RN, MS, CCRN, Sheree Comer - Critical Care Nursing Care Plan (1998)

CRITICAL CARE
NURSING CARE PLANS
Sheree Corner
Contributor:
Barbara Sage1 R.N., M.s., C.C.R.N.
DELMAR
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1
TABLE OF CONTENTS
This Page Intentionally Left Blank
CARDlOUASCUwl SYSTEM .................................................................................................................................... 1
Congestive Heart Failure ............................................................................................................................................................. 3
Myocardial Infaction (MI) ........................................................................................................................................................ 13
Pericarditis ................................................................................................................................................................................. 25
Infective Endocarditis (IE) ......................................................................................................................................................... 31
Hypertension ............................................................................................................................................................................. 39
Thrombophlebitis ...................................................................................................................................................................... 47
Intra-Aortic Balloon Pump (IABP) ............................................................................................................................................ 53
Pacemakers ................................................................................................................................................................................ 59
Cardiac Surgery ......................................................................................................................................................................... 67
Aortic Aneurysm ........................................................................................................................................................................ 77
RESPlRlYrORY SYSTEM ........................................................................................................................................ 83
Adult Respiratory Distress Syndrome (ARDS) .......................................................................................................................... 85
Chronic Obstructive Pulmonary Disease (C 0 P D) ................................................................................................................. 91
Pulmonary Embolism ................................................................................................................................................................ 99
Pneumonia .............................................................................................................................................................................. 105
Pneumothorax ......................................................................................................................................................................... 111
Status Asthmaticus ................................................................................................................................................................... 117
Mechanic al Ventilation ............................................................................................................................................................ 12
NEUROLOGICAL SYSTEM ..................................................................................................................................... 137

C V A ......................................................................................................................................................................................
139
Head Injuries ........................................................................................................................................................................... 147
Spinal Cord Injuries ................................................................................................................................................................. 159
Guillain-Barre Syndrome ......................................................................................................................................................... 169
Status Epilepticus ..................................................................................................................................................................... 175
Meningitis ............................................................................................................................................................................... 181
Ventriculostomy/ICP Monitoring ............................................................................................................................................ 185
Endarterectomy ....................................................................................................................................................................... 189
GASTROMTESTINAUHEPATIC SYSTEM .................................................................................................................. 191

Gastrointestinal Bleeding ......................................................................................................................................................... 193
Esophageal Varices ................................................................................................................................................................... 199
Hepatitis .................................................................................................................................................................................. 203
Pancreatitis .............................................................................................................................................................................. 207
Acute Abdomen/ Abdominal Trauma ...................................................................................................................................... 211
Liver Failure ............................................................................................................................................................................. 217
HEMATOLOGIC SYSTEM ..................................................................................................................................... 223

Disseminated Intravascular Coagulation (DIC) ....................................................................................................................... 225
H E L L P Syndrome ............................................................................................................................................................... 229
Anemia .................................................................................................................................................................................... 233
iv
RENWDOCRINE SYSTEMS .............................................................................................................................. 237

Acute Renal Failure (ARF) ....................................................................................................................................................... 239
Diabetic Ketoacidosis (D K A) ................................................................................................................................................ 251
Hyperglycemic Hyperosmolar Nonketotic Coma (H H N K) ................................................................................................ 261
Syndrome of Inappropriate ADH Secretion (SIADH) ............................................................................................................. 265
Diabetes Insipidus (DI) ........................................................................................................................................................... 269
Pheochromocytoma ................................................................................................................................................................. 273
Thyrotoxicosis (Thyroid Storm) ............................................................................................................................................. 281
MUSCULOSKELETAL SYSTEM .............................................................................................................................. 289

Fractures .................................................................................................................................................................................. 291
Amputation ............................................................................................................................................................................. 299
Fat Embolism .......................................................................................................................................................................... 307
IHTEGUMarrARY SYSTEM ................................................................................................................................... 311

Frostbite/Hypothermia ............................................................................................................................................................ 313
Malignant Hyperthermia ......................................................................................................................................................... 319
Burns/Thermal Injuries ........................................................................................................................................................... 323
OTHER ............................................................................................................................................................. 329

Multiple Organ Dysfunction Syndrome (MODS) ................................................................................................................... 331
Acute Poisoning/Drug Overdose .............................................................................................................................................. 337
Snakebite ................................................................................................................................................................................. 343
Transplants .............................................................................................................................................................................. 349
Cardiogenic Shock ................................................................................................................................................................... 357
INDEN OF NURSING DIAGNOSES ........................................................................................................................... 361
REFERENCES ..................................................................................................................................................... 365

CARDIOVASCULAR SYSTEM 1
Congestive Heart Failure

Myocardial Infarction (MI)
Pericarditis
Infective Endocarditis (IE)
Hypertension
Thrombophlebitis
Intra-Aortic Balloon Pump (IABP)
Pacemakers
Cardiac Surgery
Aortic Aneurysm
Congestive Heart Failure Right-sided heart failure is usually caused by left-

sided heart failure, but can also be caused by
Heart failure is the inability of the heart to supply pulmonary emboli, pulmonary hypertension,
blood f l ~ wto meet physiologic demands, without COPD, and the presence of right ventricular
utilizing compensatory changes. There may be infarctions.
failure involving one or both sides of the heart, The lungs can accept a certain amount of fluid
and over time, causes the development of build-up, but eventually, if no intervention is
pulmonary and systemic congestion and complica- taken, the pressure in the lungs increases to the
tions. Congestive heart failure, or CHF, is a point whereby the right ventricle cannot eject its
common complication after myocardial infarction blood into the lungs. The right ventricle fails and
and can be attributed to one-third of the deaths of then the blood in the right atrium cannot drain
patients with MIs. Usually following MI, the heart completely, and thus cannot accept the total
failure is left-sided since most infarctions involve amount of blood from the vena cavae. Venous
damage to the left ventricle. pooling occurs with the impairment of venous
blood flow, and eventually the organs become
Heart failure can also be classified as acute or
congested with venous blood.
chronic. In chronic heart failure, the body experi-
ences a gradual development as the heart becomes Treatment of heart failure involves attempts to
unable to pump a sufficient amount of blood to improve contractility of the ventricle by use of
meet the body’s demands. Chronic heart failure positive inotropic drugs, decrease of afterload by
can become acute without any overt cause. the use of nitrates and vasodilators, and in some
instances, by use of the IABP, and decrease of pre-
Often, the patient will have no early symptoms of
left-sided heart failure. Symptoms of decreased load by the use of diuretics, IV nitroglycerin, and
cardiac output will develop once the heart fails to fluid/sodium restrictions.
pump enough blood into the systemic circulation.
The pressure in the left ventricle increases, which
in turn causes retrograde increases of pressure in Oxygen: to increase available oxygen supply
the left atrium because of the increased difficulty
for blood to enter the atrium from the pulmonary Morphine: used to induce vasodilation, decrease
veins. Blood backs up in the lung vasculature, and venous return to the heart, reduce pain and anxi-
when the pulmonary capillary pressure is exceeded ety, and decrease myocardial oxygen consumption
by the oncotic pressure of the proteins in the Cardiac glycosides: digitalis (Digoxin, Lanoxin)
plasma fluid (usually > 30 mmHg), the fluid leaks PO or IV to increase the force and strength of
into the interstitial spaces. When this fluid moves ventricular contractions and to decrease rate of
into the alveoli, shortness of breath, coughing, and contractions in order to increase cardiac output
crackles (rales) occur, and the patient progresses
into overt pulmonary edema, with the classic sign Diuretics: furosemide (Lasix) PO or IV, chloroth-
of coughing up copious amounts of pink frothy iazide (Diuril) PO, bumetanide (Bumex) PO or
sputum. IV to promote excess fluid removal, to decrease
edema and pulmonary venous pressure by
preventing sodium and water reabsorption
4 CRITICAL CARE NURSING CARE PLANS
Vasodilators: hydralazine (Apresoline) PO or IV, decreases afterload, decreases preload, improves

isosorbide dinitrate (Isordil) SL or PO, prazosin cardiac output and tissue perfusion
(Minipress) PO, minoxidil (Loniten) PO, diazox-
ide (Hyperstat) IV, sodium nitroprusside NURSING CARE PLANS
(Nipride) IV, nitroglycerine (Nitrostat, Tridil) PO,
SL, IV to relax vascular smooth muscle, decrease Fluid volume excess
preload and afterload, decrease oxygen demand, Related to: increased sodium and water retention,
decrease systemic vascular resistance, and increase decreased organ perfusion, compromised
venous capacitance regulatory mechanisms, decreased cardiac output,
Renin-angiotensin system inhibitors: captopril increased A D H production
(Capoten) PO used to inhibit angiotensin Defining characteristics: edema, weight gain,
converting enzyme to reduce the production of intake greater than output, increased blood pres-
angiotensin I1 to enable the decrease in vasocon- sure, increased heart rate, shortness of breath,
striction and to reduce afterload dyspnea, orthopnea, crackles (rales), S3 gallop,
Inotropic agents: dopamine, dobutamine oliguria, jugular vein distention, pleural effusion,
(Dobutrex) IV, amrinone (Inocor) IV used to specific gravity changes, altered electrolyte levels
increase myocardial contractility, without increas-
ing the heart rate, to produce peripheral Outcome Criteria
vasodilation and decrease preload and afterload
Blood pressure will be maintained within normal
Electrolytes: mainly potassium to replace that limits and edema will be absent or minimal in all
which is lost during diuretic therapy body parts.
Laboratory: electrolyte levels to monitor for Fluid volume will be stabilized with balanced
imbalances; renal profiles to monitor for kidney intake and output.
function problems; digoxin levels to monitor for
toxicity; platelet count to monitor for thrombocy- INTERVENTIONS RATIONALES
topenia from amrinone Monitor vital signs and hemo- Fluid volume excess will cause
dynamic readings if available. increases in blood pressure, and
Chest x-ray: shows any enlargement of the heart CVP and pulmonary artery
and pulmonary vein, presence of pulmonary pressures, and these changes
will be reflected from the
ederna or pleural effusion development of pulmonary
congestion and heart failure.
Electrocardiography: used to monitor for
dysrhythmias which may occur as a result of the Auscultate lungs for presence May indicate pulmonary edema
heart failure or as a result of digitalis toxicity of crackles (rales), or other from cardiac decornpensation and
adventitious breath sounds. pulmonary congestion. Pulmon-
Echocardiography: used to study structural abnor- Observe for presence of cough, ary edema symptoms reflect left-
malities and blood flow through the heart increased dyspnea, tachypnea, sided hearr failure. Right-
orthopnea or paroxysmal noc- sided heart failure may have
Intra-aortic balloon pump: decreases the turnal dyspnea. slower onset, but symptoms of
dyspnea, orthopnea, and
workload on the heart, decreases myocardial
cough are more difficult to
oxygen demand, increases coronary perfusion, reverse.
INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Observe for jugular vein dis- May indicate impending conges- Place and maintain patient in Diuresis may be enhanced by
tention and dependent edema. tive failure and fluid excess. semi-Fowler's position. recumbent position due to
Note presence of generalized Peripheral edema begins in increased glomerular filtra-
body edema (anasarca). feet and ankles, or other de- tion and decreased production
pendent areas and ascends as ofADH.
failure progresses. Pitting
will usually occur only after
10 or more pounds of excess
fluid is retained. Anasarca will Auscultate bowel sounds and ob- C H F progression can impair
be seen only with right heart serve for abdominal distention, gastric motility and intestinal
failure or bi-ventricular failure. anorexia, nausea, or constipa- function. Small, frequent meals
tion. Provide small, easily- may enhance digestion and pre-
Investigate abrupt complaints Excessive fluid build-up can digestible meals. vent abdominal discomfort.
of dyspnea, air hunger, feeling promote other complications
of impending doom or suffocation. such as pulmonary edema or Measure abdominal girth if Progressive right-sided heart
pulmonary embolus and inter- warranted. failure can cause fluid to shift
vention must be immediate. into the peritoneal space and
cause ascites.
Determine fluid balance by Renal perfusion is impaired with
measuring intake and output, excessive fluid volume, which Palpate abdomen for liver en- Progressive heart failure can
and observing for decreases in causes decreased cardiac output largement; note any right lead to venous congestion, ab-
output and concentrated urine. leading to sodium and water upper quadrant tenderness or dominal distention, liver engor-
retention and oliguria. pain. gement, and pain. Liver func-
tion may be impaired and can
Weigh daily and notify M D of Abrupt changes in weight usually impede drug metabolism.
greater than 2 lblday increase. indicate excess fluid.
Assist with dialysis or hemo- Mechanically removing excess
filtration as warranted. fluid may be performed to
Provide patient with fluid in- Fluids may need to be restricted rapidly reduce circulating
take of 2 Llday, unless fluid due to cardiac decompensation. volume in cases refractory to
restriction is warranted. Fluids maintain hydration of other medical therapeutics.
tissues.
Instruction, Information,
Administer diuretics as ordered Drugs may be necessary to cor-
(furosemide, hydralazine, spiro- rect fluid overload depending
Demonstration
lactone with hydrochlorothiazide). on emergent nature of problem.
Diuretics increase urine flow INTERVENTIONS RATIONALES
rate and may inhibit reabsorp- Instruct patient regarding diet- Fluid retention is increased
tion of sodium and chloride ary restrictions of sodium. with intake of sodium.
in the renal tubules.
Instruct patient to observe for Weight gain may be firsr overt
Monitor electrolyte for imbal- Hypokalemia can occur with the weight changes and report these sign of fluid excess and should
ances. Note increasing lethar- administration of diuretics. to MD. be monitored to prevent compli-
gy, hypotension, or musde Signs of potassium and sodium cations.
cramping. deficits may occur due to
fluid shifts with diuretic Consult with dietitian. May be required to ensure
therapy. adequacy of caloric intake
with fluid and sodium resrric-
tion requirements.
INTERVENTIONS RATIONALES
Outcome Criteria
Instruct patient in medications Promotes knowledge and compli- Vital signs and hemodynamic parameters will be
prescribed after discharge, with ance with treatment regimen.
within normal limits for patient, with no
dose, effect, side effects, . . . .
contraindications. dysrhythmias noted.
Monitor chest x-rays. Reveal changes in pulmonary Patient will be eupneic with no adventitious
status regarding improvement breath sounds or abnormal heart tones.
or deterioration.
Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES

Determine level of cardiac func- Additional disease states and
Patient will have no edema or fluid excess. tion and existing cardiac and complications may place an
other conditions. additional workload on an
Fluid balance will be maintained and blood already compromised heart.
pressure will be within normal limits of baseline.
Auscultate apical pulses and Decreased contractility will be
Lung fields will be clear, without adventitious monitor heart rate and rhythm. compensated by tachycardia, es-
Monitor BP in both arms. pecially concurrently with heart
breath sounds, and weight will be stable. failure. Blood volume will be
lowered if blood pressure is
Patient will be able to accurately verbalize increased resulting in increased
understanding of dietary restrictions and med- afterload. Pulse decreases may
ications. be noted in association with
toxic levels of digoxin, and
Decreased cardiac output peripheral pulses may be hard
to accurately determine if per-
Related to: damaged myocardium, decreased confusion is decreased. Hypo-
tractility, dysrhythmias, conduction defects, tension may occur as a result
of ventricular dysfunction and
alteration in preload, alteration in afterload, vaso-
poor perfusion of rhe myocard-
constriction, myocardial ischemia, ventricular ium.
hypertrophy, accumulation of blood in lungs or in
systemic venous system Measure cardiac output and Provides measurement of cardiac
cardiac index, and calculate function and calculated mea-
Defining characteristics: dependent edema, hernodynamic pressures every 4 surements of preload and after-
hours and prn. load to facilitate titration of
elevated blood pressure, elevated mean arterial
vasoactive drugs and manipula-
pressure greater than 120 mmHg, elevated tion of hemodynamic pressures.
systemic vascular resistance greater than 1400
dyne-secondslcm5, cardiac output less than 4 Monitor EKG for dysrhythmias Conduction abnormalities may
and treat as indicated. occur due to ischemic myocar-
L/min or cardiac index less than 2.5 L/min/m2, dium affecting the pumping
tachycardia, cold, pale extremities, absent or efficiency of the heart.
decreased peripheral pulses, EKG changes,
Observe for development of new S3 gallops are usually asso-
hypotension, S3 or S, gallops, decreased urinary
S3 or S4 gallops. ciated with congestive hearr
output, diaphoresis, orthopnea, dyspnea, crackles failure but can be found with
(rales), frothy blood-tinged sputum, jugular vein rnitral regurgitation and left
distention, edema, chest pain, confusion,
restlessness

ventricular overload after MI. Avoid Valsalva-type maneuvers Increasing intra-abdominal pres-
S4 gallops can be associated with straining, coughing or sure results in an abrupt de-
with myocardial ischemia, ven- moving. crease in cardiac output by
tricular rigidity, pulmonary preventing blood from being
hypertension, or systemic hy- pumped into the thoracic cavity
pertension, which can decrease and thus, less blood being pump-
cardiac output. ed into the heart which then
decreases the heart rate. When
Auscultate for presence of Indicates disturbances of normal the pressure is released, there
murmurs andlor rubs. blood flow within the heart re- is a sudden overload of blood
lated to incompetent valves, which then increases preload.
septal defects, or papillary
muscle/chordae tendonae com- Provide small, easy to digest, Large meals increase the work-
plications post-MI. Presence meals and restrict caffeine. load on the heart. Caffeine
of a rub with an MI is asso- directly stimulates the heart
ciated with pericarditis and/ and increases heart rate.
or pericardial effusion.
Have emergency equipment and Coronary occlusion, lethal dys-
Observe lower extremities for Reduced venous return to the medications available at all rhythmias, infarct extensions or
edema, distended neck veins, heart can result in low cardiac times. intractable pain may precipitate
cold hands and feet, mottling, output; oliguria results from cardiac arrest that requires
oliguria. decreased venous return due to life support and resuscitation.
fluid retention.
Position in semi-Fowler’s Promotes easier breathing and Information, Instruction,

position. prevents pooling of blood in
the pulmonary vasculature.
Demonstration
Administer cardiac glycosides, Used in the treatment of vaso-
nitrates, vasodilators, diure- constriction and to reduce heart Instruct on medications, dose, Promotes knowledge and compli-
tics, and antihypertensives as rate and contractility, reduces effects, side effects, contra- ance with regimen. Prevents
ordered. blood pressure by relaxation of indications, and avoidance of any adverse drug interactions.
venous and arterial smooth mus- over-the-counter drugs without
cle’ which then in turn increases MD approval.
cardiac output and decreases the
workload on the heart. Instruct in activity limitations. Promotes compliance. Reduces
Demonstrate exercises to be done. decrease in cardiac output by
Titrate vasoactive drugs as Maintains blood pressure and lessening the worMoad placed
ordered per MD parameters. heart rate at levels to optimize on the heart.
cardiac output function.
Instruct to report chest pain. May indicate complications of
Weigh every day. Weight gain may indicate fluid decreased cardiac output.
retention and possible impend-
ing congestive failure.
Instruct patiendfamily regard- Alleviates fear and promotes
Arrange activities so as to Avoids over-fatiguing patient ing placement of pulmonary ar- knowledge. Pulmonary artery
not over-tax patient. and decreasing cardiac output tery catheter, and post- catheter necessary for direct
further. Balancing rest with procedure care. measurement of cardiac output
activity minimizes energy expen- and for obtaining values for
diture and myocardial oxygen other hemodynamic measurements.
demands by maintaining cardiac
output.

