heart. Placement of the electrodes can be used when transvenous pacing is contradicted or

BOX 8-8 Nursing Responsibilities in Transvenous Pacing

Assessment Presence/absence of hiccupping or muscle

During insertion: twitching
Vital signs, oxygen saturation, peripheral pulses Status of insertion site and sutures (if present)
Level of sedation/sedative agents used Signs of infection
Date, time, method, and site of insertion Pulse perfusion distal to insertion site (if
Location of wire inserted (atrial, ventricular, atrial and appropriate)
ventricular) Connective ends of pacer wires covered (as
Measured values: capture threshold (mA) and intrinsic appropriate)
amplitude (mV) Interventions
Patients tolerance of procedure Continuous cardiac monitoring
Complications Verify replacement 9-V battery available.
Continuous cardiac monitoring and 12-lead electro- Verify connections are intact.
cardiogram (ECG) Label epicardial pacer wires atrial or ventricular.
Final settings: mode, rate, output, and sensitivity Clean and dress pacer wire insertion site(s) daily
After insertion: with gauze dressing or transparent dressing per
institutional protocol. Label time and date of dressing
Rate setting, mV setting, mA setting, mode of opera- change and initial.
tion (demand, asynchronous) and atrioventricular Observe electrical safety precautions.
(AV) interval (if appropriate)  Keep electrical equipment in the room to a mini-
Pacemaker turned off or on mum and ensure that it is properly grounded.
Rhythm strip, capture and intrinsic (if appropriate);  Avoid simultaneous contact with the patient and any
12-lead ECG electrical equipment.
Status of insertion site and sutures (if present)  Cover connective ends of pacer wires to prevent
Completion of chest radiograph and results on chart microshock hazard.
Every change of shift:  Wear rubber or latex gloves when handling the

Pacemaker turned off or on connective ends of pacer wires.

Pacemaker secured appropriately to patient Documentation
All connections secured Assessments
Setting for rate, mA, sensitivity, mode of operation AV Instructions to patient/family
interval (if appropriate) Pacing wire insertion site care
Rhythm strip (also assessed with any clinical change Pacing and sensing thresholds (print ECG strips)
or intervention) Pacing problems or complications, nursing
Sensing and capture thresholds (compare to baseline) interventions, and results of interventions

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Dysrhythmia Interpretation and Management C H A P T E R 8 85

the hearts intrinsic rhythm. In either case, the nurse

must recognize the problem and reposition either
the patient or the electrodes to ensure efcacious
transcutaneous pacing.
Transthoracic Pacing. Transthoracic pacing,
+ which involves placing a pacing needle in the ante-
rior wall of the heart, is used only as a last resort
in emergency situations. It has limited success rates
and a high potential for complications.

Functioning of Pacing Systems

The sensing function is the ability of the pacemaker
to detect the hearts intrinsic activity. The sensing
amplitude is the largest intrinsic signal that is
consistently detected by the pacemaker electrode
(eg, the R wave is usually the largest signal sensed
F I G U R E 8 - 2 3 Positioning of pads for transcutaneous pacing. by the ventricular lead). The smallest number on
the sensor control represents the most sensitive set-
ting in millivolts (mV), and it indicates the smallest
not immediately available. The transcutaneous signal the pacemaker will sense.
pacemaker is used in a demand mode for brady- When the intrinsic heart rate is adequate, the pace-
cardia and asystole; it paces the heart only when maker responds by inhibiting a pacing stimulus. When
needed. This mode is safer because the chance the intrinsic heart rate drops below the programmed
of ring on the T wave (R-on-T phenomenon) is minimum rate, the pacemaker delivers an electrical
greatly reduced. stimulus that depolarizes the cardiac chamber con-
The procedure for initiating transcutaneous pac- taining the pacemaker lead. The minimal amount of
ing and monitoring considerations are summarized voltage required from the pacemaker to initiate con-
in Box 8-9. Because transcutaneous pacing can cause sistent capture is known as the pacing threshold and
signicant discomfort, the patient should be made is measured in milliamps (mA). Many factors affect
aware of this and adequately sedated. Following ini- the pacing threshold, including hypoxia, hyperkale-
tiation of therapy, diligent monitoring is required. mia, antidysrhythmic drugs, catecholamines, digoxin
A loss of capture can occur if the electrodes fail to toxicity, and corticosteroids. The pacing threshold is
maintain good contact with the skin. Inappropriate determined by establishing successful pacing at higher
pacing may result if the pacemaker cannot detect energy and then gradually decreasing the energy out-
put of the generator until capture ceases. The gen-
erator output is then set at two or three times the
threshold level to allow for an adequate safety margin.
BOX 8-9 Nursing Responsibilities in A coding system, called the NBG pacemaker
Transcutaneous Pacing code, has been formed to identify the various modes
of pacemaker operation (Box 8-10). Knowledge of
1. Explain procedure to patient.
the three- and ve-letter pacemaker code helps the
2. Clip excess hair from chest (do not shave skin);
nurse determine the type of implanted device, the
ensure skin is dry.
intended mode of operation, and the actual mode of
3. Apply anterior electrode to chest at the fourth inter-
costal space to the left of the sternum.
4. Apply posterior electrode to patients back in the Nursing Care of the Patient Undergoing Cardiac
area of the left scapula.
5. Connect pacing electrodes to transcutaneous Pacing
pacemaker. Preprocedure
6. Set pacemaker mode, heart rate, and output. Prior to permanent pacemaker implantation, the
7. Turn unit on. nurse assesses the patients medical and social history.
8. Assess for effectiveness of pacing: Information gleaned from the medical and social his-
Observe for pacemaker spike with subsequent tory can inuence decisions such as which approach
capture. to use during the procedure, and which side is favored
Assess heart rate and rhythm. for implantation. For example, a subclavian approach
Assess blood pressure. (Measure blood pressure may be avoided in a person with a history of a collapsed
in the right arm to avoid interference from the lung or previous lobectomy, and the right pectoral
pacemaker.) region may be avoided for pacemaker implantation in
Check level of consciousness. a right-handed tennis player. Psychosocial assessment
Observe for patient anxiety/pain and treat is also important. Patients psychosocial responses to
accordingly. the need for cardiac pacing may differ. Some may be
relieved to have a device that supports the functioning

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86 P A R T T W O Essential Interventions in Critical Care

BOX 8-10 Using the NBG Pacemaker Code

I: Chamber(s) II: Chamber(s) III: Response to IV: Rate V: Multisite

Paced Sensed Sensing Modulation Pacing

O = none O = none O = none O = none O = none

A = atrium A = atrium T = triggered R = rate modulation A = atrium
V = ventricle V = ventricle I = inhibited V = ventricle
D = dual (A +V) D = dual (A + V) D = dual (T + I) D = dual (A + V)

Adapted from North American Society of Pacing and Electrophysiology/British Pacing and
Electrophysiology Group: The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate,
and multisite pacing. Pacing Clin Electrophysiol 25(2):260264, 2002.

The rst position describes the chamber or chambers The fourth position describes the presence or absence
paced. of rate modulation (variation of the pacing rate in
The second position describes the chamber or cham- response to a physiological variable).
bers sensed. The letter O denotes no rate modulation.
The third position describes the pacemakers The letter R means that the rate modulation
response to sensed intrinsic cardiac activity. feature is active. When the rate modulation fea-
The letter I means that the pacemaker is inhibited ture is active, the pacer detects the physiological
from ring in response to a sensed intrinsic event. response in response to patient activity (eg, muscle
The letter T indicates that the pacemaker trig- vibration, increased respiratory rate) and increases
gers pacing stimuli in response to a sensed intrinsic the pacing rate to meet increased metabolic
beat. demands. The rate modulation feature is not used in
The letter D designates a dual response (inhib- temporary pacing.
ited pacing output and triggered pacing after sensed The fth position describes whether multisite pacing
event). is present.
The letter O designates a mode in which the The absence of a fourth- or fifth-letter designa-
pacemaker does not respond to sensed intrinsic tion signifies no rate modulation and no multisite
activity (asynchronous pacing). pacing.

of their heart, whereas others may be anxious about chest radiographs, blood tests, and other relevant
the technology and express fears of dying. laboratory tests. In addition, the nurse monitors for
Patient and family teaching about cardiac pac- potential complications (Table 8-10).
ing begins at the time the decision for pacemaker
Electrocardiogram Monitoring. Careful moni-
insertion is made. After assessing the patients base-
toring of the ECG of the patient with a cardiac pace-
line knowledge about pacemakers and clarifying
maker is an essential component of comprehensive
any misperceptions, the nurse explains the need for
patient assessment.
pacing, how the pacing system works, the insertion
The rst step in ECG analysis involves examin-
procedure, and the immediate postprocedure care
ing the strip for evidence of pacemaker stimulation.
that can be expected. Patient teaching continues
When the pacemaker discharges, an artifact called
during the postprocedure period, when the nurse
provides the patient with product specications for a pacing spike appears on the ECG. If the pacing
lead is in the atria, a pacing spike is followed by a P
all components of the system (eg, manufacturer,
wave. If the pacing wire is in the ventricle, the spike
model number, serial number), explains signs and
is followed by a wide QRS complex (Fig. 8-24, p. 87).
symptoms of pacemaker malfunction and how to
Failure of the pacing stimulus to capture the ven-
report them, explains the importance of keeping
tricles or atria is noted by the absence of the QRS
follow-up appointments, and explains the gen-
or P wave immediately after the pacing spike on the
eral time line and procedure for pulse generator
ECG (Fig. 8-25, p. 88).
The sensing function of the pacemaker is
Postprocedure evaluated next. If the pacemaker does not sense
Assessment helps the nurse determine the patients intrinsic cardiac activity (undersensing), inappro-
physiologic response to cardiac pacing. Important priate pacemaker spikes may appear throughout
parameters to assess include pulse rate; underlying the underlying rhythm (Fig. 8-26A, p. 88). An over-
cardiac rhythm; blood pressure; activity tolerance; sensing problem can be detected when the pace-
signs and symptoms such as dizziness, syncope, maker senses events other than the intrinsic rhythm
dyspnea, palpitations, or edema; and the results of and is inappropriately inhibited in that chamber or