Assist with insertion and main- Cardiac pacing may be necessary Monitor respiratory status for Changes in respiratory pattern
tainance of pacemaker when during the acute phase of MI or rate, regularity, depth, ease of or patency of airway may result
needed. may be necessary as a permanent effort at rest or with exertion, in gas exchange imbalances.
measure if the MI severely inspiratory/expiratory ratio.
damages the conduction system.
Observe for presence of cyanosis Cyanosis results from decreases
and mottling; monitor oximetry in oxygenated hemoglobin in the
for oxygen saturation; monitor blood and this reduction leads
Discharge or Maintenance Evaluation ABGs for ventilation/perfusion to hypoxia. Reading of 90%
problems. on pulse oximeter correlates
Patient will have no chest pain or shortness of with p O 2 of GO.
breath.
Monitor for mental status chan- Hypoxia affects all body systems
Vital signs and hemodynamic parameters will ges, deterioration in level of and mental status changes can
be within normal limits for age and disease con- consciousness, restlessness, ir- result from decreased oxygen to
ritability, easy fatigueability. brain tissues.
dition.
Position in semi- or high- Promotes breathing and lung ex-
Minimal activity will be tolerated without
Fowler's position. pansion to enhance gas distri-
fatigue or dyspnea. bution.
Urinary output will be adequate. Administer oxygen via nasal can- Maintains adequate oxygenation
nula at 2-3 L/min, or other de- without depression of respira-
Cardiac output will be adequate to ensure ade- livery systems. tory drive. C O 2 may be retained
quate perfusion of all body systems. with higher flow rates when used
in patients with COPD.
Impaired gas exchange
Assist with placement of ETT Mechanical ventilation may be
Related to: ventilationlperfusion imbalance caused and placement on mechanical required if respiratory failure
from excess fluid in alveoli and reduction of air ventilation. is progressive and adequate oxy-
exchange area in lung fields, fluid collection shifts gen levels cannot be maintained
by other delivery systems.
into the interstitial space
Defining characteristics: confusion, restlessness,
irritability, hypoxia, hypercapnea, dyspnea, Instruction, Information,
orthopnea, abnormal ABGs, abnormal oxygen sat- Demonstration
uration INTERVENTIONS RATIONALES
Instruct in breathing exercises as Assists to restore function to
Outcome Criteria warranted. diaphragm, decreases work of
breathing, and improves gas
Patient will have adequate oxygenation with respi- exchange.
ratory status within limits of normal based on age Assess for nausea and vomiting. May indicate effects of hypoxia
and other conditions, and ABGs will be within on gastrointestinal system.
normal limits.
Avoid activities that promotes Activity increases oxygen con-
dyspnea or fatigue. Allow for sumption and demand, and can
periods of rest between impair breathing pattern.
activities.
INTERVENTIONS RATIONALES Outcome Criteria

Instruct in safety concerns with Promotes safety with oxygen
oxygen use. and provides knowledge.
Patient will have and maintain skin integrity.
Instruct patiendfamily in need Promotes knowledge and
for placement on mechanical decreases anxiety and fear of the Monitor mobility status and pa- Immobility is the primary cause
ventilation, what to expect, unknown. tient's ability to move self. of skin breakdown.
what benefits are to be received,
what potential problems may be Inspect all skin surfaces, espe- Skin is at risk because of de-
encountered. cially bony prominences, for skin creased tissue perfusion, im-
breakdown, altered circulation to mobility, decreased peripheral
areas, or presence of edema. perfusion, and possible nutri-
tional alterations.
Discharge or Maintenance Evaluation
Provide skin care to blanched Stimulates blood flow and de-
Patient will exhibit no ventilation/perfusion or reddened areas. creases tissue hypoxia. Excess
imbalances. dryness or moistness of skin
can promote breakdown.
Patient will be eupneic with no adventitious
breath sounds. Provide eggcrate mattress, al- These items can reduce pressure
ternating pressure mattress, on skin and may improve circu-
ABGs will be within acceptible ranges for sheepskin, elbow protectors, lation.
heel protectors, etc.
patient with adequate oxygenation of all tissues.
Patient will be able to verbalize/demonstrate the Reposition frequently, at least Improves circulation by reduc-
every 2 hours. Assist with ROM tion of time pressure is on any
correct use of oxygen. exercises. Maintain body align- one area. Proper body alignment
ment. Raise head of bed prevents contractures. Eleva-
Risk f i r impaired skin intephy no higher than 30 degrees. tions higher than this may pro-
mote pressure and friction from
Related to: bed rest, decreased tissue perfusion, sliding down, and shearing force
edema, immobility, decreased peripheral may result in breakdown of skin.
perfusion, shearing forces or pressure, secretions,
excretions, altered sensation, skeletal prominence, Avoid subcutaneous or IM injec- Edema and tissue hypoxia
tions when possible. impede circulation which can
poor skin turgor, altered metabolic rate cause decreased absorption of
medication and can predispose
Defining characteristics: disruption of skin sur- patient to tissue breakdown and
face, pressure areas, reddened areas, blanched development of abscess/
areas, mottling, warmth, firmness to area of skin, infection.
irritated tissues, excoriation of skin, maceration of
skin, lacerations of skin, pruritis, dermatitis
Demonstration
Instruct on safety precautions May cause breaks in skin inte-
in bed-avoiding bumping against grity.
rails, falls, etc.
Instruct on hazards of immobili- Bedrest promotes pressure to

ty; avoid lying or sitting in skin and tissues.
one position for prolonged time.
Instruct on the use of lotions Prevents skin dryness and chance

and oil to apply to skin. of tissue breakdown.

Patient will have intact skin, free of redness, irri-
tation, rashes, or bruising.
Patient will be able to verbally relate measures
to reduce chance of tissue injury.
Anxiety
[See MI]
Related to: change in health status, fear of death,
threat to body image, threat to role functioning,
pain
Defining characteristics: restlessness, insomnia,
anorexia, increased respirations, increased heart
rate, increased blood pressure, difficulty concen-
trating, dry mouth, poor eye contact, decreased
energy, irritability, crying, feelings of helplessness
Knowledge deficit
[See MI]
Related to: lack of understanding, lack of under-
standing of medical condition, lack of recall
Defining characteristics: questions regarding
problems, inadequate follow-up on instructions
given, misconceptions, lack of improvement of
previous regimen, development of preventable
complications
LEFT-SIDED HEART FAILURE

Burden placed on cardiovascular system by any of the following: hypertension, myocardial infarction, valvular heart disease, dys-
rhythmias, tachy/bradycardia, cardiomyopathy, cardiac tamponade, constrictive pericarditis, aortic stenosis, mitral insufficiency, or
anemia 4
Decreased cardiac output + - - - - - - - - - - - - - - - - - - - - - - - - - - - +Sympatheticnervous system stimulated
Fatigue, weakness Heart rate increases
Arteriolar vasoconstriction
4 Myocardial contractility increases
Venous tone increases
Venous and ventricular filling
pressures increase
Decreased effective arterial blood volume
J,
Renal com ensatory changes occur

Rend bfood flow decreases
GFR decreases
Cortical blood flow decreases
Renin and angiotensin increase
Aldosterone increases
ADH increases
J,
Sodium reabsorption and free water clearance decreases
Effective blood volume increases
4
Accumulation of blood in lungs
J,
LV cannot pump blood from lungs into systemic circulation

J
LV pressures and LV volume increase
4
LA pressures and volume increase
J,
Fluid backs U into pulmonary vasculature = pulmonary congestion

Paroxysmafnocturnal dyspnea, orthopnea
4
Pulmonary hypertension, PA diastolic and PCWP pressure increases
6
Fluid leaks into interstitial and alveoli
4
Pulmonary edema
Cou h
Frotl& blood-tinged sputum
Rales (crackles)
4
Decreased oxygen in blood
Impaired as exchange and hypoxia
Tackypnea Restlessness
Cyanosis Pulmonary effusion
Confusion Pulsus alternans
RIGHT-SIDED HEART FAILURE

Burden placed on the cardiovascular system by any of the following: left-sided heart failure, pulmonary hypertension, COPD, cor
pulmonale, pulmonary embolus, anemia, thyrotoxicosis, pulmonary stenosis, or mitral stenosis.
4
Accumulation of blood in systemic venous system
Lung pressure increases
Pressure in pulmonary vasculature increases
4
Increased right atrial and ventricular pressures
Increased peripheral venous pressure
J,
Right heart cannot pump blood into pulmonary system

Right-sided heart failure
Bounding pulses
Dysrhythmias
S j or S4 gallop
4
Venous return decreases
Organs become congested with blood
Peripheral dependent edema occurs
J,
Congestion of portal circulation

Hepatomegaly, hepatojugular reflux
JVD, weight gain
Anorexia
Ascites, abdominal pain, anorexia, nausea
Fatigue, cyanosis
4
Advanced heart failure
4
Air hunger, gasping
Tachycardia
Crackles, frothy blood-tinged sputum
Skin cool and moist
Cyanotic lips, nailbeds
Confusion, stupor
Enlarged RA and RV
Tricuspid murmur
MYoeardial Infaretion (MD tricular filling pressures and often has severe tri-
cuspid regurgitation. Transmural infarcts involve
Myocardial infarction (MI) is a critical emergency the entire thickness of the myocardium and are
that requires timely management to save heart characterized by Q waves on the
muscle and limit damage that may evolve over electrocardiogram. Nontransmural infarcts are
several hours. Blood flow is abruptly decreased or characterized by S-T segment and T wave
stopped through the coronary arteries and results changes. Subendocardial infarcts usually involve
in ischemia and necrosis to the myocardium if not the inner portion of the myocardium where wall
treated. Many people die prior to receiving med- tension is highest and the blood flow is most vul-
ical care due to the denial that anything may be nerable to circulatory problems. Occlusion of the
wrong and postponement of seeking medical care. right coronary artery will result in an inferior
Cardiac dysrhythmias, mainly ventricular fibrilla- infarction that may also include posterior portions
tion, is usually the cause of death in these of the heart. Occlusion of the left main artery,
individuals. An MI is diagnosed based on type of known as “the widow maker,” usually results in
chest pain, electrocardiographic changes, and death due to the extensive damage. Occlusion of
increase of cardiac enzymes, such as CK, SGOT, the left anterior descending artery results in an
and LDH. Precordial pain is similar to but usually anterior infarction and may include some inferior
more intense and prolonged than anginal pain, parts of the heart, and occlusion of the circumflex
and in the instance of MI, the chest pain is usu- artery results in a lateral infarction.
ally constant and not relieved with nitroglycerin Precipitating factors that preclude MIs include
or rest. heredity, age, gender, presence of hypertension,
Atherosclerosis of the arteries is usually the most presence of diabetes mellitus, cigarette smoking,
common finding in patients. Atherosclerosis and hyperlipidemia, obesity, sedentary lifestyles, and
arteriosclerosis are used interchangeably when dis- stress.
cussing the fatty plaques that adhere to the inner The main goals in treating myocardial infarction
layer of the arteries. The continuous build-up of are to increase blood flow to the coronary arteries
these plaques, as well as the potential for hemor- and thus decrease infarction size, increase oxygen
rhage at the intimal layer may result in alterations supply and decrease oxygen demand to prevent
of the blood flow through the coronary arteries myocardial death or injury, and control or correct
and abnormalities in platelet aggregation may con- dysr hyt hm ias.
tribute to changes in coronary perfusion.
Infarction may occur without coronary artery dis-
ease or occlusion, and if the patient has developed
MEDICAL CARE
an adequate collateral circulation, coronary occlu- Oxygen: to increase available oxygen supply
sion may occur without infarction.
Analgesics: morphine is the drug of choice, given
MI is usually a disease involving the left ventricle in incremental doses IV every 5 minutes as
but the damage may extend to other areas, such as needed; IM injections are avoided because they
the atria or right ventricle. A right ventricular can raise the enzyme levels and do not act as
myocardial infarction usually has high right ven- quickly
Thrombolytic agents: Streptokinase, Urokinase, Laboratory: leukocyte count, sed rate and blood
or Tissue Plasminogen Activator (tPa) given either glucose may be elevated; creatinine phosphokinase
intracoronary or intravenously to activate the (CK, CPK) will normally increase within 4-6
body’s own fibrinolytic system to dissolve the clot hours, peak between 12-24 hours, and last 2-3
and resume coronary blood perfusion days but should not be used as sole indicator due
to possibility of elevation with other problems
Cardiac glycosides: digitalis to increase force and such as surgery or trauma; lactate dehydrogenase
strength of ventricular contractions and to
(LDH) will normally increase within 8-12 hours,
decrease the conduction and rate of contractions peak between 2-4 days, and last 10-14 days but
in order to increase cardiac output; usually not
should not be used as sole indicator due to possi-
used in the acute phase bility of elevation with other problems such as
Diuretics: furosemide (Lasix) to promote excess liver failure; serum glutamic oxaloacetic transami-
fluid removal, to decrease edema and pulmonary nase (SGOT) is occasionally used as an infarct
venous pressure by preventing sodium and water indicator; isoenzymes of CPK are very specific
reabsorption with CPK-MB most specific for MI, and levels
will not rise with transient chest pain or in surgi-
Vasodilators: hydralazine (Apresoline), nifedipine cal procedures; a definitive level for CPK-MB is
(Procardia, Adalat), nitroglycerin (Nitropaste, greater than or equal to 4% of the total CDK;
Nitrodur, Nitrostat, Tridil, Nitroglycerine), LDH isoenzymes, specifically LDHl is more spe-
prazosin (Minipres), captopril (Capoten)-used to
cific for MI; if the total LDH is elevated and
relax venous and/or arterial smooth muscle to LDHl is most predominant, MI is confirmed;
decrease preload, decrease afterload, and decrease
both CPK-MB and LDHl will return to normal
oxygen demand 72-96 hours after elevation
Beta-adrenergic blockers: used to decrease blood Chest x-ray: shows any enlargement of the heart
pressure, decrease elevated plasma renins, and with
and pulmonary vein, presence of pulmonary
non-selective blockers, may do so without related
edema or pleural effusion
reflex tachycardias; used to treat ventricular dys-
rhythmias and for the prophylaxis of angina Electrocardiography: shows indicative changes
associated with sites of acute infarcts using Q
Aspirin: used to decrease platelet aggregation and
waves, S-T segment elevation, and T wave inver-
helps with vasodilation of peripheral vessels sion. Also reveals changes with atrial and
Thrombolytics: used in the treatment of acute ventricular enlargement, rhythm and conduction
MI; acts by activating mechanisms for conversion abnormalities, ischemia, electrolyte abnormalities,
of plasminogen to plasmin which is able to drug toxicity, and presence of dysrhythmias
dissolve the clot; commonly used are Echocardiography: used to study structural abnor-
streptokinase, urokinase, alteplase, or anistreplase
malities and blood flow through the heart;
Heparin: used with thrombolytic protocols, and M-mode echocardiography measures structures
in the treatment of MI; prevents conversion of fib- with a single ultrasonic beam that provides a
rinogen to fibrin and prothrombin to thrombin by narrow view of the heart; two-dimensional (2D)
its action on antithrombin I11 echocardiography shows a two-dimensional and
wider look at the heart that is more useful in diag- Ventricular assist device (VAD): used on either or
nosing right ventricular infarcts; documents both ventricles to provide total support to the
increased right ventricular size, performance and heart and circulation in order to allow recovery to
segmental wall motion abnormalities, and blood the heart; usually indicated in patients who are
flow through the heart awaiting cardiac transplantation or in those
patients with cardiogenic shock and ventricular
Nuclear cardiologic testing: MUGA (multiple
failure; may be used in conjunction with IABP
gated acquisition study) provides information that
approximates ejection fractions and the analysis of Pacemakers: either temporary or permanent, used
the ventricular wall motion; 99mTc (Technetium- in anticipation of lethal dysrhythmias andlor con-
99 pyrophosphate scan) shows infarcted areas as duction problems
increased levels of radioactivity, or “hot spots’’ that
Surgery: coronary artery bypass grafting to
appear 12-36 hours after infarct and remain for 4-
reroute the coronary blood flow around the dis-
7 days; PET (positron emission tomography)
eased vessel to enable coronary perfusion
allows measurement of myocardial blood flow,
fatty acid and glucose metabolism, and blood
volume; thallium scans can determine size and NURSING CARE PLANS
location of damage as a “cold spot” Alteration in comfort
Magnetic resonance imaging (MRI): provides a Related to: chest pain due to decreased blood
three-dimensional view that can detect changes in flow to myocardium, myocardial ischemia or
tissues before structural damage is done and is safe infarct, post-procedure discomfort, chest wall pain
for pregnant women and children post-surgery, pericarditis
Cardiac catheterization: used to assess pathophys- Defining characteristics: chest pain with or with-
iology of the patient‘s cardiovascular disorder, to out radiation, facial grimacing, clutching of hands
provide left ventricular function information, to or chest, restlessness, diaphoresis, changes in pulse
allow for measurement of heart pressures and car- and blood pressure, dyspnea, dizziness
diac output, to evaluate stenotic lesions, and to
measure blood gas content
Outcome Criteria
Intra-aortic balloon pump (IABP):decreases the
workload on the heart, decreases myocardial Chest pain will be relieved or controlled to
oxygen demand, increases coronary perfusion, patient’s satisfaction.
decreases afterload, decreases preload, and helps to INTERVENTIONS RATIONALES
limit infarct size if quickly initiated, improves car- Evaluate chest pain as to type, Variations may occur with
diac output and tissue perfusion; used in location, severity, relief, change patients regarding speci-
cardiogenic shock, for support post cardiac with activity or rest, other symp- fic complaints and beha-
surgery, intractable chest pain, and in cardiac toms concurrenrly noted, such as vior. Most MI patients
pallor, diaphoresis, radiation of look acutely ill and can
catheterizations or other cardiovascular procedures pain, nausea, vomiting, shortness only focus on their pain.
of high-risk patients of breath, and vital sign changes. Respirations may be in-
creased as a result of an-
xiety and pain. Heart rate

may increase due to in- Administer calcium-channel bloc- These drugs can increase
creased catecholamines, kers as ordered (such as verapa- coronary blood flow and
stress, and pain, which can mil, diltiazem, or nifedipine). collateral circulation,
also increase blood pres- reduce preload and myocar-
sure. dial oxygen demands, which
can decrease pain due to
ischemia.
Obtain description of intensity Pain is a subjective ex- Maintain bedrest during pain, with Reduces oxygen consumption,
using 0-10 scale, with 0 being perience and personal to position of comfort; nurse to stay and demand; alleviates fear
no pain and 10 being the worst that patient. Intensity with patient during pain. and provides caring atmos-
pain experienced. scales are useful to gauge phere.
improvement or deteriora-
tion as perceived by the Maintain relaxing environment to Reduces competing stimuli
patient. promote calmness. and reduces anxiety.
Obtain history (when possible) This provides information

of previous cardiac pain and that may help to differen- Information, Instruction,
familial history of cardiac tiate current pain from
problems. previous problems, as well
Demonstration
as identify new problems and
complications. INTERVENTIONS RATIONALES
Instruct to notify nurse imme- Delay in notification can
Administer oxygen by nasal cannula Supplemental oxygen can in- diately of any chest pain. delay pain relief and may
or mask as indicated. crease the available oxygen require increased amounts
and can relieve pain asso- of medication in order to
ciated with myocardial is- finally achieve relief.
chemia. Pain can cause further
damage to an already-
Administer analgesic as ordered, Morphine is the drug of injured myocardium, and
such as morphine sulfate, meperi- choice to control MI pain, may signal extension of
dine (Demerol), or Dilaudid IV. but other analgesics may MI, spasm, or other com-
be used to reduce pain plication.
and reduce the workload
on the heart. IM injec- Instruct in relaxation tech- Helps to decrease pain and
tions should be avoided niques, deep breathing, guided anxiety and provides dis-
because they can alter imagery, visualization, etc. traction from pain.
cardiac enzymes and are
not absorbed well in
tissue that is non- or Instruct in nitroglycerin SL ad- Knowledge facilitates co-
under-perfused. ministration after hospitalization; operation and compliance
1 q5 minutes up to 3 times, and if with medical regimen. Pain
Administer beta-blockers as or- These d r u g block sym- pain is unrelieved, patient should unrelieved with N T G may be
dered (such as atenolol, pindolol, pathetic stimulation, re- seek emergency medical care. indicative of MI.
and propranolol). duce heart rate and sys-
tolic blood pressure, and Instruct in activity alterations Decreases myocardial oxygen
thus lowers the myocardid and limitations. demand and workload on the
oxygen demand. Beta- heart.
blockers should not be
given in severely impaired Instruct in medication effects, Promores knowledge and com-
contractility states due to side effects, contraindications, pliance with therapeutic
the negative inotropic and symptoms to report. regimen. Alleviates fear
properties. of unknown.
Discharge or Maintenance INTERVENTIONS RATIONALES

Evaluation Monitor vital signs. Provides information about the
Obtain hemodynamic values, hernodynamics of the patient
Patient will report pain being absent or noting deviations from base- and facilitates early intervention
controlled with medication administration. line values. for problems.
Medication will be administered prior to pain Monitor EKG for disturbances Decreased cardiac perfusion may
in conduction and for dysrhy- instigate conduction abnormali-
becoming severe.
thmias and treat as indicated. ties. Ventricular fibrillation
Patient will be able to recall effects, side effects, is the most common dysrhyth-
mia following MI. Reperfusion
and contraindications of medications accurately. dysrhythmias may occur after the
administration of thrombolytic
Activity will be modified in such a way as to therapy.
prevent onset of chest pain.
Administer oxygen by nasal Provides oxygen necessary for
Altered tissue pe+ion: cardiopulmonary, cannula as ordered, with rate tissues and organ perfusion.
cerebral, peripheral dependent on disease process
and condition.
Related to: tissue ischemia, reduction or interrup-
tion of blood flow, vasoconstriction, hypovolemia, Auscultate lungs for crackles May indicate fluid overload
(rales), rhonchi, or wheezes. that will further decrease tis-
shunting, depressed ventricular function, sue perfusion.
dysrhythmias, conduction defects
Auscultate heart sounds for May indicate impending or pre-
Defining characteristics: abnormal hemodynamic S3 or S4 gallop, new murmurs, sent heart failure.
readings, dysrhythmias, decreased peripheral presence of jugular vein dis-
pulses, cyanosis, decreased blood pressure, short- tention, or hepatojugular re-
flex.
ness of breath, dyspnea, cold and clammy skin,
decreased mental alertness, changes in mental Monitor oxygen status with ABGs, Provides information about the
status, oliguria, anuria, sluggish capillary refill, S v 0 2 monitoring, or with pulse oxygenation status of the pa-
oximetry. tient. Continuous monitoring of
abnormal electrolyte and digoxin levels, hypoxia,
saturation levels provide an in-
ABG changes, chest pain, ventilation perfusion stant analysis of how activity
imbalances, changes in peripheral resistance, affects oxygenation and per-
impaired oxygenation of myocardium, EKG fusion for the patient.
changes (S-T segment, T wave, U wave), LV Monitor for changes in respi- Decreased cardiac perfusion may
enlargement, palpitations ratory status, increased work result in pump failure and pre-
of breathing, dyspnea, etc. cipitate respiratory distress
and failure.
Outcome Criteria
Determine the presence and May indicate decreased perfusion
Blood flow and perfusion to vital organs will be character of peripheral pulses, resulting from impaired coronary
preserved and circulatory function will be maxi- capillary refill time, skin blood flow.
color and temperature.
mized.
Patient will be free of dysrhythmias.
Hemodynamic parameters will be within normal
limits.
Information, Instruction,
Demonstration
Discourage any non-essential Ambulation, exercise, transfers,
activity. and Valsalva-type maneuvers
can increase blood pressure and
decrease tissue perfusion. Instruct on medications, dosage, Promotes compliance with
effects, side effects, and con- regimen and knowledge base.
Assist patient with planned, Allows for balance between rest traindications.
graduated levels of activity. and activity to decrease myocar-
dial workload and oxygen Instruct to refrain from smok- Smoking causes vasoconstriction
demand. Gradual increases help ing. with can decrease perfusion.
to increase patient tolerance to
activity without pain. Instruct in dietary require- Reduction of high-cholesterol
ments, menu planning, sodium and sodium foods will help to
Titrate vasoactive drugs as Maintain blood pressure and restrictions, foods to avoid. control atherosclerosis, hyper-
ordered. heart rate at parameters set by lipidemia, fluid retention, and
MD for optimal perfusion with the effects on coronary blood
minimal workload on heart. flow.
Administer thrombolytic drugs Drugs Iyse the clot that may be

as ordered. occluding the coronary artery Discharge or Maintenance Evaluation
and promote restoration of oxy-
gen and blood flow to increase Lung fields will be clear and free of adventitious
perfusion.
breath sounds.
Auscultate for bowel sounds and Decreased perfusion to mesen-
monitor for complaints of nau- tery may result in loss or change Extremities will be warm and pink, with easily
sea, vomiting, anorexia, abdo- in peristalsis, resulting in GI palpable pulses.
minal distention, abdominal pain, use of analgesics, and change
or constipation. in surroundings may contribute Vital signs and hemodynamic parameters will
to changes in GI status. be within normal limits for patient.
Oxygenation will be optimal as evidenced by
Monitor urine output for ade- Decreased perfusion to renal pulse oximetry greater than 90%, SvOz greater
quate amounts, character of arteries may result in oliguria.
urine, presence of sediment, Dehydration secondary to than 75%, or normal ABGs.
and specific gravity. nausea and vomiting may affect
renal perfusion.
Patient will be free of chest pain and shortness
of breath.
Monitor labwork such as renal May indicate organ dysfunction
or liver profiles. and decreased perfusion. Patient will be able to verbalize information
accurately regarding medications, diet and activ-
ity limitations.
Decreased cardiac output
Related to: damaged myocardium, decreased con-
tractility, dysrhythmias, conduction defects,
constriction, myocardial ischemia, ventricular
hypertrophy
Defining characteristics: elevated blood pressure,

elevated mean arterial pressure greater than 120
Monitor for development of new Sg gallops are usually asso-
mmHg, elevated systemic vascular resistance Sg or S4 gallops. ciated with congestive heart
greater than 1400 dyne-seconds/cm5, cardiac failure but can be found with
output less than 4 L/min or cardiac index less mitral regurgitation and left
than 2.7 L/min/m2, tachycardia, cold, pale ventricular overload after MI.
S4 gallops can be associated
extremities, absent or decreased peripheral pulses, with myocardial ischemia, ven-
EKG changes, hypotension, S3 or S 4 gallops, tricular rigidity, pulmonary
decreased urinary output, diaphoresis, orthopnea, hypertension, or systemic hy-
pertension, which can decrease
dyspnea, crackles (rales), jugular vein distention, cardiac output.
edema, chest pain
Auscultate for presence of Indicates disturbances of normal
murmurs andlor rubs. blood flow within the heart re-
Outcome Criteria lated to incompetent valves,
sepia1 defects, or papillary
Vital signs and hemodynamic parameters will be muscle/chordae tendonae rup-
within normal limits for patient, with no ture post-MI. Presence of a
rub with an MI may be asso-
dysrhythmias noted.
ciated with pericarditis and/
INTERVENTIONS RATIONALES or pericardial effusions.
Auscultate apical pulses and Decreased contractility will be Observe lower extremities for Reduced venous return to the
monitor heart rate and rhythm. compensated by tachycardia, es- edema, distended neck veins, heart can resulr in low cardiac
Monitor BP in both arms. pecially concurrently with heart cold hands and feet, mottling, output; oliguria results from
failure. Blood volume will be oliguria. Notify M D if urine decreased venous return due to
lowered if blood pressure is output is < 30 cclhr. fluid retention.
increased resulting in increased
afterload. Pulse decreases may
be noted in association with Position in semi-Fowler's Promotes easier breathing by
toxic levels of digoxin. Hypo- position. allowing for chest expansion
tension may occur as a result and prevents pooling of blood in
of ventricular dysfunction and the pulmonary vasculature.
poor perfusion of the myocard-
ium. Administer cardiac glycosides, Used in the treatment of vaso-
nitrates, vasodilators, diure- constriction and 10 reduce heart
Monitor EKG for dysrhythmias. Conduction abnormalities may tics, and antihypertensives as rate and contractility, reduces
and treat as indicated. occur due to ischemic myocar- ordered. blood pressure by relaxation of
dium affecting the pumping venous and arterial smooth mus-
efficiency of the heart. cle which then in turn increases
cardiac output and decreases the
Determine level of cardiac func- Additional disease states and workload on the heart.
tion and existing cardiac and complications may place an
other conditions. additional workload on an Titrate vasoactive drugs as Maintains blood pressure and
already compromised heart. ordered per M D parameters. heart rate at levels to optimize
cardiac output function.
Measure CO and perform other Provides direct measurement
hemodynamic calculations. of cardiac output function, Weigh every day. Weight gain may indicate fluid
and calculated measurement retention and possible impend-
of preload and afterload. ing congestive failure.
INTERVENTIONS RATIONALES INTERVENTIONS MTIONALES

Arrange activities so as to Avoids fatiguing patient diac output by lessening
not overwhelm patient. and decreasing cardiac output the workload placed on the
further. Balancing rest with heart.
activity minimizes energy expen-
diture and myocardial oxygen Instruct to report chest pain May indicate complications of
demands by maintaining ade- immediately, decreased cardiac output.
quate cardiac output.
Instruct patientlfamily regard- Alleviates fear and promotes
Avoid Valsalva-type maneuvers Increasing intra-abdominal pres- ing placement of pulmonary ar- knowledge. Pulmonary artery
with straining, coughing or sure results in an abrupt de- tery catheter, and post- catheter necessary for direct
moving. crease in cardiac output by procedure care. measurement of cardiac output
preventing blood from being and for obtaining values for
pumped into the thoracic cavity other hemodynamic measure-
and thus, less blood being ments.
pumped into the heart which
then decreases the heart rate. Assist with insertion and main- Cardiac pacing may be necessary
When the pressure is released, tenance of pacemaker when need- during the acute phase of MI or
there is a sudden overload of ed. may be necessary as a permanent
blood which then increases pre- measure if the MI severely
load and the workload on the damages the conduction system.
heart.
Provide small, easy to digest, Large meals increase the work-

meals and restrict caffeine. load on the heart by diverting
blood flow to that area. Caf-
feine directly stimulates the 0 Patient will have no chest pain or shortness of
heart and increases heart rate. breath.
Have emergency equipment and Coronary occlusion, lethal dys- Vital signs and hemodynamic parameters will be
medications availabIe at all rhythmias, infarction extensions within normal limits for age and disease condi-
times. or intractable pain may preci-
tion.
pitate cardiac arrest that re-
quires life support and resus- Minimal activity will be tolerated without
citation.
fatigue or dyspnea.
Urinary output will be adequate.
Demonstration Cardiac output will be adequate to ensure ade-
quate perfusion of all body systems.
Instruct on medications, dose, Promotes knowledge and
Risk for fluid volume excess
effects, side effects, contra- compliance with regimen.
Related to: increased sodium and water retention,
indications, and avoidance of Prevents any adverse drug inter-
over-the-counter drugs without actions. decreased organ perfusion
MD approval.
Defining characteristics: edema, weight gain,
Instruct in activity limitations. Promotes compliance. Reduces intake greater than output, increased blood pres-
Demonstrate exercises to be done. potential for decrease in car- sure, increased heart rate, shortness of breath,
CARDIOVASCULARSYSTEM 21
dyspnea, orthopnea, crackles (rales), oliguria, jugu-

lar vein distention, pleural effusion, specific
Instruct patient in medications Promotes knowledge and
gravity changes, altered electrolyte levels prescribed after discharge, with compliance with treatment
dose, effect, side effects, con- regimen.
traindications.
Outcome Criteria
Blood pressure will be maintained within normal
limits and edema will be absent or minimal in all Patient will have no edema or fluid excess.
body parts.
. Fluid balance will be maintained and blood
pressure will be within normal limits of
Auscultate lungs for presence May indicate pulmonary edema baseline.
of crackles (rales).
Observe for jugular vein dis-

from cardiac decompensation.
May indicate impending conges-

. Lung fields will be clear, without adventitious
breath sounds, and weight will be stable.
tention and dependent edema. tive failure and fluid excess.
Patient will be able to verbalize understanding
Determine fluid balance by Renal perfusion is impaired with
measuring intake and output, decreased cardiac output, which
of dietary restrictions and medications.
and observing for decreases in leads to sodium and water reten-
output and concentrated urine. tion and oliguria.
Anxiety
Weigh daily and notify MD of Abrupt changes in weight usually
greater than 2 Ib/day increase. indicate excess fluid. threat to body image, threat to role functioning,
pain
Provide patient with fluid in- Fluids provide hydration of tis-
take of 2 L/day, unless fluid sues. Fluids may need to be Defining characteristics: restlessness, insomnia,
restricrion is warranted. restricted due to cardiac decom- anorexia, increased respirations, increased heart
pensation.
Administer diuretics as ordered Drugs may be necessary to cor- energy, irritability, crying, feelings of helplessness
(furosemide, hydralazine, spiro- rect fluid overload depending
lactone, hydrochlorothiazide). on emergent nature of problem.
Outcome Criteria
Monitor electrolyte for imbal- Hypokalemia can occur with the
ances. administration of diuretics. Patient will be able to use coping mechanisms
effectively, will appear less anxious, and be able to
verbalize feelings.
Demonstration INTERvENTfONS RATIONALES
Identify patient’s perception Patient may be afraid of dying
INTERVENTIONS RATIONALES of illness or situation. En- and be anxious about his imme-
Instruct patient regarding diet- Fluid retention is increased courage expressions of anger, diate problem as related to his
ary restrictions of sodium. with intake of sodium. grief, sadness, fear, and loss. lifestyle and the problems that
have been left unattended.
Instruct patient to observe for Weight gain may be first overt
weight changes and report these sign of fluid excess and should Explain all procedures to pa- Knowledge reduces fear of the
to MD. be monitored to prevent compli- tient in concise and reassur- unknown. Establishes feelings
cations. ing manner. Repeat information of trust and concern. Informa-
22 CRITICAL CAFE NURSING CARE PLANS
INTERVENTIONS RATIONALES Information, Instruction,

as needed based on patient’s tion may need to be repeated or
Demonstration
ability to comprehend. reintbrced due to competing
stimuli. INTERVENTIONS RATIONALES
Instruct patient and family Accurate information reduces
as to all procedures, tests, anxiety, facilitates the rela-
Encourage the patient to dis- Assists the patient in verba- medications, and care in a tionship between patient and
cuss his fears and feelings. lizing concerns and provides the factual consistent manner. nurse, and allows the patienr
Provide an atmosphere of accep- opportunity to deal with matters Reinforce as needed. and family to deal with the
tance without judgment. Accept of import to the patient. Ac- problem in a realistic manner.
his use of denial, but do not cepting the patient’s feelings Repetition, when needed, helps
reinforce false beliefs. Avoid may decrease his anxiety which in the retention of information
confrontations and upsets. can facilitate a therapeutic when the attention span is di-
environment for instruction. minished.
Denial can be useful to decrease
anxiety but can postpone dealing Instruct patient in relaxa- Reduces anxiety and stress.
with the reality of the problem. tion techniques. Provide for
Confrontations can lead to anger diversionary activities.
and exacerbate the use of denial
and decrease cooperation. Instruct about post-discharge Reduces anxiety and promores
care, activities, limitations, increased independence and self-
Provide opportunities for the Familiar people can decrease symptoms to report, problems confidence; decreases fear of
family to visit and assist with anxiety of the patient, as that might be encountered, and abandonment that can occur
care if possible. Orient to well as provide a more con- goals. with discharge from hospital;
routines. ducive atmosphere for learn- assists patient and family to
ing and recovery. Predicta- identi+ realisric goals and
bility can decrease anxiety. decreases the chances of discour-
Supportive family members agemenr with limitations during
can comfort the patient and recuperation.
relieve worries.
Provide private time for pa- Allows time for expression

tient and family member(s) of concerns and feelings, and
ro verbalize feelings. relieves tension by establish-
ing a more normal routine. Patient is able to recognize feelings and identify
mechanisms to cope and identify causes.
Provide opportunities for pa- Allows the patient to have some
tient to control his environ- control over his situation and Patient has significant reduction in fear and
ment and activities as much as facilitates compliance with care anxiety and appears less tense, with normal vital
feasible based on condition. of which patient is not in con-
signs.
trol.
Patiendfamily can appropriately utilize
Provide opportunity for patient Facilitates coping mechanism
to rest withour interruption as by conserving energy, and by problem-solving skills.
much as possible. providing required rest.
Patient can verbalize concerns easily and has
Adminisrer antianxiety drugs as Promotes rest and reduces anxi- increased energy.
ordered (diazepam, flurazepam, ety.
lorazepam). Patient can make appropriate decisions based on
factual information regarding his condition and
is able to discuss future plans.
Knowledge W c i t INTERVENTIONS RATIONALES

Related to: lack of understanding, lack of under- Instruct in dietary needs and Patient may need to increase
restrictions, such as limiting dietary potassium if placed on
standing of medical condition, lack of recall caffeine and sodium or in- diuretics; caffeine should be
creasing potassium, etc. limited due to the direct stimu-
Defining characteristics: verbalized questions lant effect on the heart; so-
regarding problems, inadequate follow-up on dium should be limited due to
instructions given, misconceptions, lack of the potential for fluid reten-
improvement of previous regimen, development tion.
of preventable complications Provide printed materials when Provides references for patient
possible for patientlfamily to and family to refer to once dis-
review. charged, and can enhance the
Outcome Criteria understanding of verbally-
given instructions.
Patient will be able to verbalize and demonstrate
understanding of information given regarding Demonstrate and instruct on Self-monitoring promotes self-
technique for checking pulse independence and can provide
condition, medications, and treatment regimen.
rate and regularity Instruct timely intervention for abnor-
in situations where immediate malities or complications.
Information, Instruction, action must be taken. Heart rates that exceed set
parameters may require furrher
Demonstration medial alteration in medica-
tions or regimen.
Determine patient’s baseline of Provides information regarding Have patient demonstrate all Provides information that
knowledge regarding disease pro- patient$ understanding of skills that will be necessary patient has gained a full
cess, normal physiology, and condition as well as a baseline for post-discharge. understanding of instruction
function of the heart. from which to base teaching. and is able to demonstrate
correct information.
Monitor patient’s readiness to Promotes optimal learning en- Instructldemonstrate exercises Exercise programs are help-
learn and determine best methods vironment when patient shows to be performed, avoiding over- ful in improving cardiac
to use for teaching. Attempt willingness to learn. Family taxing activities, signs/ function.
to incorporate family members members may assist with help- symptoms that may require the
in learning process. Rein- ing the patient to make in- cessation of any activity,
structlreinforce information as formed choices regarding his and to report symptoms that
needed. treatment. Anxiety or latge may require medical attention.
volumes of instruction may
impede comprehension and
limit learning. Discharge or Maintenance Evaluation
Provide time for individual in- Promotes relationship between Patient will be able to verbalize understanding
teraction with patient. patient and nurse, and estab-
blishes trus:.
of condition, treatment regimen, and
signs/symptoms to report.
Instruct patient on procedures Provides knowledge and pro-
that may be performed. motes the ability to make Patient will be able to correctly perform all
informed choices. tasks prior to discharge.
Instruct patient on medications, Provides information to :he Patient will be able to verbalize understanding
dose, effects, side effects, con- patient to manage medication of cardiac disease, risk factors, dietary
traindications, and signs/ regimen and ensure compliance.
restrictions, and lifestyle adaptations.
symptoms to report to MD.
MYOCARDZAL INFARCTION (MI)