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Dysrhythmia Interpretation and Management C H A P T E R 8 87

TA B LE 8- 10 Pacemaker Complications
Complication Presentation Confirmation
Pneumothorax Pleuritic pain; hypotension; respiratory distress or Chest radiograph
Ventricular irritability Premature ventricular complexes (PVCs) appear 12-lead electrocardiogram
similar in configuration to the pacemaker (ECG) or cardiac monitoring
Perforation of ventricular wall or Change in precordial lead waveform morphology 12-lead ECG or cardiac
septum or negative QRS complex in lead V1 monitoring
Pericardial tamponade (decrease in blood Two-dimensional
pressure, increase in heart rate) echocardiogram
Catheter or lead dislodgement Failure to capture 12-lead ECG, chest radiograph
Infection and phlebitis or Swelling, inflammation, drainage, hematoma Inspection and cultures
hematoma formation
Abdominal twitching or hiccups Twitching, hiccups, discomfort; when associated Observation
with perforation, a drop in blood pressure
Pocket erosion Swelling, inflammation, drainage Inspection, culture

F I G U R E 8 - 2 4 Pacing artifacts (spikes) on the electrocardiogram (ECG). A: With an atrial pacemaker, each
pacing spike is followed by a P wave. B: With a ventricular pacemaker, each pacing spike is followed by a
wide QRS complex. C: With a dual-chamber pacemaker, the first pacing spike is followed by a P wave and
the second pacing spike is followed by a QRS complex. All strips show 1:1 capture.

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88 P A R T T W O Essential Interventions in Critical Care

F I G U R E 8 - 2 5 Failure to capture. The pacing spike is not followed by a QRS complex.

causes a triggered response in the other chamber when the patient has no underlying rhythm. The
(see Fig. 8-26B). following steps are taken:
The third step in evaluating the ECG is to mea-
1. Increase pulse generator output (in mA) to the
sure various intervals (Fig. 8-27). The duration of
highest setting, asynchronous mode (VOO,
each interval is compared with the programmed set-
DOO). Asynchronous mode allows assessment for
ting for that interval.
appropriate ring and capture when the patients
The pacing interval (ie, the amount of time between rhythm is overridden by the xed pacing pulse.
two consecutive pacing spikes in the chamber 2. Check the patients hemodynamics and simulta-
being paced) is used to determine the pacing rate. neous multiple ECG lead recordings and inter-
The AV interval is analogous to the PR inter- vene if appropriate with transcutaneous pacing
val on the ECG. The AV interval is measured or atropine sulfate.
from the beginning of an intrinsic P wave or an 3. Check all connections.
atrial pacing spike to the beginning of the intrin- 4. Replace the pulse generator or battery; be pre-
sic QRS complex or the ventricular pacing spike pared to provide transcutaneous pacing backup
(see Fig. 8-27). during the change.
The ventriculoatrial (VA) interval, also called the 5. When the patient is stable, proceed with trouble-
atrial escape interval, is the amount of time from a shooting (Table 8-11).
ventricular paced or sensed event to the next atrial
paced stimulus (see Fig. 8-27).
Implantable CardioverterDefibrillators
Troubleshooting Pacing Systems. Malfunction An ICD monitors the patients rhythm continu-
of a pacemaker can be a result of inappropriate ously, diagnoses rhythm changes, and treats life-
programming (pseudomalfunction) or a true com- threatening ventricular dysrhythmias. Similar to a
ponent malfunction. A malfunction of the pace- pacemaker, the ICD consists of a lead system and
maker is addressed systematically. Immediate a pulse generator. Ideally, the ICD generator is
action is required to restore pacemaker function

F I G U R E 8 - 2 6 Undersensing and oversensing. A: Failure of the ventricular demand pacemaker to detect the
intrinsic rhythm (undersensing) is shown by pacemaker spikes at inappropriate intervals after spontaneous
QRS complexes. B: Failure of the pacemaker to discharge (oversensing) causing pacing inhibition (noted in
the first half of the strip).

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Dysrhythmia Interpretation and Management C H A P T E R 8 89

Pacing rate The rst-generation ICDs were nonprogram-

V-A A-V mable devices that used a factory-specied rate
interval interval criterion.
The second-generation ICDs have programmable
features, including bradycardia and antitachycar-
dia pacing and synchronized cardioversion. These
features allow the use of tiered therapy (ie, differ-
ent levels of therapy to treat a dysrhythmia). The
rst tier of therapy is usually antitachycardia pac-
ing, which involves the carefully timed delivery
of pacing stimuli. If antitachycardia pacing is not
successful, the second tier of therapy (low-energy
synchronized cardioversion) is initiated. Some
AP = atrial pacing spike devices allow multiple attempts at cardioversion.
VP = ventricular pacing spike If cardioversion is not successful, the third tier of
F I G U R E 8 - 2 7 The intervals measured on an electrocardiogram therapy, debrillation, is used. The number of de-
(ECG) strip for a patient with a pacemaker. brillation attempts varies with different devices,
but six attempts is usually the maximum. If the
implanted in the left pectoral area so that the heart patient is successfully converted to a life-com-
is central to the vector of the debrillation current patible rhythm, but the rate is slow, ventricular
(Fig. 8-28). demand pacing is initiated. Bradycardia pacing is
ICDs have been categorized into generations, usually intended for brief periods of pacing until
based on their functionality. normal rhythm resumes.

TA B LE 8- 11 Troubleshooting a Temporary Pacemaker

Problem Cause Intervention
Failure to pace: No evidence of Battery depletion or pulse generator Replace battery or generator.
pacing stimulus, patients heart failure, output or timing circuit failure Check all connections for tightness.
rate below programmed rate Loose cable connection
Failure to capture: Pacing Lead dislodgment Review chest film, turn patient to left
stimulus not followed by lateral decubitus position until lead can
electrocardiogram (ECG) be replaced.
evidence of depolarization Broken connector pins or fractured Connect wire directly to generator to
extension connecting cable diagnose cable problem, replace
connecting cable.
Incompatibility of wire pins with cable Ascertain a secure fit of the exposed pin
or to generator to the cable or the generator, adjust
connection or replace pulse generator.
Output setting (mA) too low Check capture thresholds and adjust
Perforation output to a two- to threefold safety
Lead fracture without insulation break Review 12-lead ECG, report signs of
perforation, stabilize hemodynamics.
Increase in pacing threshold from Check intracavitary ECG; if evidence of
medication or metabolic changes fracture in one pole, unipolarize lead; if
total fracture, replace lead.
Check laboratory test results, correct
metabolic alterations, review
medications and vital signs, increase
Oversensing: Device detects Oversensitive setting Reduce sensitivity (value [in millivolts]
noncardiac electrical events should be larger to make pacer less
and interprets them as sensitive); if patient is pacer dependent
depolarization (no intrinsic R wave), program to
asynchronous mode until problem is
Device detecting tall T waves and Increase ventricular refractory period
interpreting them as R waves beyond T wave.

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90 P A R T T W O Essential Interventions in Critical Care

TA B L E 8 - 11 Troubleshooting a Temporary Pacemaker (continued)

Problem Cause Intervention
In dual-chamber pacing, cross talk Atrial lead dislodgment Recheck atrial capture thresholds; if high,
is a form of oversensing: The dislodgment is probable.
device detects signals from
the other chamber and inhibits;
in atrial channel, R waves are
detected as P waves.
In ventricular channel, atrial High output from atrial channel Reduce output from atrial channel,
pacing stimulus afterpotential decrease ventricular channel sensitivity
is detected as an R wave, (higher millivolt value).
with V pacing inappropriately
Electrical interference, improperly Remove nongrounded equipment.
grounded electrical devices
Undersensing: Device fails to Asynchronous mode setting (VOO, Reprogram to synchronous mode (VVI,
detect intrinsic cardiac activity DOO, AOO) DDD, AAI).
and fires inappropriately
Small intrinsic amplitude Increase sensitivity (turn sensitivity dial
toward lower millivolt value).
Lead dislodgment Recheck capture thresholds; if high,
lead probably dislodged and needs
Lead insulation break Check lead with pacing system analyzer, if
impedance too low (<200 ), insulation
break is likely, and lead needs to be
replaced or can be temporarily placed
in unipolar configuration.

Third-generation devices have many programma- common features of current ICDs. To improve
ble features that allow the physician to tailor the discrimination of tachydysrhythmias, the device
device to the patients needs and that provide mem- allows programming of discrimination algorithms,
ory and event retrieval capabilities. Bradycardia which withhold therapy for ventricular tachycar-
pacing therapies with biventricular pacing are dia when PSVT is conrmed. The availability of an
atrial sensing lead allows for a more specic PSVT
discrimination algorithm. Some devices also have
separate tiers of therapy for atrial tachycardia and
atrial brillation or utter. All third-generation
ICDs are noncommitted (ie, therapy is aborted
if the tachycardia terminates even while the ICD
is charging).
As with cardiac pacemakers, a coding system, known
as the NBD debrillator code, has been developed to
describe modes of ICD function. The rst position of
the code indicates the shock chambernone, atrium,
ventricle, or dual (O, A, V, or D). The second position
indicates the chamber in which antitachycardia pac-
ing is deliveredalso coded O, A, V, or D. Position
three indicates the means by which tachydysrhythmia
is detected, either with the intracardiac electrogram
(E) or by hemodynamic means (H). Most current
ICDs detect dysrhythmias through intracardiac elec-
trograms. The fourth position of the code is the three-
or ve-letter code for the pacemaker capability of
the device. For example, a ventricular debrillator
that detects tachydysrhythmias using intracardiac
F I G U R E 8 - 2 8 Positioning of the implantable cardioverterdefibrilla- electrograms and with adaptive rate ventricular
tor (ICD). antibradycardia pacing would be labeled VOE-VVIR.

Morton_Chap08.indd 90 2/4/2012 2:34:19 PM

Dysrhythmia Interpretation and Management C H A P T E R 8 91

CASE STUDY References

1. Collins M: Using continuous ST segment monitoring.
Mr. M. is a 64-year-old man admitted to the Nursing 40:1113, 2010.
2. Pickham D, et al: How many patients need QT interval monitor-
critical care unit for unstable angina and to rule out ing in critical care units? J Electrocardiol 43(6):572576, 2010.
non-ST-segment elevation myocardial infarction 3. Advanced Cardiovascular Life Support (ACLS) for Healthcare
(NSTEMI). He is placed on a continuous cardiac Providers. (2010); American Heart Association.
monitor using a five-lead placement. The monitor is 4. Wilber DJ, et al.: Comparison of antiarrhythmic drug ther-
set to read leads II and MCL1 and display the ECG apy and radiofrequency catheter ablation in patients with
paroxysmal atrial brillation: a randomized controlled trial.
waveform continuously. A 12-lead ECG is obtained JAMA 303(4):333340, 2010.
to assess for signs of ischemia, injury, or infarction. 5. Wigand, D. (ed): AACN Procedure Manual for Critical Care,
Mr. M is noted initially to be in a sinus tachycardia 5th ed. Philadelphia: Elsevier, 2011.
(rate of 110 beats/min). Two hours later, the high rate
alarms sound on the cardiac monitor and he is found
to have an irregular rhythm with indiscernible P Want to know more? A wide variety of resources to enhance your learn-
waves. On further assessment, he is noted to have ing and understanding of this chapter are available on . Visit
the following vital signs: BP, 97/64 mm Hg; HR, 140 to access chapter review
beats/min; RR, 32 breaths/min, as well as increasing questions and more!
chest pain and shortness of breath. The physician
decides to perform synchronized cardioversion. The
nurse prepares Mr. M. for the procedure and seda-
tion is administered. The rhythm is converted with 50
J into a sinus tachycardia with a rate of 106 beats/
min. On assessment, Mr. M.s blood pressure is
increased to 138/74 mm Hg. An antidysrhythmic is
ordered and cardiac monitoring is continued.
1. What are the advantages of monitoring in leads I
and MCL1?
2. What rhythm did Mr. M. develop?
3. What are the immediate nursing priorities for a
patient who develops a rhythm change?
4. Why was synchronized cardioversion used for
Mr. M.?

Morton_Chap08.indd 91 2/4/2012 2:34:19 PM

Hemodynamic Monitoring

Based on the content in this chapter, the reader should be able to:
1 Describe the type of information provided by, and common indications for,
hemodynamic monitoring.
2 State the basic components of a pressure monitoring system and describe
nursing interventions that ensure accuracy of pressure readings and
3 Describe nursing interventions associated with arterial pressure monitoring.
4 Interpret data obtained through arterial pressure monitoring.
5 Describe nursing interventions associated with central venous pressure
6 Interpret data obtained through central venous pressure monitoring.
7 Describe nursing interventions associated with pulmonary artery pressure
8 Interpret data obtained through pulmonary artery pressure monitoring.
9 Describe methods commonly used in the critical care setting to determine
cardiac output.
10 List factors that affect oxygen demand and oxygen delivery, and describe
methods used to evaluate the balance of oxygen supply, oxygen
consumption, and oxygen demand.

emodynamic monitoring provides information
at the bedside about intracardiac and intravascular
conditions that are characterized by insufcient
cardiac output due to alterations in intravascular
pressures and cardiac output. It is used in the critical volume (preload), alterations in vascular resistance
care setting to assess cardiac function and evaluate (afterload), or alterations in myocardial contractility
the effectiveness of therapy. Because a primary goal (Box 9-1). Although invasive hemodynamic monitor-
of management of critically ill patients is to ensure ing technology is used most frequently in the criti-
adequate oxygenation of tissues and organs, hemo- cal care setting, minimally invasive and noninvasive
dynamic monitoring is indicated for patients with hemodynamic monitoring technologies also exist.


Morton_Chap09.indd 92 2/4/2012 2:35:24 PM

Hemodynamic Monitoring C H A P T E R 9 93

BOX 9-1 Common Indications for

Hemodynamic Monitoring

Cardiogenic shock Pressure infuser

Severe heart failure Saline
Sepsis or septic shock
Pressure gauge
Multiple organ system dysfunction (MODS)
Acute respiratory distress syndrome (ARDS)
Cardiac surgery

Overview of the Pressure Monitoring

System Components
A pressure monitoring system (Fig. 9-1) transmits
pressures from the intravascular space or cardiac Cable to
chambers through a catheter and uid-lled non- monitor
compliant pressure tubing to a pressure transducer.
The transducer converts the physiological signal
from the patient into an electrical signal, which the Catheter tubing
monitor converts to a pressure tracing and digital
value. The monitor is able to display several pres-
sure tracings and digital values simultaneously.
Controls on the monitor also allow the user to label
waveform locations, set or adjust alarms and tracing
scale size, and zero the system.
A patent pressure system is maintained by using
a continuous ush solution, typically normal saline
or dextrose and water (D5W). The ush solution may
also be heparinized. The bag of solution is placed Transducer
in a continuous pressure infusion device to exert F I G U R E 9 - 1 Pressure monitoring system. An indwelling catheter
approximately 300 mm Hg of pressure. A continu- is attached by noncompliant pressure tubing to a transducer. The
ous ow of approximately 3 to 5 mL/h prevents transducer is connected to a monitor that displays a waveform and
backow of blood through the catheter and tubing, systolic, diastolic, and mean pressure values. The system is com-
thereby maintaining system patency and ensuring posed of a solution under pressure to maintain system patency,
accurate transmission of pressures. The system can a flush device and stopcocks are used for drawing arterial blood
samples and zeroing the system.
be ushed manually by activating the ush device.

Ensuring Accuracy damping coefcient is a measure of how quickly the

oscillations diminish (dampen) and eventually cease.
For optimal use of pressure monitoring systems, it is The dynamic response of the system determines the
essential to ensure accurate pressure recordings and natural frequency and the damping coefcient of the
waveform display. Techniques used to ensure accu- system. Factors that can affect the dynamic response
racy include the square-wave test (dynamic response of the system include the systems natural frequency,
testing) and leveling and zeroing the system. the quality of the pressure tubing, the number of stop-
cocks, and the presence of blood sampling systems.
Square-Wave Test (Dynamic Response Testing) The test done to evaluate dynamic response is
The square-wave test is used to determine the sys- commonly known as the square-wave test.1 To per-
tems ability to accurately measure pressures. Each form the square-wave test, the ush device is acti-
beat of the heart generates a pressure waveform, vated and rapidly released. The nurse observes the
which is propagated at a certain frequency (ie, bedside monitor for the waveform to rise sharply
beats per minute) through the systemic circulation. and square off at the top of the scale. After the ush
Vascular resistance diminishes (dampens) the wave- device is released, the nurse observes the waveform
forms magnitude over time. In a pressure monitor- as it returns to baseline, counts the number of oscil-
ing system, the natural frequency indicates how fast lations, and observes the distance between them. In
the pressure monitoring system oscillates in response an ideal (optimally damped) system, the square wave
to a signal (eg, the arterial pressure pulse). The has a straight vertical upstroke from the baseline, a

Morton_Chap09.indd 93 2/4/2012 2:35:27 PM

94 P A R T T W O Essential Interventions in Critical Care

A. Optimally damped B. Overdamped C. Underdamped

F I G U R E 9 - 2 Dynamic response (square-wave) testing. A: Optimally damped system. Activation of the flush
device generates a sharp vertical upstroke, horizontal line, and straight vertical downstroke ending with 1.5
to 2 oscillations close together before returning to baseline. B: Overdamped system. Activation of the flush
device generates a slurred upstroke and downstroke with less than 1.5 oscillations above or below the base-
line. C: Underdamped system. Activation of the flush device generates more than 2 to 3 oscillations above
and below the baseline. (Courtesy of Edwards Lifesciences LLC.)