Endothelial cells in intimal layer Vasoconstriction occurs
of artery are injured s
J,
Permeability to lipoproteins increase
4
Platelets and fibrin aggregate at injury site
Platelet-fibrin thrombus form
J,
Macrophages aggregate Coronary artery spasm occurs
4 s
Lipoproteins enter smooth muscle cells of
intima and create a fatty plaque
s
Plaque ruptures and fatty thrombus or clot forms
.............................................. c
J,
Progressive narrowing of vessel occurs
s
Partial or complete obstruction of coronary artery(s) occur
J,
Blood flow decreases
Oxygen supply decreases
s
Coronary insufficiency
s
Coronary ischemia
J,
Myocardial necrosis = Myocardial infarction
COMPLICATIONS RESULTING FROM MI THAT MAY LEAD TO DEATH IF NOT TREATED:

Congestive heart failure
Dysrhythmias
Conduction problems
Cardiogenic shock
Systemic embolus
Pulmonary embolus
Papillary muscle rupture
Dressler’s syndrome
Ventricular rupture
Ventricular septal defects
PerScarditis The main symptoms of pericarditis include sharp,

retrosternal and/or left precordial pain that wors-
ens while in a supine position, and a pericardial
Pericarditis is an inflammation of the pericardium friction rub best auscultated at the lower left ster-
that can occur due to a variety of circumstances. nal border. The pain may be exacerbated by
The inflammation is usually a manifestation of coughing, swallowing, breathing, or twisting.
another disease process, but may be drug induced, Other symptoms may be seen depending on the
from agents such as procainamide, hydralazine, severity of the pericarditis and the rapidity in
phenytoin, penicillin, phenylbutazone, minoxidil, which the fluid accumulates. Volumes of 100 cc
or daunorubicin. Other causes for pericarditis that accumulates quickly may produce a more
include idiopathic causes, viral, bacterial, fungal, life-threatening complication, cardiac tamponade,
protozoal, uremia, MI, tuberculosis, neoplasms, than a larger accumulation of fluid that is gener-
trauma, surgical procedures, autoimmune disor- ated over a long period of time.
ders (lupus, rheumatoid arthritis, scleroderma),
inflammatory disorders (amyloidosis), dissecting MEDICAL CARE
aortic aneurysms, or radiation treatments to the
Oxygen: to increase available oxygen supply
thorax.
Analgesics: morphine or meperidine used to alle-
Pericarditis may be classified as acute or chronic, viate pain
as well as constrictive or restrictive. Constrictive
pericarditis occurs when fibrin material is Steroids: large doses of corticosteroids, such as
deposited on the pericardium and adhesions form prednisone, are given to reduce inflammation and
between the epicardium and pericardium. control the symptoms of pericarditis
Restrictive pericarditis results when effusion into NSAIDs: aspirin or indomethacin are used to
the pericardial sac occurs. Both types cause inter- reduce fever and inflammation
ference with the heart’s ability to fill properly,
which causes increases in systemic and pulmonary IV fluids: given to help restore left ventricular fill-
venous pressures. Eventually systemic blood pres- ing volume and to offset any compressive effects
sure and cardiac output decrease. of intrapericardial pressure increases
The visceral pericardium is a serous membrane Inotropic drugs: isoproterenol or dobutamine IV

that is separated from a fibrous sac, or parietal given for their positive inotropic effects as well as
pericardium, by a small (less than 50 cc) amount peripheral vasodilating properties
of fluid. If the fluid increases to the point where Laboratory: white blood cell count may be
the heart function is compromised, pleural effu- elevated, sed rate may be elevated from non-spe-
sion occurs and cardiac tamponade becomes a cific inflammatory response; CKMB may be
critical concern. The pericardium is important mildly elevated; blood cultures done to identify
because it holds the heart in a fixed position to organism responsible for infective process and to
minimize friction between it and other structures. ascertain appropriate drug for eradication; renal
Other functions include prevention of exercise- or profile done to evaluate for uremic pericarditis
hypervolemic-induced dilatation of the cardiac and worsening renal status
chambers and assistance with atrial filling during
systole.
Electrocardiography: used to monitor for S-T ele- imbalances, changes in peripheral resistance,
vation, T wave changes associated with impaired oxygenation of myocardium, EKG
pericarditis, and to monitor for dysrhythmias changes (S-T segment, T wave, U wave), LV
Echocardiography: used to establish presence of enlargement, palpitations, abnormal renal function
pericardial fluid and an estimate of volume, any studies
vegetation on valves, and to observe for right
atrium and right ventricular dilatation Outcome Criteria
Chest x-ray: used to show cardiomegaly and to Blood flow and perfusion to vital organs will be
assess lung fields preserved and circulatory function will be
Pericardiocentesis: used to relieve fluid build-up maximized.
and pressure in emergency situations where the Patient will be free of dysrhythmias.
patient is deteriorating or is in shock
Hemodynamic parameters will be within normal
Surgery: open surgical drainage is usually the limits.
treatment of choice for cardiac tamponade
NURSING CARE PLANS Obtain vital signs.

Obtain hemodynamic values,
Provides information about the
hemodynamics of the patient.
Alterution in comfort noting deviations from base-
line values.
[See MI]
Determine the presence and May indicate decreased perfusion
Related to: chest pain due to pericardial inflam- character of peripheral pulses, resulting from impaired coronary
mation capillary refill time, skin blood flow.
color and temperature.
Defining characteristics: chest pain with or with-
out radiation, facial grimacing, clutching of hands Discourage any non-essential Ambulation, exercise, transfers,
or chest, restlessness, diaphoresis, changes in pulse activity. and Valsalva-type maneuvers can
increase blood pressure and de-
and blood pressure, dyspnea crease tissue perfusion.
Altered tissue perfision: curdiopulmonury, Monitor EKG for disturbances Decreased cardiac perfusion may
renal, peripherul, cerebrul in conduction and for dysrhy- instigate conduction abnormali-
thrnias and treat as indicated. ties. Dysrhythmias may occur
Related to: tissue ischemia, reduction or interrup- due to compromised function of
tion of blood flow, vasoconstriction, hypovolemia, ventricles due to pressure exer-
shunting, depressed ventricular function, ted on them by excess fluid.
dysrhythmias, conduction defects Titrate vasoactive drugs as Maintain blood pressure and
ordered. heart rate at parameters set by
Defining characteristics: abnormal hemodynamic
M D for optimal perfusion with
readings, dysrhythmias, decreased peripheral minimal workload on heart.
pulses, cyanosis, decreased blood pressure, short-
ness of breath, dyspnea, cold and clammy skin, Administer oxygen by nasal Provides oxygen necessary for
cannula as ordered, with rate tissues and organ perfusion.
decreased mental alertness and changes in mental dependent on disease process
status, oliguria, anuria, sluggish capillary refill, and condition.
abnormal electrolyte and digoxin levels, hypoxia,
ABG changes, chest pain, ventilation perfusion
INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Auscultate lungs for crackles Suggestive of fluid overload Lung fields will be clear and free of adventitious
(rales), rhonchi, or wheezes. that will further decrease tis-
sue perfusion. breath sounds.
Auscultate heart sounds for Suggestive of impending or

Extremities will be warm, pink, with easily pal-
S g or S4 gallop, new murmurs, present heart failure. pable pulses of equal character.
presence of jugular vein dis-
tention, or hepatojugular re- Vital signs and hemodynamic parameters will
flex. be within normal limits for patient.
Monitor oxygen status with ABGs, Provides information about the Oxygenation will be optimal as evidenced by
SvO, monitoring, or with pulse oxygenation status of the pa- pulse oximetry greater than 90%, S v 0 2 greater
oximetry. tient. Continuous monitoring of
saturation levels provide an in-
than 75%, or normal ABGs.
stant analysis of how activity
Patient will be free of chest pain and shortness
can affect oxygenation and per-
fusion. of breath.
Assist patient with planned, Allows for balance between rest

Patient will be able to verbalize information cor-
graduated levels of activity. and activity to decrease myocar- rectly regarding medications, diet and activity
dial workload and oxygen limitations.
demand. Gradual increases help
to increase patient tolerance to Decreased cardiac output
activity without pain occurring.
[See MI]
Related to: fluid in pericardial sac from pericardial
Information, Instruction, effusion, potential for cardiac tamponade because
Demonstration of effusion, damaged myocardium, decreased con-
tractility, dysrhythmias, conduction defects,
Instruct on medications, dosage, Promotes compliance with regi-
effects, side effects, and con- men and knowledge base.
constriction, myocardial ischemia, ventricular
traindications. hypertrophy
Defining characteristics: decreased blood pressure,
Instruct to refrain from smok- Smoking causes vasoconstriction tachycardia, pulsus paradoxus greater than 10
ing. with can decrease perfusion. mmHg, distended neck veins, increased central
Instruct in dietary require- Reduction of high-cholesterol
venous pressure, dysrhythmias, decreased QRS
ments, menu planning, sodium and sodium foods will help to voltage or electrical alternans, diminished heart
restrictions, foods to avoid. control atherosclerosis, hyper- sounds, dyspnea, friction rub, cardiac output less
lipidemia, fluid retention, and
than 4 L/min, cardiac index less than 2.5
the effects on coronary blood
flow. L/min/m’
Anxiety
[See MI]
pain

Knowledge &+&it
[See MI]
complications
PERICARDITIS
Inflammation
c
Infiltration of neutrophils
c
Increased pericardial vascularity
4
Increased deposits of fibrin
c
Fibrinous adhesions form between pericardium and epicarium
e
Fluid accumulates in pericardial sac
c
Pericardial effusion
c
Heart function restricted
J,
Cardiac output decreased
c
Pressures in heart equalize
c
Cardiogenic shock occurs
c
Death
(NBTE). After this stage, the heart is then set up

for vegetation to colonize from bacteria from other
areas of the body during transient episodes of bac-
Bacterial endocarditis is now referred to as infec- teremia. As these organisms grow, more platelets
tive endocarditis due to the presence of other and fibrin adhere and eventually valves are
organisms besides bacteria being the causative destroyed, vegetation breaks off and embolizes to
agent. It is an infection of the cardiac valves and other areas of the body, and a systemic immune
inner lining of the heart that is characterized as a response occurs.
systemic illness. Endocarditis may be misdiagnosed
Patients who are at risk for endocarditis include
as other infections in the early stages if signs and
those with rheumatic heart disease, open-heart
symptoms of cardiac involvement are not present,
surgery, congenital heart defects, prosthetic valve
Common complaints range from fever with tem-
replacements, dental procedures, gynecological
perature less than 102 degrees, chills, arthralgia,
surgery or procedures, genitourinary surgery or
lethargy, and anorexia. Acute endocarditis may procedures, invasive tests or lines, infected periph-
result in death within a matter of hours if not eral or central venous lines, IUDs, AV shunts or
treated. Antimicrobial therapy can decrease mor-
fistulas, skin abnormalities in preexisting cardiac
tality to 15%, but heart failure secondary to
disease, immunosuppressive therapy, and IV drug
valvular scarring and damage can occur after the
use.
infection is resolved.
Patients who have had prosthetic valves placed and
Almost any organism can cause endocarditis but who develop endocarditis are divided into early
the most common ones noted have been (occurring less than two months postoperatively)
Streptococcus viridans, Staphylococcus aureus, and late (occurring greater than two months post-
Enterococci, Staphylococcus epidermidis, operatively) classes, and develop chills, fever,
Streptococcus pneumoniae, Pseudornonas aerugi- leukocytosis, and/or a new murmur. Mortality is
nosa, Candida albicans, and Aspergillus fumigatus. higher in early prosthetic valve endocarditis and is
Endocarditis may be subdivided into the acute and a serious problem.
subacute classes, depending on the virulence of the
organism involved and the length of duration. MEDICAL CARE
Acute infective endocarditis (AIE) has less than Antibiotics: penicillin is the treatment of choice for
one month duration whereas subacute infective Streptococcus viridans, with cephalothin or
endocarditis (SIE) is usually greater than one vancomycin being alternate choices; penicillin plus
month in duration, SIE usually involves congeni- gentamicin is the treatment of choice for
tally-deformed or damaged heart valves, and AIE Steptococcus faecalis; synthetic penicillins, such as
usually involves normal heart valves. Trauma in oxacillin or nafcillin, cephalothin and/or gentam-
many forms can occur to the epithelia1 layer of the icin are used in Staphylococcus epidermidis
valves/endocardium causing injury and deposits of
platelets and fibrin to adhere to this surface. This Laboratory: a series of blood cultures is done to
is known as nonbacterial thrombotic endocarditis isolate the causative organism and sensitivity to
antimicrobial agents; CBC is used to assess for
anemia that may occur in up to 70% of patients,
to monitor leukocyte levels, and to assess platelet areas, hematuria, oliguria, anuria, chest pain, short-
counts; sedimentation rates may increase; immune ness of breath, dyspnea, confusion, weakness,
titers show antigen-antibody response convulsions, coma, hemiplegia, aphasia, hemipare-
sis, cardiac tamponade, pericardial friction rub,
Electrocardiography: shows alterations in conduc- murmur, dysrhythmias, conduction defects, cold
tion, dysrhythmias, ischemia clammy skin, cyanosis, mental status changes,
Echocardiography: used to establish diagnosis, to hypotension, tachycardia, decreased urinary output,
determine underlying cardiac disease, to estimate increased BUN
myocardial contractility, and demonstrate early
mitral valve closure and aortic insufficiency Outcome Criteria
Nuclear cardiologic testing: Technetium-99 scans Patient will achieve and maintain adequate tissue
and gallium-67 imaging used to evaluate the perfusion to all body systems.
extent of the infective process and to evaluate
potential as a surgical candidate INTERVENTIONS RATIONALES
Determine mental status and Symptoms may indicate emboliza-
Surgery: valve replacement is necessary if patient level of consciousness. Observe tion to cerebrum which may re-
develops intractable congestive heart failure with for hemiparesis, paralysis, apha- quire emergency treatment.
hemodynamic compromise, persistent bacteremia sia, convulsions, visual field de-
fects, or coma, and notify M D .
despite antimicrobial treatment, prosthetic valve
endocarditis, major systemic emboli, gram negative Monitor EKG for conduction ab- Due to the close proximity of
or fungal infection; drainage of abscesses or normalities, especially prolonged aortic valve cusps to the con-
empyema; repair of peripheral or cerebral mycotic PR interval, new left bundle duction system, bacterial in-
branch block, new right bundle vasion and proliferation may
aneurysms branch block with or without left extend the infection process
anterior hemiblo&. Treat as in- into the myocardium and cause
Prophylaxis: prophylactic antibiotic therapy must dicated per protocol. dysrhythmias. Extension of
be prescribed prior to dental procedures, urethral the infection from the mitral
or gynecological procedures, or surgery valve to the Bundle of His and
AV node may result in junctional
tachycardia, Mobitz I, second
NURSING CARE PLANS degree or third degree AV
blocks.
Risk for altered tissue pe@ion: cardiopul-
monary, cerebral, renal, gastrointestinal, Observe for sudden shortness of Arterial emboli may affect the
and peripheral breath, tachypnea, pleurisy-type heart and other vital organs.
pain, pallor or cyanosis. Venous congestion may result
Related to: valvular vegetation emboli, platelet- in thrombus formation in deep
veins and cause embolization
fibrin emboli, and immunologic responses causing
to lungs, or embolization of
allergic vasculitis; embolu vegetation thrombi may result
in pulmonary embolus.
Defining characteristics: petechiae, arthritis,
arthralgia, myalgias, decreased peripheral pulses, Evaluate chest pain, tachycar- Arterial emboli may affect the
Janeway’s lesions, Roth‘s spots, Osler’s nodes, lower dia, decreased blood pressure. heart and cause myocardial in-
Auscultate heart sounds for new farction. New murmurs may
back pain, splinter hemorrhages to subungual
or changed murmurs, pericardial occur as a result of valve scarring INTERVENTIONS RATIONALES
friction rubs, or abnormal lung and distortion, valve aneurysm,
sounds (crackles, rales). septal rupture, papillary muscle 1-10 mm in diameter, red with
rupture, or myocardial abscess white centers, overtly
rupture. Rupture into the pericar- tender, and are usually a late
dial sac can cause cardiac tarn- sign of endocarditis,
ponade, in which heart tones will typically found in subacute endo-
be muffled. Pericardial friction carditis infections. Jane-
rubs may indicate pericarditis. way’s lesions are non-tender
Abnormal lung sounds may reddened or pink macular lesions,
indicate impending congestive 1-5 mm in diameter, and usually
heart failure. change to tan and fade within 2
weeks. These are usually an
Observe extremities for swelling, Bedrest promotes venous stasis early sign of endocarditis.
erythema, tenderness, pain, pos- which can increase the risk of
itive Homans’ sign, positive thromboembolus formation. Ac- Evaluate complaints of arthri- Occur in endocarditis due to
Pratt’s sign. Observe for de- tual vegetation emboli can mi- tis, arthralgia, and severe lower localized immune responses
creased peripheral pulses, pal- grate and occlude peripheral back pain. Medicate as needed. or in decreased perfusion.
lor, coldness, cyanosis. arteries, leading to tissue
ischemia and necrosis.
Monitor blood culture and sen- Usually 3-6 blood cultures are
Monitor for complaints of ab- May indicate embolization to sitivity reports. done in a series ro assess for
dominal pain to lek upper abdo- spleen. Vegetative emboli may sustained bacteremia because
men with radiation ro left occlude mesenteric artery and bacteria are continually re-
shoulder, abdominal rigidity, cause bowel infarction. Spleno- leased into the system in endo-
tenderness, nausea, or vomiting. megaly may be caused by anti- carditis. The series prevents
gen stimulation and allergic the possibility of false read-
vasculitis. ings. Cultures determine the
specific organism responsible
Observe urine for hematuria, Allergic vasculitis from endo- for the bacteremia, and sensi-
oliguria, anuria, complaints of carditis can result in focal, tivity results enable the choice
flank or back pain. acute, or chronic glomerulo- of antimicrobials to be suited
nephritis and progress to renal to the specific infection.
insufficiency, renal failure,
and uremia. Administer antimicrobials Antibiotics should not be start-
as ordered. ed until culture series is com-
Observe for petechiae on mucous Petechiae is one of the classic pleted in subacute IE, but with
membranes, conjunctiva, neck, symptoms of endocarditis as a acute IE, empiric antibiotics are
wrists, and ankles. Observe for result of allergic vasculitis. given until cultures are available.
splinter hemorrhages in subungu- Petechiae are usually 1-2 m m in In some instances, early negative
al areas, Osler’s nodes to distal diameter, flat, red with white results may indicate only that the
fingers and toes, sides of fin- or gray centers, non-tender, and culture could not be grown due to
gers, palms or thighs, and for groups fade within a few days. low levels of bacteria or an
Janeway’s lesions to the palms, Petechiae may be noted in other unusual organism being present.
soles of feet, arms and legs. diagnoses and they should be Obtaining cultures after anribi-
ruled our. Hemorrhages to the otics have been started do not give
subungual areas may be seen in accurate information.
early infective endocarditis but
may be seen in trauma, with
hemo- or peritoneal dialysis, or
in mitral stenosis. Osler‘s
nodes are nodules that range from
Instruction, Information, Hyperthermia