straight horizontal component, and a straight verti- (typically, the stopcock nearest the transducer) with
cal downstroke with approximately 1.5 to 2 sharp the phlebostatic axis. If the airuid interface is
oscillations before returning to baseline. The dis- raised above the phlebostatic axis, the values dis-
tance between the oscillations is also short. Figure played will be erroneously low, and if the interface
9-2 depicts the results of dynamic response testing is lowered below the phlebostatic axis, the values
for an optimally damped system, an overdamped sys- displayed will be erroneously high.
tem, and an underdamped system. Overdamped sys- Pressure measurements are taken with the patient
tems, which may be caused by system leaks, blood in the supine position. The head of the bed may be
clots, excessively long tubing, or large air bubbles in elevated as much as 60 degrees, provided that the
the tubing or transducer, produce erroneously low airuid interface is releveled after any changes in
systolic pressures. Underdamped systems, which the patients position (see Fig. 9-3B). The elevation
may be caused by small air bubbles in the system of the head of the bed should be noted to maintain
or very rigid pressure tubing, produce erroneously consistency among measurements.
high systolic pressures and erroneously low diastolic
pressures. RED FLAG! Consistency in leveling and
measurement techniques is important because
Leveling and Zeroing small variations in the zero reference point can
To ensure accurate pressure monitoring, the trans- elicit large and erroneous changes in the pressures
ducer is leveled to an external landmark known as observed.
the phlebostatic axis (zero reference point), and
then zeroed to atmospheric pressure. The phlebo- Troubleshooting
static axis is the fourth intercostal space, midaxil-
lary level (Fig. 9-3A). Once the phlebostatic axis is Technical or mechanical factors can produce errone-
established, the patients chest wall can be marked ously high or low pressures and altered waveforms.
to ensure consistent leveling when obtaining subse- Any impedance between the patient and transducer
quent pressure readings. With the patient placed in (eg, air bubbles, blood, additional stopcocks) can
the supine position, a carpenter-type level or laser- alter the signal and consequently, the pressures and
light level is used to align the airuid interface waveforms. Less than 300 mmHg in the continuous

Phlebostatic axis

1 0


F I G U R E 9 - 3 A: The phlebostatic axis is the intersection of the midaxillary line drawn between the anterior
and posterior surfaces of the chest (1) and the line drawn through the fourth intercostal space at the sternum
(2). B: The position of the phlebostatic axis changes when the head of the bed is raised; therefore, the air
fluid interface must be releveled if the patients position changes.

Morton_Chap09.indd 94 2/4/2012 2:35:27 PM

Hemodynamic Monitoring C H A P T E R 9 95

pressure device, compliant tubing, or excessive Data Interpretation

lengths of tubing may also distort the signal to the
transducer. The nurse periodically checks the sys- The normal arterial pressure waveform (Fig. 9-5,
tem to ensure patency of the catheter and tubing, p. 97) consists of a rapid upstroke (produced by the
sufcient pressure in the pressure bag, and proper rapid ejection of blood from the left ventricle into
positioning of the stopcocks, and to ensure that the the aorta), a clear dicrotic notch (which signals clo-
alarms are set and functioning properly. Table 9-1 sure of the aortic valve and the beginning of dias-
describes causes of technical problems that can tole), and a denite end point (which reects the end
affect pressure monitoring systems and trouble- of diastole). Loss of the dicrotic notch is a sign of
shooting techniques to address them. overdamping.
The value measured at the peak of the waveform is
the systolic pressure, and the value measured at the
Arterial Pressure Monitoring lowest point of the waveform is the diastolic pressure.
The difference between the systolic and diastolic pres-
Arterial pressure monitoring allows continuous mon- sure is the pulse pressure. The pulse pressure closely
itoring of the systemic arterial blood pressure and reects the stroke volume from the ventricle. Bedside
provides vascular access for obtaining blood samples. monitors do not automatically display the pulse pres-
Vasoactive IV infusions; cardiovascular instability; sure but can be easily calculated and is a value useful
uctuating, unstable blood pressures; and frequent in assessing the patients volume status.
blood draws are indications for arterial pressure Mean arterial pressure (MAP) is used to evaluate
monitoring. In addition, when therapeutic decisions perfusion of vital body organs. Normal MAP is 70
depend on obtaining accurate blood pressure values, to 105 mm Hg. The formula used to calculate MAP
arterial pressure monitoring is the gold standard. takes into account the fact that diastole is approxi-
mately two times longer than systole during a car-
diac cycle:
Equipment and Setup
Systolic pressure + (Diastolic pressure 2)
When selecting the artery for cannulation
The artery should be large enough to accommo-
date the catheter without occluding or signi- Most bedside monitors automatically calculate and
cantly impeding ow. continuously display the MAP. Algorithms to deter-
The site should be easily accessible and free from mine MAP may vary depending on the manufacturer
contamination by body secretions. of the equipment.
There should be adequate collateral blood ow Blood pressures obtained by an intra-arterial
in the event that the cannulated artery becomes catheter using an optimally damped pressure
occluded. monitoring system are the most accurate. In nor-
The radial artery, which usually meets all of these motensive patients, blood pressure measurements
criteria, is the most frequently used site for arte- obtained through arterial pressure monitoring are
rial catheter placement. It is supercially located very similar to those obtained with a cuff (the intra-
and therefore easy to palpate. Cannulation of this arterial systolic pressure is 5 to 10 mm Hg higher).
artery also poses the least limitation on the patients However, comparisons between intra-arterial and
mobility. Before a catheter is inserted into the radial cuff pressures may be misleading because the meth-
artery, the presence of adequate collateral circula- ods of measurement reect different physiologic
tion to the hand via the ulnar artery is assessed by events and therefore are not truly comparable. A
ultrasound or by performing Allens test (Fig. 9-4, trend value obtained using one method of measur-
p. 97). Alternative sites for arterial catheter place- ing blood pressure consistently is often more help-
ment include the femoral and brachial arteries. ful than comparing values obtained using different
After the catheter is inserted, the nurse ensures methods. Documenting the site of pressure mea-
that the arterial blood pressure alarms on the moni- surements and what method was used to obtain
tor are properly set and activated. The alarms must them is important.
be visible and audible to the caregiver. Alarms are
set either around specic parameters for the patient, Complications
or according to facility protocol. Typically, high and
low alarms are set for systolic, diastolic, and mean Accidental Blood Loss
pressures and for pressures within 10 to 20 mm Hg Accidental blood loss from an arterial catheter
of the patients blood pressure. can be catastrophic. Prevention of accidental dis-
lodgement and easy access to the insertion site
RED FLAG! Although the arterial monitoring and connections is imperative. To reduce the risk
system provides vascular access for obtaining for accidental blood loss, a Luer-Loktype con-
blood samples, no IV solution or medication should nector is used for all connections in the system.
be administered through the arterial pressure The extremity in which the catheter is placed
monitoring system at any time. may be immobilized (eg, by placing the wrist on

Morton_Chap09.indd 95 2/4/2012 2:35:28 PM

96 P A R T T W O Essential Interventions in Critical Care

TA B L E 9 - 1 Troubleshooting Pressure Monitoring Systems

Problem Cause Prevention Intervention

No waveform Transducer not open to catheter Check and correct stopcock position.
Settings on bedside monitor Check scale setting and monitor
incorrect or off setup.
Catheter clotted Maintain continuous flush. Aspirate blood clot.
Do not irrigate with syringe.
Faulty cable Check function with cable checking
device; change cables if
Faulty transducer Change transducer if necessary.
Overdamped Improper scale selection Change to proper scale.
waveforms Air bubbles in tubing and near Flush system by gravity. Flush air from system.
transducer On initial setup, expel all air from
flush solution bag.
Blood clot partially occluding Use heparinized solution Aspirate clots with syringe.
catheter tip according to facility protocol. Use heparinized solution according
to facility protocol.
Forward migration of catheter Reposition patient.

Catheter tip occluded by balloon Reposition catheter by pulling back

or vessel wall on it while observing waveforms.
Leak in pressure system Tighten all connections and Tighten all connections and
stopcock on set up. stopcocks.
Change faulty system components if
Pressure bag not inflated at Reinflate bag or apply pressure to
300 mm Hg device to 300 mm Hg.
Change device if faulty.
Underdamped Excessive movement of Ensure correct catheter Try different catheter tip position.
waveforms catheter placement. Eliminate excessive stopcocks.
Use appropriate catheter size for
Air bubbles in tubing Eliminate excessive length of Eliminate excessive tubing.
pressure tubing.
False low Leveling or zero reference Check level periodically. Relevel transducer airfluid interface
readings (transducer) is too high Check monitor settings. to phlebostatic axis.
Observe waveforms. Rezero monitor.
Improper zeroing Optimize length of pressure tubing.
Overdamped waveforms Perform square waveform test
False high Leveling or zero reference Check level periodically. Relevel transducer airfluid interface
readings (transducer) is too low Check monitor settings. to phlebostatic axis.
Observe waveforms.
Improper zeroing Rezero monitor.
Overdamped waveforms Perform square waveform test Remove excessive length of
pressure tubing.
Inappropriate Incorrect catheter position Establish optimal position Reposition patient.
pressure Migration of pulmonary carefully during the insertion Obtain chest x-ray.
waveform artery catheter (PAC) into process. Reposition catheter.a
mechanical wedge position Use proper balloon inflation Observe waveforms and confirm with
volume (1.251.5 mL air) for initial insertion tracings.
obtaining a pulmonary artery If right ventricular tracing is observed
occlusion pressure (PAOP) from PAC distal tip, slowly inflate
tracing. balloon to allow PAC to float into
pulmonary artery.
If PAOP tracing is observed with
balloon deflated, withdraw
catheter slightly while observing
waveforms. Stop withdrawing
as soon as a pulmonary artery
tracing is observed.
Bleed back into Loose connections Tighten connections.
pressure Stopcocks not returned to Ensure stopcocks are in correct
tubing or proper position position.
transducer Pressure bag not at 300 mm Hg Check pressure device.