Demonstration
- ~ ~~~ ~
Related to: bacteremia, allergic vasculitis, arterial
INTERVENTIONS RATIONALES occlusion/infarction, abscess
Instruct patient in signs/ Promotes knowledge and cornpli- Defining characteristics: body temperature greater
symptoms to report to MD. ance with regimen.
than normal range, flushed warm skin, chills,
increased heart rate, increased respiratory rate
Outcome Criteria
Patient will have adequate tissue perfusion to all
body systems. Patient will maintain body temperature within
Patient will be mentally lucid, with no confusion normal limits and be free of infection.
or neurological deficits. INTERVENTIONS RATIONALES
Patient will have adequate urinary output with Monitor temperature every 2-4 Endocarditis usually results
hours and prn. Observe for in temperatures less than 102
no hematuria, and renal function studies will be chills and diaphoresis. degrees; temperatures grearer
within normal limits. than this indicate an acute
infective process. Chills
Patient will be able to recall accurately the infor- frequently precede a tempera-
mation instructed. ture spike.
Decreased cardiac output Monitor environment tempera- Room temperature may be al-
[See MI] ture and limit or add blankets tered to assist with main-
as warranted. Change linens as tenance of normal body tem-
Related to: complications with infected heart needed. perature.
valves, potential for cardiac tamponade because of
Monitor I&O; provide adequate Diaphoresis and increased meta-
effusion, damaged myocardium, decreased contrac- fluids. bolic rate from temperature
tility, dysrhythmias, conduction defects, alteration elevations increase fluid loss
in preload, alteration in afterload, vasoconstriction, and may cause dehydration.
myocardial ischemia, ventricular hypertrophy Give tepid sponge baths prn. May assist in lowering tempera-
ture by means of evaporation.
Using cooler water or alcohol
tachycardia, pulsus paradoxus greater than 10 may cause chilling and thus
mmHg, distended neck veins, increased central increase body temperature.
venous pressure, dysrhythmias, decreased QRS
Place on cooling blanket as Cooling blankets are usually
voltage or electrical alternans, diminished heart warranted. only used for severe fever
sounds, dyspnea, friction rub, cardiac output less greater than 104 degrees when
than 5 L/min, cardiac index less than 2.5 risk of brain damage or seizures
L/min/m2, change in mental status, change or new is imminent.
cardiac murmur, arterial emboli, decreased urine Administer antipyretic medi- Reduces fever by action on the
output, cyanosis, cold clammy skin cations as warranted. hypothalamus. Low grade ternp-
eratures may be beneficial to
the body’s immune system and
ability to retard the growth
of organisms.
Information, Instruction, Outcome Criteria

Demonstration
Patient will be free of infection, afebrile, with no
INTEKVENTIONS RATIONALES over symptoms of infection or infective process
Instruct on procedures for de- Provides knowledge and reduces noted.
creasing temperature. kar and enhances compliance.
Instruct to take temperature Temperature elevations indicate Monitor temperature trends. Decreases in body temperature
frequently and to notify MD for infection and prompt notifica- below 9G degrees may indicate
elevations immediately. tion will allow for prompt advanced s h o d states and 1s
treatment. a critical indicator of de-
creased tissue perfusion and
Instruct on medications, effects, Promotes knowledge and compli- lack of the body’s ability
side effects, contraindications, ance. to muster enough defense to
symptoms to report. raise the temperature. Tem-
peratures greater than 10 1
degrees are due to the effect
Discharge or Maintenance Evaluation of endotoxins on the hypo-
thdamus and of pyrogen-
Patient will be normothermic with no overt released endorphins.
signs/symptoms of infection. May indicate ineffective anti-
Monitor for signs/symptoms of
deterioration of patient and biotic therapy or abundance of
Risk for infiction failure to improve within a resistant organisms.
Related to: inhibition of antibodies due to timely manner.
immunological system action, inflammatory Observe mouth for patches of Thrush or yeast infections may
processes due to vegetation growth, predisposition white plaque and perineal occur as a secondary infection
to bacteremia, septic emboli, myocardial abscess, areas for vaginal drainage or when normal flora is killed by
itching, and notify MD. massive antibiotic therapy.
occlusion of arteries leading to necrosis of body
systems, invasive procedures and lines, dental pro- Inspect wounds, IV sites, cath- May indicate local secondary
cedures, nosocomial infections, lack of recognition eter sites, invasive devices and infection or inflammation.
of infection, lack of prophylactic treatment, sup- lines, changes in drainage or
. A . body fluids.
rainfection
Maintain aseptic or sterile Reduces the risk of opportun-
Defining characteristics: elevated temperature, ele- technique as warranted. istic infection and chances of
vated WBC count, positive blood cultures, cross-contamination.
reddened, draining IV sites
Obtain urine, blood, sputum, Assists with identification of
wound, and invasive Iindcathe- source of infection, causative
ter specimens for culture and organism, and antibiotic of
sensitiviry and Gram stain as choice to enable prompt and
warranred. effective treatment.
Reposition patient every 2 Frequent changes in position

hours; encourage coughing and and breathing exercises en-
deep breathing. hance pulmonary toilet and may
help to prevent pneumonia.
INTERVENTIONS RATIONALES Discharge or Maintenance

Administer antibiotics as or- Antibiotics may be started
Evaluation
dered. prior to receiving final culture
reports based on the likelihood Patient will have normal temperature and vital
of the infective organism. Spe- signs.
cific antibiotics are determined
by the culture information. Patient will exhibit no overt symptoms or signs
of infection.
Information, Instruction, 0 Patient will be able to recall instructions accu-
Demonstration rately.
INTERVENTIONS RATIONALES Patient will seek prophylactic antibiotic therapy

Instruct patient to cover mouth Prevents spread of infection
prior to any procedure and will have no
and nose during coughing/sneezing. from airborne organisms. Good evidence of reinfection.
Instruct in handwashing and dis- handwashing reduces spread of
posal of contaminated materials. infection. Infection control Anxiety
procedures limit contamination [See MI]
and spread of infective mater-
ials. Related to: change in health status, fear of death,
Instruct patient in good dental Avoids trauma to gums which
hygiene to use soft tooth- may promote reinfection.
pain
brush; to avoid water pik Water pik and toothpi& may
and toothpicks; to obtain cause bleeding and promote
regular dental exams. infection. anorexia, increased respirations, increased heart
Instruct patient to take tempera- Temperature elevations may trating, dry mouth, poor eye contact, decreased
ture every day for 1 month post indicate infeaion/reinfec-
discharge. tion.
Prepare patient for surgery as Surgery may be required to

Knowledge dejcit
warranted. remove necrotic tissue or limbs [See MI]
and to remove purulent material
in order to enhance healing. Related to: lack of understanding, lack of under-
Surgery may be required to re- standing of medical condition, lack of recall
place damaged heart valves due
to vegetative infection. Defining characteristics: questions regarding
Instruct patient in obtaining Prophylaxis will be required
prophylactic antibiotic therapy
for any invasive procedure due
prior to procedures. to likelihood of reinfection. previous regimen, development of preventable
complications
INFECTIVE ENDOCARDITIS
Trauma to valves predispose epithelia1 surface to injury
(valvular insufficiency, ventricular septal defects, artificial valves, and indwelling catheters and lines)
c
Platelets and fibrin deposit
c
Microscopic platelet-fibrin thrombi
(known as NBTE-nonbacterial thrombotic endocarditis)
J,
Bacteria lodge on endocardiumlvalves
c
Bacteria increase
Platelets, fibrin, RBCs, and PMN leukocytes deposited
c
7c I Vegetations formed
Vegetations embolize Valvular tissue deformed Inflammation adjacent to vegetation

J, 4 c
Arteries occlude Valves incompetent Immunologic antibodies inhibit PMNs
c Humoral immunity system stimulated
CHF Cellular immunity system decreased
e J
Ruptured perforated cusps Hypergammaglobulinemia
J, J,
Myocardial abscess Cryoglobulins increase
e Hypersensitivity reaction
Rupture to pericardial sac c
c Allergic vasculitis
Pericarditis c
4 Petechiae
Tamponade Arthritis
Mydgias
Janeway's lesions
Roth's spots
Osler's nodes
I
c c J, J, e c
Cerebral Cardiac Pulmonay s;L L a Perbheral
TIA Myocardial ischemia Pulmonary embolus Bowel infarction Renal infarction Claudication to extremities
CVA Myocardial infarction Dyspnea Mesentery infarct Glomerulonephritis Arterial insufficiency
Mycoric cerebral Anysm. CHF Splenic infarction Renal insufficiency Pain
Confusion Pericarditis Radiating pain Renal failure Pulselessness
Weakness Cardiac tamponade Fever Flank pain Cyanosis
Mental changes Chest pain Abdominal pain Hematuria Pallor
Hemiparesis Radiating pain Oliguria Mottling
Hemiplegia Nausea, vomiting Azotemia
Aphasia Sweating, diaphoresis Albuminuria
Convulsions Dyspnea
Coma
Hypertension lems. The mean arterial pressure, or MAP (or

MABP) is the average pressure attempting to push
the blood through the circulatory system and
Essential hypertension, which is an elevated blood
pressure of unknown origin, and secondary hyper- should be greater than 60 mmHg in order to ade-
tension, which is an elevated blood pressure quately perfuse organs.
resulting from a known cause, will cause inflam- Elevated blood pressure may occur as a result of
mation and necrosis in the arterioles which then emotional stress with as much as 40 mmHg
result in decreased blood flow to vital body increase, and may also result from ventilatory
organs, and places stress on the heart and vessels. insufficiency, post-seizures, electroconvulsive ther-
Uncontrolled hypertension is associated with per- apy, intracerebral injury, CNS disorders due to the
manent damage to body systems. Blood pressure is mass,ive stimulation of catecholamines, coronary
considered to be hypertension if the systolic pres- artery bypass surgery, myocardial infarction, heart
sure is greater than 140 mmHg or the diastolic failure, renal insufficiency, eclampsia/toxemia,
pressure is greater than 90 mmHg, and is classi- endocrine disorders, and some drugs.
fied based on the severity from a high normal to
malignant hypertension. Hypertensive crisis is Risk factors include: ages between 30 and 70 years
defined as a sustained increase in diastolic blood of age, race (black), use of birth control pills, obe-
pressure above 120 mmHg, which is high enough sity, familial history, smoking, stress, diabetes
mellitus, and sedentary lifestyle.
to cause irreversible damage to organs and tissue
death. Treatment is aimed at lowering blood pressure by
Hypertension may result from several origins- use of antihypertensive medications, diuretics to
increase urinary output, and by eliminating factors
adrenal origin (as in pheochromocytoma,
Cushing’s disease, brain tumor, etc.), renal origin that promote the elevation of blood pressure. A
(as in pyelonephritis), cardiovascular origin (as in “stepped care” regimen is used most often, with
step one involving the use of thiazide diuretics and
atherosclerosis or coarctation of the aorta, etc.), or
calcium ion antagonists; step two involves the sup-
unknown origin which accounts for the majority
plemental use of beta-adrenergic blockers; step
of all known hypertension.
three includes vasodilators; and step four involves
Untreated, hypertension will result in death due to guanethidine.
cerebrovascular accident, congestive heart failure,
intracerebral hemorrhage, kidney failure, or dis- MEDICAL CARE
secting aneurysms.
Diuretics: chlorothiazide (Diuril), spironolactone
Systolic blood pressure is the pressure that the (Aldactone), chlorthalidone (Hygroton),
heart pumps against to force blood from the left hydrochlorothiazide (Esidrix, HydroDiuril),
side of the heart to the aorta and to major arteries. triamterene (Dyrenium), metolazone (Zaroxolyn,
Diastolic blood pressure is the pressure required to Diulo), ethacrynic acid (Edecrin), furosemide
permit filling of the ventricles before the next sys- (Lasix) to promote diuresis and block reabsorption
tole cycle. The pulse pressure, which is the value of sodium and water in the kidney
of the difference between the systolic and diastolic
pressures, may be used to indicate perfusion prob- Calcium ion antagonists: verapamil (Calan), dilti-
azem (Cardizem), nifedipine (Procardia),
nitrendipine to produce vasodilation on vascular turia for possible indication of nephrosclerosis;

smooth muscle thyroid profile used to identify hyperthyroidism
Adrenergic inhibitors: reserpine, methyldopa which may lead to vasoconstriction and hyperten-
(Aldomet), propranolol (Inderal), prazosin sion; aldosterone level used to identify primary
hydrochloride (Minipress) used to impair synthe- aldosteronism; urine VMA to identify elevation of
sis of norepinephrine, suppression of sympathetic catecholamine metabolites which may indicate
outflow by central alpha-adrenergic stimulation, pheochromocytoma
or blocking of preganglionic to postganglionic Radiographic testing: IVP may be used to iden-
autonomic transmission ti$ presence of kidney disease; renal arteriogram
Vasodilators: hydralazine (Apresoline), minoxidil may be used to show renal artery stenosis or other
(Loniten), nadolol (Corgard) to relax smooth causes of hypertension
muscle of arterioles and reduce peripheral vascular
resistance and thus, blood pressure NURSING CARE PLANS
ACE inhibitors: captopril (Capoten) used to R i d for decreased cardiac output
lower total peripheral resistance by inhibiting
Related to: vasoconstriction, increased preload,
angiotensin-converting enzyme
increased afterload, ventricular hypertrophy,
Electrolytes: potassium chloride (KCI, K Dur, K ischemia
tabs) to replace potassium lost through diuresis
Defining characteristics: elevated blood pressure,
Chest x-ray: shows any enlargement of the heart decreased cardiac output, decreased stroke volume,
and pulmonary vein, presence of pulmonary increased peripheral vascular resistance, increased
edema or pleural effusion systemic vascular resistance
Electrocardiography: used to monitor for changes
in rate and rhythm, conduction abnormalities, left Outcome Criteria
ventricular hypertrophy, ischemia, electrolyte
Patient will have no elevation in blood pressure
abnormalities, drug toxicity, and presence of dys-
above normal limits and will have adequate car-
rhythmias
diac output, and will maintain blood pressure
Laboratory: cholesterol levels and lipid profile within acceptable limits.
used to determine cholesterol and triglyceride INTERVENTIONS RATIONALES
levels and their pertinence to atherosclerosis; elec-
Monitor blood pressure every 1-2 Changes in blood pressure may
trolyte profiles used to monitor for hypokalemia hours, or every 5 minutes during indicate changes in patient
and hypernatremia which may be prevalent due to active titration of vasoactive status requiring prompt atten-
diuretic therapy; CBC used to identify potential drugs. Measure pressure in both tion. Comparing pressures in
renal failure and polycythemia; glucose levels used arms using appropriate size of both sides provides information
cuff. When possible, obtain as to amount of vascular in-
to identify potential causes of hypertension; BUN pressures lying, sitting, and volvement. Blood pressure may
and creatinine levels used to identify renal standing. vary depending on body position
dysfunction; urinalysis used to identify proteinuria and postural hypotension may
result in syncope.
for possible indication of renal disease and hema-
INTERVENTIONS RATIONALES Infarmatian, Instruction,

Monitor EKG for dysrhythmias, Decreases in cardiac output
Demonstration
conduction defects, and for may result in changes in car-
heart rate and rhythm changes. diac perfusion causing dys- INTERVENTIONS RATIONALES
Treat as indicated. rhythmias. Instruct on fluid and diet Restrictions can assist with
requirements and restrictions decrease in fluid retention
Observe skin for color, temp- Peripheral vasoconstriction of sodium. and hypertension, thereby im-
erature, capillary refill time, may result in pale, cool, proving cardiac output.
and diaphoresis. clammy skin, with prolonged
capillary refill time due to Instruct on medications, ef- Promotes knowledge and com-
cardiac dysfunction and de- feas, side effects, contra- pliance with drug regimen.
creased cardiac output. indications, signs to report.
Auscultate lungs for adventi- Crackles (rales) or wheezing

tious breath sounds. may indicate pulmonary con- Prepare patient for surgery if Pheochromocytoma may require
gestion due to cardiac warranted. surgical intervention for re-
failure as a result of in- moval of the tumor in order
creased blood pressure. to correct hypertension.
Ausculate heart tones. Hypertensive patients often

have S4 gallops due to atrial Discharge or Maintenance Evaluation
hypertrophy. Ventricular
hypertrophy may result in
s3 gallops.
Patient will be normotensive, with adequate car-
diac output and index.
Administer thiazide, loop, or Thiazides are used to reduce
potassium-sparing diuretics as blood pressure in patients with Medications will be taken as ordered with no
ordered. normal renal function and these side effects.
limit fluid retention. Loop
diuretics inhibits reabsorption of Patient will have stable heart rate, rhythm, and
sodium and chloride and are used heart tones, with no adventitious breath sounds.
in patients who have renal dys-
function. Potassium-sparing di- Patient will be able to verbalize instructions
uretics are used in conjunction
accurately.
with thiazides to decrease the
amount of potassium lost. Risk for altered tissue perjkion: cardiopul-
Administer sympathetic inhibi- These drugs reduce blood pres- monary, cerebral, renal, gastrointestinal,
tors as ordered. sure by decreasing peripheral and perapherul
resistance, reducing cardiac
output, inhibiting sympathetic Related to: increased catecholamine stimulation,
activity, and suppressing the increased blood pressure, decreased cardiac output,
release of renin which is a decreased baroreceptor sensitivity, changes in cere-
potent vasoconstrictor.
brospinal fluid pressure, angiotensin and
Administer vasodilators as May be used in severe hyper- aldosterone stimulation, sodium intake, environ-
ordered. tension to increase coronary mental factors, genetic factors, strain on arterial
blood flow and decrease after-
load to improve cardiac output.
wall, atherosclerosis
Administer antiadrenergic drugs Prevents blood vessels from

as ordered. constricting and increasing
blood pressure.
Defining characteristics: increased blood pressure, Instruction, Information,

retinopathy, retina1 hemorrhage, headache, Demonstration
epistaxis, tachycardia, rales, S3 or S4 gallops, rest-
lessness, bruits to femoral, carotids, abdominal INTERVENTIONS RATIONALES
aorta, blurred vision, chest pain, shortness of Instruct patient in signs/ Promotes knowledge and compli-
breath, optic disc papilledema, seizures, coma, nys- symptoms to report to M D , such ance with treatment. Promotes
tagmus, mental changes as headache upon rising, in- prompt detection and facilitates
creased blood pressure, chest prompt intervention.
pain, shortness of breath, in-
Outcome Criteria creased heart rate, weight gain
of > 2 lblday or 5 Ib/wk, edema,
Patient will achieve and maintain adequate tissue visual changes, nosebleeds, diz-
ziness, syncope, muscle cramps,
perfusion to all body systems. nausedvomiting, impotence or
decreased libido.
Monitor for sudden onset of May indicate dissecting aortic
chest pain. aneurysm. Discharge or Maintenance Evaluation
Monitor EKG for changes in rate, Decreased perfusion may result
rhythm, dysrhythmias, and con- in dysrhythmias due to decrease
duction defects. Treat as in- in oxygen. body systems.
dicated.
Patient will be mentally lucid, with no confu-
Monitor hemodynamic parameters Provides immediate information sion or neurological deficits.
closely and titrate vasoactive regarding efficacy of medication
drugs as warranted. and status of hypertension. Patient will have adequate urinary output with
no hematuria, and renal function studies will be
Observe for shift of point of Shift occurs in cardiac enlarge-
maximal impulse (PMI) to left ment.
within normal limits.
0 Patient will be able to recall accurately the infor-
Auscultate over peripheral ar- Atherosclerosis may cause bruits
teries for bruits. by obstructing blood flow. mation instructed.
Observe extremities for swelling, Bedrest promotes venous stasis Anxiety

erythema, tenderness, pain, pos- which can increase the risk of [See MI]
itive Homans’ sign, positive thromboembolus formation, Ac-
Pratt’s sign. Observe for de- tual vegetation emboli can mi- Related to: change in health status, fear of death,
creased peripheral pulses, pal- grate and occlude peripheral threat to body image, threat to role functioning,
lor, coldness, cyanosis. arteries, leading to tissue
pain
ischemia and necrosis.
Knowledge Aficz't INTERVENTIONS RATIONALES

Related to: lack of understanding, lack of under- Instruct patient in medications, Promotes understanding chat
standing of medical condition, lack of recall dose, effects, side effects, con- side effects are common and may
traindications, and signs/ subside over time, and facili-
Defining characteristics: questions regarding symptoms to report to MD. tates compliance.
problems, inadequate follow-up on instructions Instruct in dietary needs and Patient may need to increase
given, misconceptions, lack of improvement of restrictions, such as limiting dietary potassium if placed on
previous regimen, development of preventable caffeine and sodium, or increas- diuretics; caffeine should be
ing potassium and calcium. limited due to the direct srimu-
complications
lant effect on the heart; so-
dium should be limited due to
Outcome Criteria the potential for fluid reten-
tion. Additional calcium has
been shown to lower blood pres-
Patient will be able to verbalize and demonstrate sure. Excessive intake of fat
understanding of information given regarding and cholesterol are additional
condition, medications, and treatment regimen. risk factors in hypertension.
Low fat diets can decrease BP
through prostaglandin balance.
Demonstration Instruct on hypertension, ef- Promotes understanding of the
fects on the blood vessels, disease process and enhances
heart, brain, and kidneys. In- compliance with treatment.
struct on normal values for BI?
Determine patient's baseline of Provides information regarding
knowledge regarding disease pro- patient's understanding of
cess, normal physiology, and condition as well as a baseline Instruct on maintaining medica- Assist patient to understand
function of the heart. from which to base teaching. tion regimen to keep blood pres- need for life-long compliance
sure well controlled, and in to reduce incidence of CVA, MI,
Monitor patient's readiness to Promotes optimal learning en- keeping medical appointments. cardiac and renal dysfunction.
learn and determine best methods vironment when patient shows Lack of compliance is the major
to use for learning. Attempt willingness to learn. Family reason for failure of anti-
to incorporate family/significant members may assist with help- hypertensive therapy.
other in learning process. Rein- ing the patient to make in-
strucdreinforce information as formed choices regarding his Instruct on ways to modify risk Risk factors contribute to dis-
needed. treatment. Anxiety o t large factors, such as smoking, obe- ease and complications associ-
volumes of instruction may sity, high Fat diets, stressful ated with hypertension, as well
impede comprehension and lifestyle, etc. as exacerbate symptoms. Nico-
limit learning. tine increases catecholamine
release and increases heart
Provide time for individual in. Promotes relationship between rate, blood pressure, and myo-
teraction with patient. patient and nurse, and estab- cardial oxygen demand.
blishes trust.
Instruct in self-monitoring for Provides reinforcement and the
Instruct patient on procedures Provides knowledge and pro- blood pressure; technique to be ability to monitor response to
that may be performed. motes rhe ability to make used post discharge. medical regimen.
informed choices.
Instruct to take diuretics in Decreases incidence of nocturia.
am.
INTERVENTIONS RA'TIBNALES Discharge or Maintenance Evaluation

Instruct to weigh daily at Monitors effectiveness of diure-
same time on same scale. tics and for fluid retention.
Patient will be able to verbalize understanding of
condition, treatment regimen, and signs/symp-
toms to report.
Instruct on leg exercises and Decreases venous pooling that
position changes. can be potentiated by vasodila- Patient will be able to correctly perform all tasks
tors and prolonged time in one prior to discharge.
position.
Instruct to avoid hot baths, These promote vasodilation and
cardiac disease, risk factors, dietary restrictions,
saunas, hot tubs, and alcohol when combined with diuretics,
intake. may increase chance of orthosta- and lifestyle adaptations.
tic hypotension and syncope.
Instruct to avoid over-the- Some drugs contain sympathetic

counter medications unless pre- stimulants that can increase
scribed by MD. blood pressure or may cause
drug interactions.
Instruct to rise slowly, allow- Assist body to equilobrate and

ing time between position adjust in order to decrease the
changes. risk of syncope.
Provide printed materials when Provides references for patient

possible for patiendfamily to and family to refer to once dis-
understanding of verbally-
given instructions.
Demonstrate and instruct on Self-monitoring promotes self-

technique for checking pulse independence and can provide
rate and regularity. Instruct timely intervention for abnor-
in situations where immediate malities or complications.
action must be taken. Heart rates that exceed set
parameters may require further
medical alteration in medica-
tions or regimen.
Have patient demonstrate all Provides information that

skills that will be necessary patient has gained a full
for post-discharge. understanding of instruction
and is able to demonstrate
HYPERTENSION
Increased TPR, PVR, CO Decreased baroreceptor sensitivity Sympathetic stimulation

c
Impaired myocardial oxygen c c
Increased workload on heart Chronic hypertension Angiotension/aldosterone release
Increased myocardial oxygen consumption c Decreased renal blood flow
Changes in CSF pressures Decreased renal oxygenation
c Decrease in cerebral perfusion c
Dyspnea on exertion Decrease in cerebral oxygen supply Ischemia of renal tissues
Ventricular hypertrophy c Renidaldosterone secretion
Chest pain Memory impairment Increased blood pressure
c Dull headache in a.m. c
Cardiac decompensation Vertigo, tremors Nocturia
Coronary artery disease c Sodium/water retention
Myocardial infarction Cerebral edema Increased blood volume
Cardiac failure c Decreased GFR
Retina1 hemorrhage, blurred vision c
TIAs, epistaxis Azotemia
Cerebral hemorrhage Renal failure
Cerebral aneurysm
Cerebral thrombosis, CVA
Thrombophlebitis 1251 Fibrinogen uptake test: a radioactive scan

performed after radioactive fibrinogen is injected,
Thrombophlebitis occurs when a clot forms in a which concentrates in the area of clot formation;
vein secondary to inflammation or when the vein not sensitive to thrombi high on the iliofemoral
is partially occluded from some disease process. As region or with inactive thrombi
a general rule, two out of the following three fac-
Anticoagulants: heparin, coumadin, warfarin to
tors occur prior to the formation of a
prolong clotting time to prevent further clot for-
thrombus-blood stasis, injury to the vessel, and
mation
altered blood coagulation.
Deep vein thrombosis, or DVT, pertains to clots NURSING CARE PLANS
that are formed in the deep veins and may result
in complications such as pulmonary embolus and Alteration in tissue pe+ion: peripheral
postphlebotic syndrome, or chronic venous insuf- Related to: impaired blood flow, venous stasis,
ficiency. This can be a residual effect of venous obstruction
thrombophlebitis in which the veins are partially
occluded or valves in the vessels have been dam- Defining characteristics: pain, tissue edema,
aged. This chronic insufficiency may cause decreased peripheral pulses, prolonged capillary
increased venous pressure and fluid accumulation refill time, pallor, cyanosis, erythema, paresthesia
in the interstitial tissues, which results in chronic
edema, tissue fibrosis, and induration. Outcome Criteria
DVT may be asymptomatic, but usually produces Patient will have improved peripheral perfusion,
side effects such as fever, pain, edema, cyanosis or with palpable and equal pulses, normal skin color,
pallor to the involved extremity, and malaise. temperature, and sensation, and have no evidence
of edema.
Superficial vein thrombophlebitis causes may -
include trauma, infection, chemical irritations, fre- INTERVENTIONS RATIONALES
quent IVs, and recreational drug abuse. Observe lower extremities for Findings may help to differen-
edema, color, and temperature. tiate between superficial
The goals in treatment of thrombophlebitis are to Measure calf circumference every thrombophlebitis and deep vein
control thrombotic development, relieve pain, shift. Monitor for capillary thrombosis. Measurements can
improve blood flow, and prevent complications. refill time. facilitate early recognition
of edema and changes. Ederna,
redness, and warmth are indi-
MEDICAL CARE cative of superficial phlebi-
tis whereas DVT usually is
Venography: used to visualize the vascular system exhibited by cool pale skin.
and locate any impairment in blood flow DVT may prolong capillary
refill time.
Plethysmography: a non-invasive measurement of
Observe extremity for prominence Superficial veins may become
changes in calf volume that corresponds to chang-
of veins, knots, bumps, or distended because of backflow
ing blood volume as a result of impairment in stretched skin. through veins. Evidence of
blood flow thrombophlebitis to super-
ficial veins may be visible
or easily palpable.

Maintain bedrest. Activity limitation may mini- Demonstration
mize the potential for dis-
lodgment of the dot. INTERVENTIONS RATIONALES
Instruct on avoidance of rubbing May promote risk of dislodging
Elevate legs while in bed or Reduces swelling and increases or massaging extremity involved. clot and causing embolization.
sitting in chair. venous return. Some experts
believe that elevation may Avoid crossing legs, prolonged Positions tend to restrict cir-
actually enhance the release positions with legs dangling, culation and increases venous
of thrombi. or knees bent. stasis, and increases edema.
Observe for positive Homanb Homan’s sign may or may not Instruct in deep breathing Promotes emptying of large
sign (pain in calf upon dorsi- be present consistently and exercises. veins by increasing negative
flexion of foot). should not be used as a sole pressure in the thorax.
indicator of thrombophlebitis.
Instruct on maintaining fluid Dehydration promotes increased
Perform active or passive ROM Promote increased venous blood intake of at least 2 Llday. viscosity of blood, and in-
exercises while at bedrest. return and decrease venous
creases venous stasis.
stasis.
Prepare patient for surgery if Surgical intervention may be
Apply TED hose after acute phase Assists to minimize postphle- warranted. required if circulation is se-
is over. Remove for at least 1 botic syndrome and increases verely compromised. Recurrent
hour every shift. blood flow to deep veins. Re-
episodes of thrombi may require
moval allows time for compres-
a vena caval umbrella to filter
sion of veins to be relaxed.
out thrombi going to l u n g .
Apply warm moist soaks as or- Promotes vasodilation and may

Instruct on lying in a slightly Promotes blood flow to depend-
dered. improve venous return and de- reversed trendelenburg position. ent extremities; preferable to
crease in edema.
have extremities full of blood
as opposed to empty.
Administer anticoagulants as Heparin is used initially be-
ordered. cause of its action on thrombin
formation and the removal of
the intrinsic pathway to pre- Discharge or Maintenance Evaluation
vent hrther clot formation.
Coumadin is usually used for Patient will have palpable pulses of equal
long-term therapy. strength to all extremities.
Monitor laboratory studies for Monitors efficacy of anticoagu- Skin will be within normal limits of coloration,
PT, PTT,A M T , and CBC. lant therapy and potential for temperature, and sensation.
d o t formation due to hemocon-
centration/dehydration. Patient will be able to recall all instructions
accurately.
Patient will have no complications from antico-
agulation therapy.
Risk for impaired skin integrity INTERVENTIONS RATIONALES

Related to: edema, venous stasis, bedrest, surgery, Monitor any drainage tubes for Provides indication of decreas-
amounts and character of draining or increasing wound drain-
pressure, altered circulation and blood flow, altered age. Use ostomy bags over tubes age and assessment of healing
metabolic states when drainage is massive. process. Collection of drain-
age in bags facilitates more
Defining characteristics: skin surface disruptions, accurate measurement of fluid
incisions, ulcerations, wounds that do not heal loss and prevents excoriation
of skin from copious drainage.
Outcome Criteria Use skin prep, moisture barrier, Provides protection to skin
or benzoin to skin prior to tape and reduces potential for skin
Patient will have no evidence of impairment to application. Use hypoallergenic trauma. Reduces potential for
tape or Montgomery straps to se- skinlwound disruption when
skin tissues.
cure dressings. frequent dressing changes are
required.
Patient will have surgical wound approximated and
well-healed with no evidence of infection.
Monitor extremities for presence Provides prompt assessment and
Demonstration
-
of ulcers, wounds, symptoms of treatment for impaired tissues.
decreased circulation. INTERWNTIONS RATIONALES
Instruct to avoid scratching, Injuries may damage tissues
If surgery is required, change Prevents drainage accumulations hitting or bumping legs, or that may deteriorate into ulcer
dressing using aseptic or ster- from excoriating skin, provides other injurious activities. formation.
ile technique as warranted. assessment to monitor for chan-
Leave wound open to air as soon ges in wound appearance and de- Instruct on signslsymptoms of Provides prompt notification
as is feasible, or apply light teriorationlimprovement, and infection to woundlskin and to to enhance prompt treatment.
dressing. prevents wound from contamina- report to nurselMD.
tion. Allowing air to reach
wound facilitates drying and Instruct on cleansing incision Reduces skin surface contami-
promotes the healing process. area post discharge. nants and prevents infection.
Sutures may be abrasive to
skin or get caught on garments
and irritation may be reduced Discharge or Maintenance Evaluation
with a light gauze dressing.
Cleanse wound as ordered with Various agents can be used to Patient will have approximated, healed surgical
each dressing change. remove exudate or necrotic ma- wound with no drainage, erythema, or ederna to
terial from wound to promote site.
healing. Any packing of the
wound should be done using Patient will be able to recall instructions
sterile technique to reduce accurately.
the risk of contamination.
Patient will be compliant with avoiding injurious
Monitor wound for skin integ- Prompt recognition of problems
rity to incision and surround- with healing may prevent exa-
activities, and will seek medical help when injury
ing tissues, noting increases cerbation of wound. Increased occurs.
and changes in characteristics drainage or malodorous drainage
of drainage. may indicate infection and de-
layed wound healing.
Alteration in comfort INTERVENTIONS RATIONALES

[See MI] Provide time for individual in- Promotes relationship between
teraction with patient. patient and nurse, and estab-
Related to: inflammation, impaired blood flow, blishes trust.
intermittent claudication, venous stasis, lactic acid
in tissues, surgical procedures, fever Instruct patient on procedures Provides knowledge and
that may be performed. promotes the ability to make
Defining characteristics: complaints of pain, ten- informed choices.
derness to touch, aching, burning, restlessness,
Instruct on signslsymptoms of Provides knowledge and assists
facial grimacing, guarding of extremity possible complications, such as patient to understand health
pulmonary emboli, venous insuf- care needs.
Knowledge deficit ficiency, and venous stasis ul-
cers.
standing of medical condition, lack of recall Instruct on care to lower ex- Chronic venous stasis may occur
tremities and to n o t i b MD for and promotes risk of infection
Defining characteristics: questions regarding prob- development of any lesion. and/or ulcer formation.
lems, inadequate follow-up on instructions given,
misconceptions, lack of improvement of previous Instruct patient in medications, Promotes understanding that
dose, effects, side effects, con- side effects are common and may
regimen, development of preventable compli-
traindications, and signs/ subside over time, and facili-
cations symptoms to report to MD. tates compliance.
Instruct on leg exercises and Decreases venous pooling that

Outcome Criteria position changes. Assist with can be potentiated by vasodila-
setting up activity program tors and prolonged time in one
Patient will be able to verbalize and demonstrate post-discharge. position. Exercise may assist
understanding of information given regarding con- in developing collateral circu-
lation and enhances venous re-
dition, medications, and treatment regimen.
turn.
Information, Instruction, Instruct to rise slowly, allow- Assist body to equilobrate and
ing time between position adjust in order to decrease the
Demonstration changes. risk of syncope.
INTERVENTIONS RATIONALES Instruct to balance rest with Rest decreases oxygen demands
Determine patient’s baseline of Provides information regarding activity. of compromised tissue and
knowledge regarding disease pro- patient‘s understanding of decreases potential for emboliza-
cess, normal physiology, and condition as well as a baseline tion of thrombus. Balancing rest
function. from which to base teaching. with graduated activity prevents
exhaustion and impairment of
Monitor patient’s readiness to Promotes optimal learning en- tissue perfusion.
learn and determine best methods vironment when patient shows
to use for learning. Attempt willingness to learn. Family Instruct on proper application Improper application may cause
to incorporate family/significant members may assist with help- of TED stockings. a tourniquet-like effect and
other in learning process. Rein- ing the patient to make in- impede circulation.
struct/reinforce information as formed choices regarding his
needed. treatment. Anxiety or large Avoid valsalva-type maneuvers. Increases venous pressure in the
volumes of instruction may Provide increased fiber to diet leg which increases potential
impede comprehension and and administer stool softeners for thrombophlebitis.
limit learning. as warranted.
Instruct on anticoagulation Promotes compliance with medi-
therapy-dosage, effects, side cal regimen and decreases poten-
effects, when to administer, tial for improper dosage and
other medications to avoid. adverse drug interactions.
Aspirin and salicylatesdecrease
prothrombin activity, vitamin K
increases prothrombin activity,
antibiotics may interfere with
vitamin K synthesis, and barbi-
turates can potentiate anticoagu-
lant effect.
Instruct on importance of keep- Promotes compliance with treat-

ing MD appointments for follow- ment and decreases potential for
up laboratory studies. non-therapeutic levels of anti-
coagulation therapy.
Provide printed materials when Provides references for patient

possible for patientlfamily to and family to refer to once dis-
understanding of verbdly-
given instructions.
Have patient demonstrate all Provides information that

skills that will be necessary patient has gained a full
for post-discharge. understanding of instruction
and is able to demonstrate

of condition, treatment regimen, and
signs/symptoms to report.
Patient will be able to correctly perform all tasks
prior to discharge.
of safety precautions, correct dosage and admin-
istration of all medications, and activity
limitations.
THROMBOPHLEBITIS
Narrowing of vein
s
Platelet aggregation
s
Venous obstruction
s
Decrease in blood flow
s
I I I
Venous stasis Vein wall abnormality Abnormal clotting
s
Inflammation
JI
Edema
3.
Movement of the thrombus within circulation
s
Migration and lodging in pulmonary vasculature
Pulmonary embolism
J
Respiratory insufficiency
Ventilation/perfusion mismatching
s
Cardiovascular collapse
4
Death
~
Intra-Aortic Balloon Pump brain syndrome, irreversible brain damage, absent

femoral pulses, trauma that has resulted in internal
bleeding, active bleeding ulcers, blood dyscrasias,
or previous aortofemoral or aortoiliac bypass
The intra-aortic balloon pump (IABP) is an grafts.
advanced procedure that is used in the manage- Because the potential for complications is high,
ment of cardiovascular problems that are this procedure should be utilized only by person-
refractory to routine medical therapeutics. An nel well-versed and competent in all aspects of the
intra-aortic balloon catheter (IAB) is inserted into IABP function and troubleshooting complications.
the descending aorta, most commonly by way of
the femoral artery. The IAB is then attached to Two of the major complications associated with
the IABP which inflates and deflates the balloon the use of the IABP are compromise of the left cir-
in synchronization with the cardiac cycle. The bal- culation and difficulty with weaning the patient
loon inflates during diastole when the aortic valve from the IABP.
closes and increases the aortic pressure when the
blood distally to the balloon is forced back
towards the aortic valve. The coronary arteries are Oxygen: to increase available oxygen supply
supplied with additional blood to improve coro-
nary blood flow and perfusion and to decrease Nitrates: (nitroglycerin, isosorbide dinitrate,
preload. Deflation occurs prior to the onset of sys- Nitro-bid, Nitrostat) used to relax vascular smooth
tole and decreases the aortic pressure and muscle to produce vasodilation, decrease preload,
ventricular resistance and makes it easier for the decrease afterload, decrease venous return, decrease
ventricle to contract and expel its normal volume peripheral vascular resistance, decrease oxygen
of blood, thus decreasing afterload. This counter- demand
pulsation and displacement of blood decreases Beta-blockers: (propranolol, metoprolol, nadolol,
myocardial oxygen demand by decreasing myocar- atenolol, timolol, pindolol) used to reduce
dial workload and increases coronary perfusion myoca.rdia1 oxygen demand by blocking
and cardiac output. catecholamine and sympathetic induced increases
Indications for use of IAB counterpulsation in heart rate, contractility and blood pressure;
include cardiogenic shock, valvular disease, slows AV node conduction; decreases sodium and
intractable chest pain resistant to medical water retention by reduction of renin secretion;
treatment, prophylactic support during coronary decreases platelet aggregation and may reduce
angiography or anesthesia induction, papillary vasospasm
muscle rupture, ventricular septal defects, compli- Calcium-channel blockers: (verapamil, nifedipine,
cations of acute myocardial infarctions, weaning diltiazem) used for decreasing myocardial oxygen
from the cardiopulmonary bypass, septic shock, demand and to enhance relaxation in hypertrophic
and as a bridge to cardiac transplantation. ardiomyopathies, reduces blood pressure and
Counterpulsation is contraindicated in patients afterload, and help prevent coronary spasm from
with severe aortic insufficiency, dissecting decreased oxygen supply
aneurysms, peripheral vascular disease, organic
Sympathomimetic drugs: (doparnine, Intropin)

used for treatment of hypotension in
NURSING CARE PLANS
normovolemic states and in the treatment of Altered tissue perfusion: cardiopulmonary,
severe heart failure and cardiogenic shock cerebral, gastrointestinal, renal, peripheraL
Placement of LAB: necessary for counterpulsation Related to: cardiac failure, tissue ischemia,
to begin vasoconstriction, hypovolemia, shunting, depressed
ventricular function, dysrhythmias, conduction
Cardiac catheterization: used to define lesions and
defects, hypoxia, reduction or interruption of
evaluate their severity, to provide information on
blood flow
ventricular function, and to allow for
measurement of heart pressures and cardiac output Defining characteristics: visual disturbances,
paresthesias, mental changes, change in level of
Labwork: PT, PTT, and platelets are obtained to consciousness, confusion, restlessness, pulse and
monitor anticoagulation status; general chemistry
blood pressure changes, changes in cardiac output,
profiles and renal profiles are monitored every day
changes in peripheral resistance, impaired oxygena-
for chemical imbalances and impending hepatic or
tion of myocardium, chest pain, cardiac
renal problems; cardiac isoenzymes are used to
dysrhythmias, changes in EKG (S-T segment, T
monitor for heart damage; CBC and differentials
wave, U wave), LV enlargement, dyspnea, short-
are done every day to monitor for infection and
ness of breath, tachypnea, palpitations, nausea,
changes in hematologic status; cultures of blood,
vomiting, slow digestion, oliguria, anuria,
urine and sputum are done for temperature eleva-
electrolyte imbalance, cold, clammy skin,
tions greater than 102 degrees to assess for
decreased peripheral pulses, mottling, cyanosis,
infection/suspected organisms
diaphoresis
Arterial blood gases: used to assess oxygenation
status Outcome Criteria
Chest x-ray: used daily to monitor placement of
Blood flow and perfusion to vital organs will be
IAB and watch for migration, to assess
preserved and circulatory function will be
enlargement of the heart and/or pulmonary ves-
maximized.
sels, and to assess pulmonary fluid status and
atelectasis Patient will be free of dysrhythmias and hemody-
namic parameters will be within normal limits.
Electrocardiography: reveals changes with atrial
and ventricular enlargement, rhythm and conduc- INTERVENTIONS RATIONALES
tion abnormalities, ischemia, electrolyte Monitor vital signs every 15 to IABP timing is based on heart
abnormalities, drug toxicity, and presence of dys- 30 minutes until stable, then rate, and when rate changes >
every hour. Notify MD of devi- 10 beatslminute, adjustments
rhythmias
ations from parameters. in timing are necessary to
Pacemakers: either temporary or permanent, used ensure optimal counterpulsation.
Dysrhythmias hamper optimal
in anticipation of lethal dysrhythmias and/or con- oxygenation and function of
duction problems the IABP.