A physician or advanced practice nurse is usually responsible for repositioning a PAC.

Morton_Chap09.indd 96 2/4/2012 2:35:29 PM

Hemodynamic Monitoring C H A P T E R 9 97

Unclenched hand returns

to baseline color because
of ulnar artery and
connecting arches

Pallor produced
by clenching

Ulnar artery
Radial artery and patent
Ulnar artery occluded
Radial artery occluded
FIGURE 9-4 Modified Allens test. If color returns in less than 7 seconds, the ulnar circulation to the hand
is adequate. If color returns in 7 to 15 seconds, ulnar filling may be impaired. If the hand remains
blanched for longer than 15 seconds, ulnar circulation is inadequate and the radial artery should not be

an arm board). If a wrist restraint is used, opti- Impaired Circulation

mally, it should not be placed over the insertion
Circulation to the extremity in which the arterial line
site. Similarly, the extremity should not be cov-
is placed must be monitored frequently. The nurse
ered by bed linens, to facilitate visual checks.
assesses the color, sensation, temperature, and move-
Frequent assessments of the site is required if a
ment of the extremity after insertion of the arterial
wrist restraint is present.
catheter and per facility policy. Any sign or symp-
tom of impaired circulation may be an indication for
Infection catheter removal and must be reported immediately.
Factors that reduce the risk for infection include
proper attention to sterile technique during cath-
eter insertion, care of the insertion site, and Central Venous Pressure Monitoring
blood sampling, and maintenance of a sterile,
closed monitoring system. The nurse assesses Central venous pressure (CVP) is typically measured
the insertion site for signs of infection; uses ster- in the superior vena cava near the right atrium via
ile technique when changing dressings, tubing, a PICC line or a central line catheter placed in the
and ush solution; and maintains the integrity jugular or subclavian vein. The CVP reects the
of the system. Applying sterile nonvented (dead- pressure of blood in the right atrium and provides
ender) caps to the stopcock ports helps eliminate information about intravascular blood volume,
contamination. Closed systems for blood sam- right ventricular end-diastolic pressure (RVEDP),
pling help reduce the potential for open stopcock and right ventricular volume. To a limited degree, in
infections and assist with managing potential people with normal pulmonary vasculature and left
blood loss. ventricular function, the CVP also indirectly reects
left ventricular end-diastolic pressure (LVEDP) and
function, because the left and right sides of the heart
are linked by the pulmonary vascular bed.

Dicrotic notch
Data Interpretation
pressure Normal CVP is 2 to 8 mmHg. Abnormally high or
Systole low CVP measurements are usually associated with
alterations in intravascular volume status or ventric-
ular function (Box 9-2). A CVP value alone is mean-
End diastole
ingless, but when used in conjunction with other
clinical data (eg, breath sounds, heart and respira-
F I G U R E 9 - 5 Normal arterial pressure waveform. The dicrotic tory rate, neck vein distention, urine output, electro-
notch indicates the end of ventricular systole and the beginning of cardiographic data), it is a valuable aid in managing
diastole. and predicting the patients clinical course.

Morton_Chap09.indd 97 2/4/2012 2:35:29 PM

98 P A R T T W O Essential Interventions in Critical Care

absent breath sounds, tachycardia, and elevated

BOX 9-2 Causes of Alterations in Central
peak inspiratory pressures (if the patient is receiv-
Venous Pressure (CVP) Measurements
ing mechanical ventilation).
Low CVP Measurements
Hypovolemic state Air Embolism
Diuretic therapy Air embolism occurs as a result of air entering the
Vasodilation (eg, sepsis, vasodilating medications) vasculature and traveling through the vena cava to
High CVP Measurements
the right ventricle. When the tubing is disconnected
Right ventricular failure from the catheter, changes in intrathoracic pres-
Pulmonary embolism sure with inspiration and expiration can draw air
Pulmonary hypertension into the catheter. Approximately 10 to 20 mL of air
Left ventricular failure entering the venous system can cause the patient to
Mechanical ventilation become symptomatic. Signs and symptoms include
Hypervolemic state sudden hypotension, confusion, lightheadedness,
anxiety, and unresponsiveness. Cardiac arrest may
occur if the air bolus is large. If air embolism is
suspected, turning the patient on the left side in
the Trendelenburg position may allow the air to
Complications rise to the wall of the right ventricle and improve
blood ow. Supplemental oxygen is started unless
Infection contraindicated.
Infection may occur intravascularly or around the
insertion site. Signs and symptoms of central venous
catheterassociated infection may include erythema Pulmonary Artery Pressure Monitoring
at the insertion site, fever, or an elevated white blood
cell (WBC) count. Denitive diagnosis is obtained In pulmonary artery pressure (PAP) monitoring,
with blood cultures. Primary measures to prevent a catheter is placed through the right side of the
infection include routine dressing and IV uid tub- heart into the pulmonary artery. By measuring
ing changes (per Centers for Disease Control and pressures in the right atrium, right ventricle, and
Prevention [CDC] guidelines and facility protocol) pulmonary artery, it is possible to assess right ven-
and adherence to sterile technique during catheter tricular function, pulmonary vascular status, and,
insertion and dressing changes. indirectly, left ventricular function. The pulmonary
artery catheter (PAC) also allows evaluation of car-
Thrombosis diac output.
Thrombi occasionally form and may vary from a
thin layer of brin over the catheter tip to a large Equipment and Setup
thrombus. Loss of the hemodynamic waveform or
the inability to infuse uid or withdraw blood from Pulmonary Artery Catheter
the catheter may be indications that the catheter is Several types of PACs are available. The type of
occluded by a large thrombus. Because a thrombus catheter used is determined by the parameters to be
may embolize (putting the patient at risk for pul- monitored. All PACs have multiple external lumens.
monary embolism) or impair circulation to a limb, A typical PAC (Fig. 9-6) has four lumens:
it constitutes an emergency and must be reported The distal lumen is located into the pulmonary
to the physician immediately. Facility protocol artery and is attached to the transducer to measure
may permit nurses to attempt aspirating the clot. PAPs. Mixed venous blood (used to calculate mixed
Frequently, facilities also have protocols to admin- venous oxygen saturation [SvO2], oxygen extrac-
ister small doses of thrombolytic agents to dissolve tion, oxygen consumption, and intrapulmonary
the clot. shunt measurements) may be withdrawn from the
distal lumen. Use of the distal lumen for admin-
Pneumothorax stering uid or medication is not recommended.
Anatomical factors can make placement of a cen- The proximal lumen terminates in the right atrium
tral line difcult, particularly if the patient is obese or the superior vena cava. The lumen is used for
or has torturous subclavian veins. The needle or infusing uids and is often connected to a trans-
introducer sheath may pass through the vessel wall ducer to provide RAP measurements and dis-
and puncture the lung during insertion, causing an play of the RAP waveform. The proximal lumen
apical pneumothorax. A postinsertion chest radio- is also used to inject solution for cardiac output
graph is routinely obtained to verify proper cath- measurement.
eter placement and assess for pneumothorax. Signs The thermistor receives input from a thermistor
and symptoms of a pneumothorax include pleu- on the tip of the PAC and measures the patients
ritic chest pain, shortness of breath and dyspnea, core temperature. It detects the blood tempera-
asymmetrical chest wall movement, diminished or ture change when solution is injected through

Morton_Chap09.indd 98 2/4/2012 2:35:29 PM

Hemodynamic Monitoring C H A P T E R 9 99

The thermistor lumen

connects to a monitor
to display a core

The proximal lumen typically opens

into the right atrium or vena cava.
In addition to measuring right atrial
pressure, it is used to deliver the bolus
injection that is used to measure cardiac
output and functions as a fluid
infusion route.

The balloon inflation lumen

serves as the access point
for inflating the balloon at
the distal tip of the catheter
for PAOP measurement.
The inflated balloon
wedges in a branch of the
The distal lumen opens into
pulmonary artery during
the pulmonary artery
PAOP measurement.
and is used to measure
pulmonary artery pressures.

F I G U R E 9 - 6 Pulmonary artery catheter. PAOP, pulmonary artery occlusion pressure. (Courtesy of Edwards
Lifesciences, LLC.)

the proximal lumen during cardiac output Pulmonary Artery Catheter Insertion
The nurse assists with PAC insertion.2 Strict ster-
The balloon ination lumen is used to inate the
ile technique is required. The physician inserts the
balloon near the catheter tip with air. Ination
PAC through a large vein, usually the right internal
of the balloon causes the catheter to occlude (or
jugular, the right or left subclavian, or the femoral
wedge) into a distal artery, allowing measure-
vein. The physician advances the catheter with the
ment of the pulmonary artery occlusion pressure
balloon inated once it is in the right atrium. To
(PAOP), formerly known as the pulmonary artery
determine catheter tip location, the nurse moni-
wedge pressure (PAWP). Fluid is never inserted
tors the waveforms and pressures on the bed-
into the balloon ination lumen. It is an indirect
side monitor as the catheter passes into the right
measurement of LAP.
atrium, through the tricuspid valve into the right
Specialty PACs have additional lumens and capa- ventricle, across the pulmonic valve, into the pul-
bilities (Fig. 9-7). For example, a ve-lumen catheter monary artery, and eventually into the wedged
has an additional lumen for venous infusion into the position (Fig. 9-8, p. 101). The balloon is allowed
right atrium. A seven-lumen catheter includes an to deate passively after the pulmonary artery
additional lumen for venous infusion, as well as an wedge is noted on the monitor and the return of
optical module lumen (which connects to a special the pulmonary artery is conrmed. The amount of
oximetry monitor for SvO2 monitoring) and a ther- air required to wedge the balloon is noted. The
mal lament lumen (which allows display of cardiac PAC is secured, a sterile dressing is placed over the
output on a continuous basis). Another type of spe- insertion site, and a chest radiograph is obtained
cialty PAC determines right ventricular volumes, and to verify catheter position. The distal (pulmonary
then calculates the right ventricular ejection fraction. artery) lumen is connected to pressure tubing, and