Monitor mean arterial blood Assesses volume status to help terload. Late deflation en-
pressure every hour. monitor for efficacy of counter- croaches on the next systole
pulsation. MABP can be calcula- and increases afterload.
ted by adding 113 (systolic BP- IAB cannot be left in patient
diastolic BP) + diastolic Bl? longer than 30 minutes without
MABP is a function of cardiac movement of balloon due to
output and systemic vascular thrombus formation on the IAB.
resistance. Levels < 60 have
little, if any, perfusion to
brain. Provide adequate amounts of Underinflation of IAB can re-
gas (CO2 or helium) in IAB; sult in subtherapeutic effects
Obtain pulmonary artery pres- Provides information as to refill IAB every 2 hours or from minimizing blood displace-
sures every hour. fluid status and heart pres- more often if fever present. ment. Increased body tempera-
sures. PA systolic pres- ture increases the normal loss
sures represent RV pressures of gas from the balloon.
with normals ranging from 20-
30 mmHg. PA diastolic pres- Notify M D if augmentation can- Signals problems with catheter
sures reflects the LVEDP and not be maintained, afterload is pump, or patient requiring imme-
is an indirect measurement not reduced, or if reddish- diate attention. Discoloration
of LV function with normals brown fluid noted in tubing of in IAB tubing signifies that a
ranging 10-20 mmHg. PCWP IAB. fracture in the catheter has oc-
reflects the LA pressure and curred and the fluid is actually
is used to assess LV filling blood. At this point, prepare
pressures with normals rang- for removal of the catheter.
ing from 4- 12 mmHg.
Determine level of conscious- Mental changes will result as
Measure cardiac outputlcardiac Directly measures the volume ness, mental changes, neurolo- tissue perfusion to brain de-
index and perform hemodynamic of cardiac output in Llmin, gical deficits. creases.
measurements every 1-4 hours. and gives calculated informa-
tion regarding preload and Monitor urine output every hour. Low cardiac output will cause
afterload. Normal CO should Notify M D if < 30 cclhr, or decreased tissue perfusion to
range from 4-8 Llmin and > 200 cclhr in the absence of kidneys and oliguria. Migration
CI from 2.5-4 L/min/m2. SVR diuretics or fluid challenge. of the IAB can partially or to-
which represents afterload tally occlude the renal arteries
should range between 900- leading to oliguria or anuria.
1400 dyneslseclcm5. Increased urine may indicate
problems with other body systems,
Monitor for malfunction of Improper timing of balloon can such as SIADH.
IAB and IABP and correct prob- promote complications and wor-
blems rapidly. Manually flut- sen condition. Early inflation Monitor presence and equality Decreased or absent pulses may
ter IAB prn pump failure. leads to regurgitation into of peripheral pulses, extremi- indicate migration of IAB and
the left ventricle or premature ty color, temperature, and sen- possible occlusion of arteries.
closing of the valve, and in- sations. Notify M D of problems.
creases afterload. Late infla-
tion decreases augmentation and Elevate head of bed no more than Flexion greater than this may
reduces coronary perfusion. 30 degrees. D o not flex invol- cause catheter to kink and
Early deflation allows the pres- ved leg. fracture.
sure to rise to normal end-
Assist with ROM to uninvolved Reduces complicarions from im-
diastolic levels preceding sys-
leg as needed, and with flexionl mobility.
tole which does not reduce af-
extension of involved foot.
INTERVENTIONS RATIONALES Urinary output will be within normal limits.

Monitor generd chemistry, Provides information about Minimal activity will be tolerated without
renal profile, and CBC. potential blood loss and infec- shortness of breath or extreme fatigue.
tion; chemistry profiles provide
information about impending
hepatic or renal insufficiency.
. Medications will be administered with no unde-
sirable effects.
Risk for injktion
Demonstration Related to: invasive lines, catheters, puncture
wounds, invasive procedures, environmental expo-
INTERVENTIONS RATIONALES sure from devices left in place for extended
Instruct patiendfarnily on pro- Provides knowledge and allows periods of time
cedure, benefits, risks, post- patient to make an informed
procedure care. choice. Defining characteristics: disruption of skin sur-
faces, redness, drainage, elevated temperature
Instructldemonstrate R O M to Provides activity as tolerated
uninvolved leg, and flexionl while on IABP
extension to foot of involved Outcome Criteria
leg.
Patient will be free of infection with no fever or
Prepare patiendfamily for IABP may be necessary to in-
placement on IABP, post- crease cardiac output, and chills.
procedure care. decrease afterload and preload
in order to decrease the work- All invasive lines will be free of erythema, edema,
load on the damaged heart. and drainage.
Discharge
- or Maintenance Evaluation Inspect all invasive lines for Invasive lines provide entry
signs of infection andlor bleed- route for pathogens.
Patiendfamily will be able to verbalize correct ing.
information regarding care, risks, and benefits. Change site dressing using Insertion site provides a
sterile technique every day. direct route for infection,
Patient will have optimum perhsion to all body
Notify M D for signs of infec- and must be monitored to pre-
systems. tion. vent complications.
Cardiac output will be within normal limits. Monitor temperature every 2-4 Sudden temperature increases
hours. Obtain cultures of urine, may indicate infective pro-
Patient will be able to accurately demonstrate sputum, and blood for evaluation cess. Cultures can isolate
exercises. as warranted. the specific pathogen so as
to enable specific antibiotic
Patient will report no episodes of chest pain or therapy to be ordered.
shortness of breath.
Change IV tubinglarterial line Decreases the incidence of In-
Hemodynamic parameters and vital signs will be tubing per protocol, using a- fection. Bacteria begins to
within normal limits. septic technique. Change peri- grow within 24 hours in IV so-
pheral lines every 3 days and lution. Replacement of IV lines
Lung sounds will be clear and free of pm. prevents phlebiris and risks of
infective complications.
adventitious breath sounds with optimal
oxygenation.
Instruction, Information, INTERVENTIONS RATIONALES

Demonstration Test all body fluids for pre- Anticoagulation may place
sence of occult blood. patient at risk for bleeding.
Inform patient of need for Facilitates knowledge and pa- Monitor insertion site for Bleeding tendencies are in-
changing peripheral lines, so- tient comprehension and com- bleeding, hemorrhage, or hema- creased due to concomitent use
lutions, and care to sites. pliance with treatment. toma. Apply pressure dressing of systemic anticoagulants and
if warranted, and notify M D patient is at risk for bleed-
for sustained bleeding from ing.
Instruct patient to notify May indicate infection. site.
nurse for pain to invasive sites,
or other symptoms of infection. Monitor PT, PTT, platelets, PT, PTT, and platelets provide
and CBC. information about coagulation;
C B C provides information about
potential blood loss.
Administer IV solutions and IV solutions and volume expan-
Patient will have no signs of infection to invasive volume expanders as indicated. ders may be required to treat
line sites. rapidly decreasing circulating
volume due to exsanguination.
Peripheral lines will be changed within 3 days to
avoid risk of infection. Administer packed RBG, blood, Hemorrhagic volume losses may
or platelets as warranted. be life-threatening. Replace-
Patient will have no signs of systemic infection. ment of platelets may be neces-
sary to provide normal coagu-
Riskfirflz4id volume &@it lation.
Related to: potential blood loss from Administer vitamin K or prota- May be required to return coag-
mine sulfate if warranted. ulation times to normal or re-
oozing/draining sites of invasive lines
verse effects of heparin.
Defining characteristics: bleeding from puncture
sites and wounds, actual blood loss as measured by
hemoglobin/hematocrit, hypotension, tachycardia
Demonstration
Outcome Criteria INTERVENTIONS RATIONALES

Instruct patient to report any Prompt observation of complica-
Patient will have no significant blood loss from noted bleeding or oozing on body. tions can result in prompt
invasive lines. treatment.
INTERVENTIONS RATIONALES Instruct patient to avoid any Prevents accidental injury and
activity that may promote bleed- decreases chance of hemorrhage.
Measure all sources of intake Provides information to evalu-
ing.
and output. ate fluid status.
Weigh daily. Weight gain over 24 hours usu-

ally indicates fluid gain.
Fluid imbalance can be approxi-
mated as 1 Ib = 500 cc fluid.
Monitor vital signs and hemo- Tachycardia, hypotension, and

dynamic pressures. changes in hernodynamics may
indicate volume depletion.

Patient will be able to verbalize signs/symptoms
of bleeding to report.
Patient will be compliant in avoidance of safety
concerns.
Patient will have stable hemodynamic status with
no over hemorrhage from any site.
Pacemakers by the pacemaker and is measured in millivolts

(mV), with the smaller number relating to the
Artificial cardiac pacemakers are used to provide most s'ensitivity. Pacemakers are used for varying
an electrical stimulus to depolarize the heart and degrees of heart block, sick sinus syndrome, sinus
cause a contraction to occur at a controlled rate. node dysfunction, overriding of some cardiac dys-
The function of the pacemaker, or pacer, is to rhythniias, prophylactically during diagnostic
maintain the heart rate when the patient's own testing, myocardial infarctions, congestive heart
intrinsic system is unable to do so. The stimulus is failure due to rhythm disturbances, after open
produced by a pulse generator and delivered via heart surgery or in congenital anomalies of the
electrodes/leads that are implanted in the heart.
epicardium or endocardium. The electrodes may Temporary pacers are used when the duration of
be unipolar or bipolar and the proximal end need is short and permanent pacers are placed for
attaches to the pulse generator. In the unipolar life-long use. Temporary pacemakers can be placed
electrode, one wire, positioned in the heart, senses via a transthoracic approach during open heart
and stimulates the electrical heart activity and is surgery, transvenous approach into the right
connected with the negative terminal on the pulse atrium or right ventricle, or transcutaneously
generator. The other electrode, or ground, is (exteraal pacer) with skin electrodes while await-
attached to the positive terminal on the pulse gen- ing placement of an internal pacemaker.
erator. This type of lead usually requires a lower
threshold of stimulation. The bipolar electrode Placement of the temporary pacemaker can be
has both the sensing and ground electrode in the performed at the bedside in cases of emergency,
catheter, and provides better contact with the but use of fluoroscopy is recommended when fea-
heart muscle. In the event that one of the bipolar sible to ensure proper placement. External
wires malfunctions, it can still be used as a unipo- pacemaker electrodes can either be placed on the
lar lead. The pacemaker will produce a pacer chest, or one to the anterior and one posterior to
spike on the EKG prior to the depolarized wave- the chest.
form and this indicates pacemaker capture. Synchronous pacing, known as demand pacing, is
Continuous observation for problems with the commonly used because the pacer is able to sense
pacemaker should be performed to ensure that the patient's heart impulse. If the patient's rate
failure to pace, failure to capture, and failure to falls below the rate set on the pacer, the pacer is
sense are treated promptly. able to sense this and send an impulse to the
The pacemaker rate is set depending on the desired chamber of the heart and cause the rate to
patient's requirements. The optimal setting is one remain at the preset level. Dual chamber synchro-
in which the lowest rate that controls the particu- nous pacing, or AV sequential, is the closest to
lar dysrhythmia and provides for adequate cardiac normal physiologic function and facilitates the
output. The stimulation threshold is the minimal atrial kick.
amount of electrical energy required to stimulate Asynchronous, or fEed-rate, pacing provides
the heart to produce a 1:1 capture, and is impulses to the atrium, ventricle, or both regard-
measured in milliamperes (mA). The sensitivity less of the patient's intrinsic rate. This should be
control reflects the size of the wave that is sensed used solely for those occasions when no electrical
activity is present to avoid potential lethal compet-
itive dysrhythmias.
Pacemakers are classified by a 5-letter code devel- Outcome Criteria

oped by the Inter-Society Commission for Heart
Disease in which letters are used to denote the Patient will be free of dysrhythmias with adequate
chamber paced, the chamber sensed, response to cardiac output to perfuse all body organs.
sensing, programmable functions and antitachy- INTERVENTIONS RATIONALE
dysrhythmia functions.
Monitor EKG for changes in Observation for pacemaker mal-
Several complications may occur as a result of rhythm, rate, and presence of function promotes prompt treat-
dysrhythmias. Treat as india- ment. Pacer electrodes may ir-
pacemakers-pneumothorax, hemothorax, ted. ritate ventricle and promote
myocardial perforation, hematoma, bleeding, dys- ventricular ectopy.
rhythmias, pulmonary embolism, electrical
Keep monitor alarms on at all Provides for immediate detec-
microshock, cardiac tamponade, coronary artery
times, with rate limits set 2-5 tion of pacemaker failure or
laceration, failure to pace, failure to sense, and beats above and below set rate. malfunction.
failure to capture.
Obtain and observe rhythm strip Identifies proper functioning
MEDICAL CARE every 4 hours and prn. Notify

MD for abnormalities.
of pacemaker, with appropriate
capture and sensing.
Chest x-ray: used to evaluate placement of lead Monitor vital signs every 15 Assures adequate perfusion and
wires minutes until stable, then cardiac output.
every 2 hours.
Electrocardiography: used to monitor for heart
rhythm problems, dysrhythmias, and for Monitor for signs of failure Potential causes are low volt-
function/malfunction of pacemakers to capture and correct problem. age, battery failure, faulty
connections, catheter or wire
Surgery: for placement of permanent pacemakers fracture, improper placement
of catheter, or fibrosis at
tip of catheter.
NURSING CARE PLANS Monitor for signs of failure Potential causes are lead dis-
Alteration in tissue perfision: to sense patient’s own rhythm lodgment, battery failure, low
curdiopulmonay, cerebral and correct problem. sensitivity, catheter wire frac-
ture, or improper placement of
Related to: cardiac dysrhythmias, heart blocks, catheter.
tachydysrhythmias, decreased blood pressure,
Monitor for signs of failure Potential causes are battery
decreased cardiac output to pace and correct problem. failure, lead dislodgment, dis-
connection, or catheter lead
Defining characteristics: decreased blood fracture.
pressure, decreased heart rate, decreased cardiac
output, changes in level of consciousness, mental Ensure that all electrical Prevents potential for micro-
equipment is grounded. Avoid shock and accidental electrocu-
changes, cold clammy skin, cardiopulmonary touching equipment and patient tion. Electric current seeks
arrest at same time. Patients should the path of least resistance,
not use radios, shavers, etc. and the potential for stray cur-
rent to travel through the elec-
trode into the patient’s heart
may precipitate ventricular fib-
rillation.
~
INTERVENTIONS RATIONALES INTERTENTIONS RATIONALES