Morton_Chap09.indd 99 2/4/2012 2:35:29 PM

100 P A R T T W O Essential Interventions in Critical Care

Optical module
Distal Thermal filament
lumen Thermistor Distal lumen
lumen lumen

Venous Venous
infusion infusion
lumen lumen

Balloon Balloon
Proximal inflation Proximal inflation
lumen lumen lumen lumen



Thermal filament
F I G U R E 9 - 7 Specialty pulmonary artery catheters. A: A five-lumen catheter that includes an additional
venous infusion lumen that is used for infusions into the right atrium. B: A seven-lumen catheter that
includes a venous infusion lumen, an optical module lumen for continuous mixed venous oxygen satura-
tion (SvO2) monitoring, and a thermal filament lumen for continuous cardiac output monitoring. (Courtesy of
Edwards Lifesciences, LLC.)

the other lumens are connected as appropriate, tracing. Interpretation of pressure measurements
either to the pressure monitoring system or an IV obtained through PAP monitoring is summarized in
solution. Table 9-2, on page 102.
If the PAC is not properly secured, it may become Measurement of all pressures is most accurate
dislodged and the tip may fall back into the right when obtained at the end of expiration. During the
ventricle. The patient may experience dysrhythmias end-expiration period, there is minimal airow and
(as a result of endocardial irritation by the catheter little variation in pleural pressures that inuence
tip), and the hemodynamic pressures and waveform cardiac pressures. Thus, end expiration provides
will reect those of the right ventricle instead of the a standard reference point for obtaining measure-
pulmonary artery. Inating the balloon may cause ments. Spontaneous breathing causes negative
the catheter to reoat into the pulmonary artery. intrathoracic pressure during inspiration, which
Alternatively, if the catheter is in a sleeve (to protect produces a decline in the waveform. The wave-
from contamination), it may be advanced into the form used for measurement is the last clear wave
proper position in the pulmonary artery. occurring just before the inspiratory dip (Fig. 9-9A),
p. 103. Mechanical ventilation causes positive intra-
Data Interpretation thoracic pressure during inspiration, which pro-
duces an inspiratory push, or rise, in the waveform.
The pressures and waveforms obtained through PAP In mechanically ventilated patients, the waveform
monitoring are generated by pressure changes in used for measurement is the last clear wave occur-
the heart that occur throughout the cardiac cycle. ring just before the inspiratory rise (see Fig. 9-9B).
The mechanical activity of the heart (ie, systole and
diastole) follows the electrical activity of the heart.
Therefore, mechanical activity must be correlated to Right Atrial Pressure
electrical activity by interpreting the hemodynamic The right atrium is a low-pressure chamber, receiv-
waveforms alongside an electrocardiographic ing blood volume passively from the vena cava. The

Morton_Chap09.indd 100 2/4/2012 2:35:29 PM

Hemodynamic Monitoring C H A P T E R 9 101

mm Hg

a v a v
10 a c v a c v

Right atrial pressure Right ventricular pressure Pulmonary artery pressure Pulmonary artery
26 mm Hg Systolic: 2030 mm Hg Systolic: 2030 mm Hg occlusion pressure
Diastolic: 08 mm Hg Diastolic: 815 mm Hg 812 mm Hg
F I G U R E 9 - 8 Normal values and wave configurations produced during PAC insertion. Note that the RAP is
equivalent to the RVEDP, the right ventricular systolic pressure is equivalent to the pulmonary artery systolic
pressure, and the pulmonary artery diastolic pressure closely approximates the PAOP.

RAP is used to make assumptions about the volume in the ventricles. The QRS complex represents ven-
in the right ventricle during end diastole (when the tricular depolarization and ventricular contraction.
ventricle is the fullest). Simultaneously, the atria relax and ll with blood.
Atrial waveforms have three positive waves (Fig. The v wave generated by these events thus occurs in
9-10A, p. 104): the T-to-P interval. The mitral and tricuspid valves
are closed, and thus do not accurately reect the
The a wave reects the increase in atrial pressure
pressure (volume) in the ventricles.
during atrial systole (end of ventricular diastole). The
Abnormalities of the right atrial waveform include
tricuspid valve is open at this time, allowing pres-
large, elevated a or v waves. Increased resistance to
sures between the atrium and ventricle to equalize.
ventricular lling and impaired atrial emptying cause
The a wave is used to obtain the RAP (CVP) reading.
an elevated a wave. Elevated v waves are related to
The c wave results from a small increase in pres- regurgitant ow during ventricular contraction.
sure associated with closure of the tricuspid valve
and early atrial diastole (onset of ventricular sys- Right Ventricular Pressure
tole). It may be a distinct wave or a dicrotic notch.
Typically, the right ventricular pressure is obtained
It is not present in all waveforms.
only on initial PAC insertion. The right ventricle is
The v wave represents atrial diastole (and ventric-
ular systole) and reects the increase in pressure a low-pressure chamber. When the tricuspid valve is
caused by the lling of the atrium with blood. open, the RAP and the RVEDP are similar. During
right ventricular systole, the pressure increases to
Atrial waveforms also have two primary negative generate enough pressure to open the pulmonic
waves (descents): valve and eject blood into the pulmonary artery.
Therefore, the right ventricular systolic pressure nor-
The x descent follows the a wave (or c wave, if pres- mally equals the pulmonary artery systolic pressure.
ent) and represents a decrease in pressure caused by The right ventricular waveform has a distinctive
atrial relaxation at the beginning of atrial diastole. square root conguration (see Fig. 9-10B). The ini-
The y descent follows the v wave and represents the tial rapid increase in right ventricular pressure repre-
initial, passive atrial emptying into the ventricle as sents right ventricular systole, which follows the QRS
the tricuspid valve opens.1,2 complex of the ECG. After ventricular systole, the
Accurate identication of the a, c, and v waves pulmonic valve closes, and the right ventricular pres-
requires correlation of the waveform with the elec- sure rapidly decreases, creating a diastolic dip. Next
trocardiogram (ECG) (see Fig. 9-10A). On the ECG, in the cardiac cycle, the tricuspid valve opens, allow-
the P wave represents atrial depolarization, which ing the right ventricle to passively ll with blood from
causes the right atrium to contract. Therefore, the the right atrium. Right ventricular diastole occurs
a wave occurs after the P wave, usually in the PR within the period from the T wave to the next Q wave
interval. The mitral and tricuspid values are open, on the ECG. The point on the waveform just before
and thus more accurately measures the pressures the rapid increase in pressures represents the RVEDP.

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102 P A R T T W O Essential Interventions in Critical Care

TA B L E 9 - 2 Interpreting Pressures Obtained Through PAP Monitoring

Causes of
Pressure and Description Normal Values Causes of Increased Pressure Decreased Pressure
Right Atrial Pressure (RAP)
The RAP reflects the right Mean pressure: Right-sided heart failure Reduced circulating
ventricular end-diastolic pressure 26 mm Hg Volume overload blood volume
(RVEDP) and is therefore an
indication of right ventricular Tricuspid valve stenosis or
function. Note that the RAP is insufficiency
equivalent to the central venous Constrictive pericarditis
pressure (CVP). Cardiac tamponade
Pulmonary hypertension
Right ventricular infarction
Pulmonary embolism
Right Ventricular Pressure
The right ventricular systolic Systolic pressure: Mitral stenosis or insufficiency Reduced circulating
pressure normally equals 2030 mm Hg Pulmonary disease blood volume
the pulmonary artery systolic Diastolic pressure:
pressure. The right ventricular 08 mm Hg Hypoxemia
diastolic pressure is reflected Constrictive pericarditis
by the RAP. Chronic heart failure
Atrial and ventricular septal
Patent ductus arteriosus
Pulmonary Artery Systolic Pressure
The pulmonary artery systolic Systolic pressure: Left-sided heart failure Reduced circulating
pressure results from right 2030 mm Hg Increased pulmonary blood flow blood volume
ventricular systolic pressure and Mean pressure: (left or right shunting, as in atrial
reflects right ventricular function. 815 mm Hg or ventricular septal defects)
Mechanical ventilation
Any condition causing
increased pulmonary arteriolar
resistance (such as pulmonary
hypertension, volume overload,
mitral stenosis, or hypoxia)
Pulmonary Artery Diastolic Pressure
The pulmonary artery diastolic Diastolic pressure: Any condition causing Reduced circulating
pressure is an indirect reflection 815 mm Hg increased pulmonary arteriolar blood volume
of left ventricular end-diastolic Mean pressure: resistance (such as pulmonary Right ventricular
pressure (LVEDP) in a patient 1020 mm Hg hypertension, pulmonary failure
without significant pulmonary embolism, volume overload,
artery disease. mitral stenosis, or hypoxia)
Pulmonary Artery Occlusion Pressure (PAOP)
The PAOP indirectly reflects the Mean pressure: Left-sided heart failure Reduced circulating
LAP and the LVEDP, unless the 812 mm Hg Mitral stenosis or insufficiency blood volume
patient has obstructions from the Right ventricular
tip of the PAC to the left ventricle. Pericardial tamponade failure
Changes in PAOP reflect changes
in left ventricular filling pressure.

Modified from Springhouse: Critical Care Nursing Made Incredibly Easy. Philadelphia, PA: Springhouse, 2004, p 170.

Pulmonary Artery Pressure valve allows equalization of pressure from the left
In healthy people, the pulmonary vasculature is a ventricle back to the tip of the PAC. Under normal
relatively compliant, low-resistance, low-pressure conditions, with no obstructions or primary pul-
system. The pulmonary artery systolic pressure is monary hypertension, the pulmonary artery dia-
generated by right ventricular systolic ejection. The stolic pressure may be used to monitor the LVEDP.
pulmonary artery diastolic pressure reects the The pulmonary artery waveform characteristics are
resistance of the pulmonary vascular bed and, to a similar to those of the systemic arterial waveform (see
limited degree, the LVEDP because the open mitral Figs. 9-5 and 9-10C). The dicrotic notch in the downward

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Hemodynamic Monitoring C H A P T E R 9 103




Machine breath Machine breath Machine breath

End expiration End expiration End expiration

FIGURE 9-9 Measurement of pressures is most accurate when obtained at the end of expiration. A: Spontaneous
breathing. B: Pulmonary artery occlusion pressure (PAOP) tracing with positive pressure mechanical ventila-
tion. Measurement of the PAOP is made at the last clear waveform (circled areas) before the inspiratory rise.

slope of the pulmonary artery waveform corresponds wave corresponds to left atrial systole, and is used
with pulmonic valve closure and represents the begin- to obtain the measured pressure in the left atrium.
ning of the pulmonary artery diastolic phase. The v wave corresponds to left atrial diastole. The c
wave is rarely visible on the PAOP tracing because
Pulmonary Artery Occlusion Pressure the slight increase in pressure from backward bulg-
The PAOP is the measure of the left atrial pressure ing of the mitral valve is difcult to observe.
(LAP) and the LVEDP. The PAOP is obtained by The a and v waves on the PAOP tracing are slightly
inating the balloon at the catheter tip. The balloon delayed relative to the ECG because of the distance
wedges in a branch of the pulmonary artery, occlud- from the left side of the heart over which these pres-
ing forward ow and creating an unrestricted vas- sures are transmitted. The a wave falls more closely
cular channel between the tip of the catheter and in line with the QRS complex, and the v wave cor-
the left ventricle (Fig. 9-11). In this way, the PAOP relates with the T wave.
reects the LVEDP when the reading is obtained at Left ventricular dysfunction and mitral valve dis-
end diastole, when the mitral valve is open. (In the ease occur more frequently than right ventricular
presence of mitral valve stenosis, the PAOP does not dysfunction and tricuspid valve disease; therefore
accurately reect the LVEDP.) abnormal PAOP waveforms are more common than
A PAOP tracing is essentially a LAP tracing; there- abnormal right atrial waveforms. Left ventricular
fore, it has a, c, and v waves and x and y descents failure usually causes elevation of both the a and
just like the RAP tracing (see Fig. 9-10D). The a v waves and signicantly increases the PAOP (and

Morton_Chap09.indd 103 2/4/2012 2:35:30 PM

104 P A R T T W O Essential Interventions in Critical Care


Right ventricular pressure

Right atrial pressure

a c v a c v


a v a v

F I G U R E 9 - 1 0 A: Right atrium. A waveform with three small upright waves appears. The a waves represent
the right atrial systole; the v waves, right atrial diastole. B: Right ventricle. A waveform with sharp systolic
upstrokes and lower diastolic dips appears. C: Pulmonary artery. A pulmonary artery pressure (PAP) wave-
form appears. Note that the upstroke is smoother than on the right ventricular waveform. The dicrotic notch
indicates pulmonic valve closure. D: Distal branch of the pulmonary artery. The balloon wedges where the
vessel becomes too narrow for it to pass, and a PAOP waveform, with two small upright waves, appears. The
a wave represents left atrial systole; the v wave, left atrial diastole. ECG, electrocardiogram. (Courtesy of
Edwards Lifesciences, LLC.)


artery Pulmonary
Alveolus vein

Pulmonary Left
artery atrium
Pulmonic Aortic
catheter valve closed valve
Mitral valve
Tricuspid open
Right Left
valve open
ventricle ventricle

Systemic circulation
F I G U R E 9 - 1 1 Position of the pulmonary artery. When the balloon is inflated and the catheter is in the wedge
position, there is an unrestricted vascular channel between the tip of the catheter and the left ventricle in
diastole. PAOP thus reflects LVEDP, an important indicator of left ventricular function. (Courtesy of Philips.)

Morton_Chap09.indd 104 2/4/2012 2:35:31 PM

Hemodynamic Monitoring C H A P T E R 9 105

the pulmonary artery diastolic pressure) because

of reduced contractility and forward blood ow. EVIDENCE-BASED PRACTICE GUIDELINES
Normally, the PAOP closely approximates the pul- Accuracy in Hemodyamic Monitoring
monary artery diastolic pressure with a gradient of
PROBLEM: Technical aspects of monitoring affect the
1 to 4 mm Hg. A widened pressure gradient (greater
accuracy and reliability of the data obtained through
than 4 mm Hg) is a differential diagnostic sign of
hemodynamic monitoring. Accurate and reliable data are
primary pulmonary hypertension or increased pul-
essential to providing optimal patient care.
monary vascular resistance (PVR) (as opposed to
left ventricular dysfunction). EVIDENCE-BASED PRACTICE GUIDELINES
1. Verify the accuracy of the invasive pressure monitoring
Complications system by performing a square-wave test at the begin-
Generally, most complications that occur with PAP ning of each shift and any time the system is disturbed
monitoring relate to the need for percutaneous cen- (eg, blood draw). (level A)
tral venous access. Complications such as infection, 2. Position the patient in the supine position (head of bed
thrombus, pneumothorax, and air embolus were between 0 and 60 degrees), the lateral position (20, 30,
discussed earlier in the chapter. Other complica- or 90 degrees with the head of the bed flat) or prone
tions that may occur with PAP monitoring include before obtaining pulmonary artery pressure (PAP), pul-
ventricular dysrhythmias, pulmonary artery rupture monary artery occlusiive pressure (PAOP), and central
or perforation, and pulmonary infarction. venous pressure (CVP) measurements. Allow the patient
to stabilize for 5 to 15 minutes after a position change.
Ventricular Dysrhythmias (level A)
3. With the patient in the supine or prone position, level
Ventricular dysrhythmias may occur during the and reference the transducer airfluid interface to the
insertion of a PAC. As the catheter passes through phlebostatic axis (4th ICS, AP diameter of the chest)
the right ventricle, it may irritate the endocardium, or to the lateral angle-specific reference using a laser or
causing premature ventricular contractions (PVCs) carpenters level before obtaining PAP, PAOP, and CVP
and occasionally ventricular tachycardia. The dys- measurements. (level A)
rhythmias typically resolve when the catheter is 4. Obtain PAP, PAOP, and CVP measurements from a
advanced into the pulmonary artery; however, it is graphic (analog) tracing at end expiration or adjust the
essential to have ready access to emergency medi- measurement point if the patient is receiving airway
cations and equipment in case the ventricular pressure release ventilation (APRV) or is actively exhal-
dysrhythmias persist. Migration of the PAC back ing. (level A)
into the right ventricle may also cause ventricular 5. Use a simultaneous electrocardiogram (ECG) tracing to
dysrhythmias. assist with proper PAP, PAOP, and CVP waveform identi-
fication. (level A)
Pulmonary Artery Rupture or Perforation
Pulmonary artery rupture or perforation is a rare KEY
but potentially fatal complication that may occur Level A: Meta-analysis of quantitative studies or metasynthesis of
during insertion or manipulation of the PAC. During qualitative studies with results that consistently support a spe-
insertion of the PAC, proper technique (ie, advanc- cific action, intervention, or treatment
ing the catheter with the balloon fully inated with Level B: Well-designed, controlled studies with results that consis-
1.5 mL of air, avoiding advancing the catheter too tently support a specific action, intervention, or treatment
far into a small artery) minimizes the chance of rup- Level C: Qualitative studies, descriptive or correlational studies,
ture or perforation. When obtaining a PAOP trac- integrative review, systematic reviews, or randomized controlled
ing, the nurse closely observes the pulmonary artery trials with inconsistent results
waveform as the balloon is inated, and lls the bal- Level D: Peer-reviewed professional organizational standards with
loon with the proper amount of air (usually 1.25 to clinical studies to support recommendations
1.5 mL). Overlling the balloon can cause overdis-
Level E: Multiple case reports, theory-based evidence from expert
tention of the pulmonary artery, putting the patient opinions, or peer-reviewed professional organizational stan-
at risk for rupture. dards without clinical studies to support recommendations
Level M: Manufacturers recommendations only
Pulmonary Infarction
Pulmonary infarction resulting from loss of blood Adapted from American Association of Critical-Care Nurses (AACN)
Practice Alert, revised 12/2009.
ow distal to the PAC is typically a result of the PAC
migrating distally into a smaller artery (ie, sponta-
neous wedging). If less than 1.25 to 1.5 mL of air is
needed to inate the balloon and obtain the PAOP monitor should continuously display the pulmonary
waveform, then spontaneous wedging is a higher artery waveform.) Prompt identication and man-
risk. Changing of the pulmonary artery waveform agement (eg, by pulling the catheter back, per facil-
to a PAOP waveform on the bedside monitor may ity protocol) can prevent a pulmonary infarction
also indicate spontaneous wedging. (The bedside from occurring.

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106 P A R T T W O Essential Interventions in Critical Care

Determination of Cardiac Output Standard bedside monitors and cardiac output com-
puters automatically calculate the cardiac index
Assessment of cardiac output and its determinants when the patients height and weight (needed to cal-
are important adjuncts to the care of critically ill culate the BSA) are entered. Normally, the cardiac
patients. Cardiac output is the volume of blood index is 2.5 to 4 L/min/m2.
ejected from the heart per minute. Normally, car- An increased or decreased cardiac output pro-
diac output is 4 to 8 L/min at rest. Cardiac output vides global information only and needs to be evalu-
is a function of heart rate and stroke volume (the ated in light of the factors that affect cardiac output
amount of blood ejected from the left ventricle dur- (Fig. 9-12).5 stroke volume, one of the primary deter-
ing systole). Table 9-3 summarizes calculations that minants of cardiac output, is inuenced by preload,
are commonly used in evaluating cardiac output. afterload, and contractility.
The cardiac index relates cardiac output to body Preload is the amount of stretch on the myocardial
size. To obtain the cardiac index, the cardiac output muscle bers at end diastole. Preload is primarily
is divided by the patients body surface area (BSA).

TA B L E 9 - 3 Parameters Used in the Evaluation of Cardiac Output

Parameter Definition Formula Normal Values

Cardiac output (CO) The number of liters pumped HR SV 48 L/min
by the heart per minute
Cardiac index (CI) CO indexed to the patients CO/BSA 2.54 L/min/m2
body surface area (BSA)
Stroke volume (SV) The milliliters of blood ejected CO/HR 1000 60100 mL/beat
from the ventricle with
each contraction
Stroke volume index (SVI) SV indexed to the patients BSA CI/HR 3347 mL/beat/m2
Mean arterial pressure (MAP) The calculated average [Systolic BP + (diastolic BP 70105 mm Hg
arterial pressure over a full 2)]/3
cardiac cycle
Right atrial pressure (RAP) Pressure created by volume Direct measurement 26 mm Hg
of blood in the right heart
Left atrial pressure (LAP) Pressure created by volume Direct measurement 612 mm Hg
of blood in the left heart
Pulmonary artery occlusion Pressure measured in the Direct measurement 815 mm Hg
pressure (PAOP) pulmonary artery when the
PACs balloon is inflated
Right ventricular end-diastolic Amount of volume in the right SVI/RV ejection fraction 60100 mL/m2
volume index (RVEDVI) ventricle at the end of
diastole indexed to patient
Left ventricular end-diastolic Amount of volume in the left SV/LV ejection fraction 4080 mL/m2
volume index (LVEDVI) ventricle at the end of
diastole indexed to patient
Systemic vascular resistance The resistance to blood flow [(MAP RAP) 80]/CO 8001200 dyne/s/cm5
(SVR) offered by the systemic
Systemic vascular resistance SVR indexed to patients BSA [(MAP RAP) 80]/CI 13602200 dyne/s/cm5
index (SVRI)
Pulmonary vascular The resistance to blood flow (MPAP PAOP) 80/CO <250 dyne/s/cm5
resistance (PVR) offered by the pulmonary
Pulmonary vascular PVR indexed to patients BSA (MPAP PAOP) 80/CI
resistance index (PVRI)
Left ventricular stroke work A measure of work performed SVI (MAP PAOP) 0.0136 4070 g-m2/beat
index (LVSWI) by the left ventricle with
each beat
Right ventricular stroke work A measure of work performed SVI (MPAP RAP) 0.0136 510 g-m2/beat
index (RVSWI) by the right ventricle with
each beat
Stroke volume variation Variation in stroke volume SV maximum SV minimum/ <10%15%
(SVV) over a respiratory cycle SV mean

HR, heart rate.

Morton_Chap09.indd 106 2/4/2012 2:35:32 PM

Hemodynamic Monitoring C H A P T E R 9 107

inuenced by total blood volume. The RAP or CVP Thermodilution Method

is used to indirectly assess right ventricular pre-
load, and the PAOP is used to indirectly assess Thermodilution is the most common method used
left ventricular preload. Because PAP monitoring to measure cardiac output and is considered the
measures pressures, not volumes, assumptions are clinical gold standard. Determination of cardiac
made that equate volume and pressure. However, output using the thermodilution method may be
many factors alter the pressurevolume relation- intermittent or continuous.
ship; therefore, the use of pressures to evaluate Intermittent determinations require the injection
preload must be considered in light of these. of a known amount of cooler than blood indi-
Afterload is the resistance to ejection of blood cator solution. The indicator solution is injected
from the ventricles. Primary factors affecting into the proximal (right atrial) lumen of the PAC.
afterload are aortic and pulmonic valve stenosis A thermistor near the end of the catheter continu-
and vascular resistance. PVR and systemic vas- ously measures the temperature of blood owing
cular resistance (SVR) are clinical assessments of past it. The change in blood temperature follow-
right and left ventricular afterload, respectively. ing injection of the indicator solution generates a
PVR and SVR can be indexed to body size using thermodilution curve, which the computer uses as
the patients BSA. a basis for calculating cardiac output.
Contractility refers to the ability of the heart to Continuous determinations require the use of a
contract independent of preload and afterload. specialized PAC, which houses thermal laments
Contractility can be assessed by determining that emit heat as the indicator (see Fig. 9-7B). The
stroke volume and calculating the stroke work warmer than blood signal is measured at the
index for both the left and right ventricles. thermistor, and thermodilution curves are pro-
There are several methods of evaluating cardiac duced on a 30- to 60-second frequency for continu-
output. Methods may use invasive, minimally inva- ous cardiac output assessment.
sive, or noninvasive technologies. The most com- For intermittent thermodilution cardiac output
monly used methods in the critical care setting are determination, the injectate syringe is usually part
the thermodilution method, arterial pressure and of a closed system that remains intact and attached
waveform-based methods, electrical bioimpedance to the proximal (right atrial) lumen by a stopcock
cardiography, and esophageal Doppler monitoring.

Decreased cardiac output

Heart rate Preload Afterload Contractility

Increased Decreased Increased Decreased Increased Decreased

Stress Vagal Hypervolemia Hypovolemia Vasoconstriction Myocardial
Pain stimulation Heart failure Decreased Vasopressors ischemia
Anxiety Heart block venous return Compensatory blockers
Hyperthermia Acute mechanism for Electrolyte
Hypovolemia myocardial hypovolemia or disturbances
Hypoxia infarction decreased

Increased cardiac output

Preload Afterload Contractility

Increased Decreased Increased

Hypervolemia Vasodilation Inotropes
(e.g., sepsis,

F I G U R E 9 - 1 2 Alterations in cardiac output are caused by changes in heart rate, preload, afterload, and

Morton_Chap09.indd 107 2/4/2012 2:35:32 PM

108 P A R T T W O Essential Interventions in Critical Care

(Fig. 9-13). A computation constant (based on the Arterial Pressure and Waveform-Based
catheter size, volume and temperature of the injec-
tate, and injection method) is set on the computer Methods
or programmed into the bedside cardiac output Another method for determining cardiac output
computer. For most patients, 10 mL of room-tem- and stroke volume involves using arterial pressures
perature injectate (sterile D5W or normal saline) and arterial waveforms. This method is based on
provides accurate results, although iced (0C to 4C) the premise that there is a proportional relation-
solution may be used for patients with hypother- ship between pulse pressure and stroke volume, and
mia or very low cardiac output states to improve an inverse relationship between pulse pressure and
the accuracy. A temperature difference between the aortic compliance.
patients blood temperature and the injectate of at An arterial line, a special sensor, and a monitor
least 10C provides a greater signal and improves that uses an algorithm for the stroke volume
accuracy. Additional steps to promote accurate mea- and cardiac output determinations are required.
surements include Although the specic algorithm used to determine
Ensuring that the volume of injectate in the syringe the cardiac output value may vary depending on
is correct the equipment in use, all of the algorithms rely
Injecting the volume smoothly and rapidly, in less on the arterial pressure and the arterial waveform
than 4 seconds shape or size. Therefore, obtaining accurate values
Waiting approximately 1 minute between injec- and ensuring optimal waveforms are critical.
tions to allow the catheter thermistor to return to Other values obtained using arterial pressure
baseline and waveform-based methods include stroke vol-
ume variation, pulse pressure variation, and systolic
The average of several cardiac output determina- pressure variation. These values reect the differ-
tions is required to obtain a nal measurement. ence between the maximum and minimum values of
Three or more consecutive measurements are usu- stroke volume, pulse pressure, and systolic pressure
ally necessary. Measurements included in the aver- during a respiratory cycle and can be used to identify
aging process should be within 10% to 15% of each pulsus paradoxus (ie, an abnormally large decrease
other and demonstrating acceptable CO curves (Fig. in systolic blood pressure during inspiration). These
9-14A). Abnormal curves (see Fig. 9-14B) are elimi- values are used to evaluate a patients response to
nated from the cardiac output averaging process. uid administration.

Sterile injectate

Three-way stopcock
and continuous
Nonvented IV spike
flush device
Snap clamp injectate hub
probe Balloon inflation
10-mL syringe valve

Pulmonary artery
To IV/
Check pressure
valve Flow-through
Injectate housing