Place a dry rubber glove over Provides insulation to prevent Protect patient from microwave Environmental electromagnetic
exposed terminals or leads. stray current contact. Static ovens, radar, diathermy, elec- interference may impair demand
Wear rubber gloves when hand- electricity may pass from person trocautery, TENS units, etc. pacemaker function by disrupting
ling the electrodes, terminals, to person through the leads. the electrical stimulus.
etc.
If the patient experiences Disconnection prior to D C coun-
Pacemaker batteries should not Patients may be totally depen- cardiopulmonary arrest, the tershock prevents pacer damage
be changed while the pacer is dent on the pacemaker for their pacemaker should be turned off and potential of diversion of
in use. In cases of hardship, rhythm and cardiac output and and disconnected from the pa- electrical current.
batteries should be changed as loss of time incurred to change tient for ventricular fibrilla-
quickly as possible, wearing the battery may result in life- tion. After defibrillation,
rubber gloves, and using utmost threatening consequences. the pacemaker should be recon-
caution to avoid touching the nected, turned on, and output
battery terminals. should be raised to 20 mA, rate
above GO.
Monitor for musde witching or May indicate lead has dislodged
hiccoughs. and migrated to chest wall or
diaphragm after perforation of Information, Instruction,
heart.
Demonstration
~~~
Monitor for sudden complaints May indicate perforation of the

of chest pain, and auscultate pericardial sac, and impending INTERVENTIONS RATIONALES
for pericardial friction rub or cardiac tamponade. Instruct on need for pacemaker, Provides knowledge, decrezses
muffled heart tones. Observe procedures involved, expected fear and anxiery, and provides
for JVD and pulsus paradoxus. outcomes, etc. baseline for further instruc-
tion.
Monitor for dizziness, syncope, During ventricular pacing, AV
weakness, pronounced fatigue, synchrony may cease and cause Instruct in checking pulse rate Provides patient with some
edema, chest pain, palpitations, a sudden decrease in cardiac every day for 1 month, then control over situation. As-
pulsations in neck veins, or output. May indicate “pace- every week, and to notify M D if sists in promoting a sense
dyspnea. maker syndrome” or failure rate varies more than 5 beats/ of security. Allows for
of the pacer to function which minute. prompt recognition of devi-
results in decreased perfusion. ations from preset rate and
potential pacemaker failure.
Limit movement of the extremi- Prevents accidental disconnec-
ty involved near insertion site. tion and dislodgment of lead Instruct on activity limita- Full range of motion can be
wires. tions: avoid excessive bend- recovered in approximately
ing, stretching, lifting more 2 months after fibrosis
If pacemaker is used concurrent- Inflation of pulmonary artery than 5 pounds, strenuous acti- stabilizes the pacemaker
ly with pulmonary artery catheter catheter balloon for capillary vities, or contact sports. lead. Excessive activity
obtain wedge pressure only as M D wedge pressures may dislodge may cause lead dislodgment.
orders. pacer lead wires and cause
pacemaker malfunction. Instruct to avoid shoulder- May promote irritation over
strap purses, suspenders, or implanted generator site.
Monitor patient for low blood May impair the pacemaker stim- firing rifle resting over gen-
sugar levels, use of glucocor- ulation thresholds. erator site.
ticoids or sympathomimetics,
mineralocorticoids, or anesthe- Instruct to wear a medic-alert Provides information about the
tics. bracelet with information about patient, his condition, and
the type of pacemaker and rate. pacemaker should he be incapa-
citated and cannot speak for
himself.

Instruct to notify MD if radi- Therapy can cause failure of
ation therapy is needed and to the silicone chip in the pacer
Patient will have healed wound sites without
wear a lead shield. with repeated radiation. signs/symptoms of infection.
Instruct to avoid electromag- May affect the function of the INTERVENTIONS RATIONALES
netic fields, magnetic resonance pacemaker and alter the pro- Inspect pacemaker insertion Prompt detection of problems
imaging, radio transmitters, arc grammed settings. Sometimes site for erythema, edema, warmth, promotes prompt treatment.
welding equipment, large running these magnetic fields will drainage, or tenderness.
motors, or large ungrounded affect the pacemaker function
power tools. If patient notices only if direct contact is made Change dressing daily, or per Allows for observation of site
dizziness or palpitations, he and once distance is placed hospital protocol, using sterile and detection of inflammation
should try to move away from between the patient and the technique. or infection. Sterile technique
the area, and if symptoms per- equipment, normal function of is recommended due to the close
sist, to seek medical attention. the pacemaker resumes. If proximity of the portal to the
Late model microwave ovens are programmed settings are altered heart increasing the potential
no longer thought to be a threat the pacer will require repro- for systemic infection.
due to tighter seals preventing gramming. Hyperbaric oxygen
leakage of energy. chambers may also affect pacer Pacemaker lead wires should be Avoids potential for accidental-
function. coiled and taped securely to ly disconnecting pacemaker from
patient; pulse generator should generator, or dislodging leads
be secured to avoid pulling. from heart.
Patient will be free of dysrhythmias and able to Information, Instruction,
maintain cardiac output within normal limits. Demonstration
Patient will be able to recall accurately all INTERVENTIONS RATIONALES
instructions given. Instruct on wound care to pacer Promotes compliance with care
site; to avoid taking showers to decrease potential for infec-
Patient will be able to recall and adhere to all for 2 weeks after pacer insertion. Moisture can promote bac-
activity restrictions. tion. terial growth.
Permanent pacemaker function will be without lnstruct to observe for and re- Provides for prompt recognition
complication, with no lead dislodgment or com- port to MD the following symp- of complications and facilitates
petitive rhythms noted. toms: redness, drainage, remper- prompt treatment.
ature greater than 100 degrees,
Alteration in skin interity pain or tenderness to site, or
swelling at site.
Related to: insertion of temporary or permanent
Instruct to avoid constrictive May cause discomfort at incision
pacemaker, alteration in activity dothing until site has healed. site from pressure and rubbing
against skin.
Defining characteristics: disruption of skin tissue,
insertion sites Instruct on need for pacemaker Pulse generators may require re-
removal/replacement. moval for battery replacement,
fracture of lead wires, pace-
maker failure, etc.

Patient will have well-healed incision with no Monitor for dyspnea, chest pain, May indicate puncture of the
pallor, cyanosis, absent or dim- lung and pneumothorax.
signs/symptoms of infection. inished breath sounds, tracheal
deviation, and feeling of impen-
Patient will be able to recall accurately all ding doom.
instructions given.
Monitor for muscle twitching and May indicate perforation of the
Patient will be able to demonstrate appropriate hiccoughs. Notify M D . heart with pacing to the chest
wound care prior to discharge. wall or diaphragm.
Potential for injury

Observe for signslsymptoms of May indicate perforation of the
Related to: pacemaker failure, hemothorax or cardiac tamponade-pericardial pericardial sac and impending
pneumothorax after insertion, bleeding, lead friction rub, pulsus paradoxus, cardiac tamponade.
muffled heart tones, JVD.
migration, heart perforation
Defining characteristics: decreased cardiac output,
hemorrhage, diaphoresis, hypotension, restlessness,
dyspnea, cyanosis, chest pain, muscle twitching, Patient will have no complications associated
hiccoughs, muffled heart sounds, jugular vein dis- with pacemaker insertion.
tention, pulsus paradoxus
Patient will have clear breath sounds, with no
inadequacy of oxygenation.
Outcome Criteria
Patient will be free of infection or hemorrhage.
Patient will be free of any complications that may
be associated with pacemaker insertion. Alteration in comfort
[See MI]
Related to: pacemaker insertion or transcutaneous
~
Monitor for bleeding at pacer Bleeding at incisional site

site. Apply pressure dressings may occur based on the patient’s pacing
as warranted. coagulation status. Pressure
dressings or manual pressure may Defining characteristics: communication of pain,
be required to control bleeding. facial grimacing, restlessness, changes in pulse and
blood pressure
Monitor for pulse presence at Hemorrhage may promote tissue
site distal to pacer insertion. edema and compression to ar- Anxiety
terial blood flow resulting in
diminished or absent pulses. [See MI]
Monitor for hypotension, dia- May indicate puncture of the

phoresis, dyspnea, and restless- subclavian vasculature and po- threat to body image, threat to role functioning,
ness. tential hemothorax. pain
64 CRITICAL CARE NURSING CARE PUNS
Impaired physical mobility INTERVENTIONS RATIONALES

Related to: pain, limb immobilization Monitor for progression and im- Physical therapy may be re-
provement in stiffnedpain. quired if immobility results
Defining characteristics: inability to move as are severe.
desired, imposed restrictions on activity, decreased
Apply trapeze bar to bed. Allows for easier movement by
muscle strength and coordination, limited range of
allowing patient to assist with
motion movement in bed.
Reposition every 2 hours and Prevents potential for immobili-

Outcome Criteria prn. ty hazards such as pressure
areas and atelectasis.
Patient will regain optimal mobility within limita-
tions of disease process, and will have increased
strength and function of limbs. Information, Instruction,
Demonstration
Evaluate patient$ perception of Psychological and physical im- INTERVENTIONS RATIONALES
degree of immobility. mobility are interrelated. Psy- Encourage deep breathing exer- Facilitates lung expansion and
chological immobility is used as cises every 1-2 hours; avoid decreases potential for atelec-
a defense mechanism when they forceful coughing. tasis. Coughing may dislodge
have no control over their body,
pacemaker lead.
and this can lead to dispropor-
tionate fear and concern.
Changes in body image promote
psychological immobility and Discharge or Maintenance Evaluation
may result in emotional handi-
caps. Patient will regain optimal mobility of all joints
with no signs or symptoms of complications.
Maintain bedrest for 24-48 hours Provides time for stabilization
after permanent pacer inserted. of leads and decreases potential Patient will be able to demonstrate and recall
for dislodgment. instructions regarding deep breathing and range of
Immobilize extremity proximal Prevents potential for dislodg- motion exercises.
to pacer insertion site with arm ment of lead due to movement.
board, sling, etc.
Disturbance of body image
Resume range of motion exercises Promotes gradual increase of
Related to: presence of pulse generator, loss of
5 days after permanent pacer inactivity. Stretching should control of heart function, disease process
sertion to affected extremity. be avoided until lead wire
Provide ROM to unaffected extre- has been secured in heart by Defining characteristics: fear of rejection, fear of
mity as warranted. fibrotic changes. ROM reaction from others, negative feelings about body,
prevents stiffness of should- refusal to participate in care, refusal to look at
ers and joint immobility.
wound
Encourage extension/dorsiflexion Promotes venous return, pre-
exercises to feet every 1-2 vents venous stasis, and de-
hours. creases potential for thrombo-
phlebitis.
Outcome Criteria Information, Instruction,

Demonstration
Patient will accept change in body image and deal
constructively with situation. INTERVENTIONS RATIONALES
INTERVENTIONS RATIONALES Discuss potential for mood Facilitates identification that
changes, anger, grief, etc. af- feelings are not unusual and
Evaluate level of patient’s May identify extent of problem ter discharge, and to seek help must be recognized in order t o
knowledge about disease process, and interventions that will be if persisting for lengthy time. effectively deal with them.
treatment, and anxiety. required.
Evaluate the extent of loss to Depending on the time frame for Identify support groups for pa- Provides ongoing support for
the patiendfamily, and what it patient teaching prior to the tient/family to contact. patient and family and allows
means to them. insertion of the pacemaker, the for ventilation of feelings.
patient may not have received
adequate information, and may Consult counselor/therapist as May require further interven-
have difficulty dealing with warranted. tions to resolve emotional or
changes in his body appearance psychological problems.
as well as generalized health
condition and loss of control.
Evaluate stage of grieving. Provides recognition of appro-
priate versus inappropriate
behavior. Prolonged grief Patient will be able to effectively deal with body
may require further care. image disturbances in present situation.
Observe for withdrawal, manipu- May suggest problems with ad- Patient will be able to talk with family,
lation, noninvolvement with care, justment to health condition, therapist, or others about emotional or psycho-
or increased dependency. Set grief response to the loss of logical problems.
limits on dysfunctional behav- function, or worry about others
ior and help patient to seek accepting patient’s new body Patient will be able to problem-solve and iden-
positive behaviors that will status. Patients may deal with
assist with recovery. crises in the same manner as
tify short- and long-term goals within
previously dealt and may need reasonable expectations of clinical situation.
redirection in behaviors to fa-
cilitate recovery and accep- Knowledge deficit
tance. [See MI]
Provide positive reinforcement Promotes trust and establishes Related to: lack of understanding, lack of under-
during care and with instruc- rapport with patient as well as standing of medical condition, lack of recall, new
tion and setting goals. Do not provides an opportunity to plan
for rhe future based on reality
health crisis
give false reassurance.
of situation.
Provide opportunity for patient Promotes self-esteem and facili- problems, inadequate follow-up on instructions
to take active role in wound tates feelings of control of given, misconceptions, lack of improvement of
care. body and health. previ0u.s regimen, development of preventable
Provide reassurance that pace- Promotes knowledge and decreases
complications
maker will not alter sexual ac- fear.
tivity.
PACEMAKERS
Myocardial damage Incompetent valves Coronary flow compromise
s
Loss of elasticity of muscle fibers
s
Conduction aberrancies
I
Cardiac dysrhythmias
(bradydysrythmias, SSS, tachydysrythmias, heart blocks, atrial fibrillation)
I
Pacemaker insertion
s
Implanted lead(s) identifies lack of stimuli
4
Electrical stimulus produced
I
Myocardium depolarized
4
Potential problems with pacemaker
(disconnections, movement of electrodes, battery failure)
s
I I I
Failure to capture Failure to pace Failure to sense
J J
s
Lethal dysrhythmias
s
Death
fraction. This is the ratio of stroke volume com-

pared to the end-diastolic volume and an ejection
fraction greater than 55 reflects a good operative
risk. Ejection fraction less than 25% is usually
Coronary artery disease treatment requires the considered inoperable because of the high mortal-
maximization of cardiac output and this can be ity associated with it.
accomplished by improvement in heart muscle
function and increase of blood flow through coro- The surgery is performed via a median sternotomy
nary artery bypass grafting and/or valvular incision which provides exposure of the heart and
replacements. Open heart surgery is commonly avoids the pleural spaces. A cannula is placed in a
performed for three-vessel disease, valve dysfunc- vein and an artery and then attached to the
tion and congenital heart defects and requires cardiopulmonary bypass machine whereby the
blood to be diverted from the heart and lungs to diverted blood is mechanically oxygenated and cir-
facilitate a bloodless operative field. culated to the other parts of the body. The
machine, which is operated by a trained perfusion-
In coronary artery bypass graft (CABG) surgery, a ist, substitutes for left ventricular pumping and
graft from the arms or legs is anastomosed to the creates a blood-gas exchange. After the patient’s
aorta with the distal portion to the involved coro- body temperature has been cooled to around 86
nary artery to bypass the diseased obstruction and degrees, the aorta is cross-clamped and a cold car-
supply adequate blood flow to the heart. The dioplegic solution, usually containing dextrose,
internal mammary artery is also being utilized for potassium, magnesium and inderal, is placed
CABG surgery because the patency rate is 90-95% around the heart and injected into the coronary
over a 5-10 year time period, and there are less arteries. This causes an electromechanical arrest
problems with differences in lumen size since an and provides an inert operative site. Cross-clamp
artery is then anastomosed to an artery without durations longer than 3 hours usually result in
the need for routing from the aorta. In valvular severe complications for the patient. After the
surgery, incompetent or leaking valves are replaced grafts have been completed or valves replaced, per-
with prosthetic ones. fusion is slowly discontinued and cannulas are
Not all patients with coronary artery disease are removed when arterial blood pressure and cardiac
functioning are adequate. Two atrial and ventricu-
candidates for CABG surgery. It is usually recom-
lar pacing wires are placed, as well as arterial lines,
mended for those patients with intractable angina,
signs of ischemia, or an increased risk of coronary pulmonary artery catheter, left atrial line, and
mediastinal or pleural chest tubes.
ischemia/infarction as a result of angiographical
studies. Complications may occur in almost every Common complications associated with CABG
body system and may be a result of the disease surgery include perioperative MI, vein graft clo-
process or defect, the surgery, or the use of sure, hemorrhage, blood trauma, complement
cardiopulmonary bypass, and so the decision for activation, coagulation abnormalities, fluid shifts,
surgery is a multi-faceted one. increased catecholamine levels, fat emboli,
microemboli, dysrhythmias, pericarditis, postperi-
One of the most important factors in the decision
of candidacy for CABG surgery is the ejection
cardiotomy syndrome, embolism, pneumonia, Chest x-ray: used to identify heart size and posi-
atelectasis, hemothorax, pneumothorax, and post- tion, pulmonary vasculature, pulmonary changes,
cardiotomy delirium. Other complications that are verifies position of endotracheal tube, pacing
seen less often include stress ulcer, renal failure, wires, and hemodynamic catheters; monitors for
respiratory failure, cardiac tamponade, cardiogenic bar0 trauma
shock, endocarditis, gastrointestinal bleeding,
Cardiac catheterization: used to evaluate abnor-
mediastinitis, and paralytic ileus.
mal pressures preop, to assess for pressure
gradients across the valves, and to locate and mea-
MEDICAL CARE sure coronary lesions
Pulmonary function studies: used to ascertain
baseline pulmonary function NURSING CARE PLANS
Laboratory: hemoglobin/hematocrit used to mon- Risk for decreased cardiac output
itor oxygen-carrying capability, need for blood
Related to: myocardial depression, dysrhythmias,
replacement, and to monitor for dehydration
electrolyte imbalances, hypovolemia,
status; electrolytes used to monitor for imbalances
hypervolemia, myocardial infarction, coronary
which can affect cardiac function; BUN and crea-
artery spasm, vasoconstriction, impaired contrac-
tinine used to monitor renal function; liver profile
tility, alteration in preload, alteration in afterload,
used to monitor liver function and perfusion; glu-
hypo perfusion, microemboli, hypoxia, damaged
cose used to monitor for presence of diabetes,
myocardium, use of PEEP while on ventilatory
nutritional alterations, or organ dysfunction; car-
support
diac enzymes and isoenzymes used to monitor for
presence of acute or perioperative myocardial Defining characteristics: elevated blood pressure,
infarction; coagulation profiles used to determine elevated mean arterial pressure greater than 120
baseline and monitor for coagulation problems; mmHg, elevated systemic vascular resistance
antibody or complement levels used to monitor greater than 1400 dyne-seconds/cm5, cardiac
for postpericardiotomy syndrome or Dressler’s output less than 5 L/min or cardiac index less
syndrome; type and crossmatch for blood to have than 2.7 L/min/m2, tachycardia greater than 110,
available blood products on hand in case of hem- cold, pale extremities, absent or decreased periph-
orrhage; ACT used to monitor heparinization eral pulses, EKG changes, hypotension, S3 or S4
gallops, decreased urinary output, diaphoresis,
Arterial blood gases: used to monitor oxygenation
orthopnea, dyspnea, crackles (rales), jugular vein
and assess acid-base balance and ability to wean
distention, edema, chest pain
off mechanical ventilation
Electrocardiography: used to observe for changes Outcome Criteria
in cardiac function, presence of conduction prob-
lems, dysrhythmias, or ischemic changes Vital signs and hernodynamic parameters will be
within normal limits for patient, with no
Echocardiography: used to evaluate wall motion
dysrhythmias noted.
of the heart

Monitor vital signs, especially Tachycardia may occur as a res- Measure left atrial pressure Determines the left ventricular
heart rate and blood pressure. ponse to pain, anxiety, blood and pulmonary artery wedge pres- end-diastolic volume; increases
Notify MD of abnormalities. and fluid deficit, and stress, sures. in pressure may indicate conges-
Blood pressure should be taken/ but rates over 130 increases tive heart failure or pulmonary
monitored every 15 minutes until myocardial oxygen consumption edema, and decreases may indi-
stable, or every 5 minutes dur- and workload on the heart, de- cate low blood volume. Trends
ing active titration. creasing cardiac output. In- and changes in values are of
creased blood pressure may pro- more importance than single
mote alterations in heart pres- readings. Left ventricular dys-
sures and increase the risk of function can elevate left heart
complications, as well as pla- filling pressures without a rise
cing pressure on suture lines in right heart pressures.
of new grafts. Hypotension may
result from fluid deficit, dys- Monitor urine output hourly and Urine output is an indication
rhythmias, and cardiac failure, notify M D if less than 30 cclhr. of adequate cardiac output and
as well as predispose peripheral renal perfusion.
vein grafts to close.
Observe for decreased peripheral May indicate low cardiac output.
Evaluate hypotension that is May indicate cardiac tamponade pulses, cool or cold moist skin,
not responsive to fluid bolus, in a heart that is unable to or cyanosis.
tachycardia, and distant heart fill adequately to maintain
sounds. cardiac output. Tamponade usu- Monitor for changes in level of Cerebral perfusion is dependent
ally occurs immediately post-op consciousness, mental status on adequate cardiac output. Hy-
but may occur later during re- changes, restlessness, or con- poperfusion or microemboli may
covery period. fusion. result in CNS deficits.
Monitor hemodynamic pressures Assists with recognition of Monitor for JVD, peripheral ede- May indicate present or impend-
every 1 hour and prn. Maintain complications and allows for ma, and pulmonary congestion. ing congestive heart failure.
pressures with titration of va- manipulation of cardiac pres- Auscultate for crackles (rales).
soactive drugs per M D ordered sures by use of fluids and
parameters. medications. Vasoconstriction Observe for shortness of breath, May indicate hypoxia and de-
is the cause of elevated SVR, decreases in oximetry, or dyspnea. creased cardiac output.
and with increases in SVR, may
indicate left ventricular dys- Monitor EKG for cardiac conduc- Lethal dysrhythmias may occur
function. Cardiac output then tion disturbances, dysrhythmias, as a result of electrolyte im-
becomes dependent on outflow or changes in ratelrhythm. balances, myocardial ischemia
resistance. or infarction, or problems with
electrical conduction, with an
Measure cardiac outpudcardiac Cardiac output is a measurement associated drop in cardiac out-
index every 1-2 hours immedi- that is equal to the product of put.
ately post-op. the stroke volume and the heart
rate. Cardiac indexes above 3.0 Monitor for complaints of se- May indicate a perioperative or
Ymin/m2 are usually adequate vere chest pain. postoperative myocardial infarc-
except in cases of septic shock. tion.
Adequate cardiac output relates
to the adequacy of function of Provide for uninterrupted rest Prevcnts fatigue and increased
other body organs. After CABG periods and assist with care as workload on the heart leading
surgery, most patients require needed. to decrease in cardiac output
an increase in CO to meet the and perfusion.
stress imposed by the operation
and the accompanying increase
in oxygen consumption.

Administer IV fluids as ordered. Maintains fluid status and hy-
dration, as well as provides ac- Patient will be free of pain or pain will be
cess for emergency medications. controlled to patient’s satisfaction.
Administer blood products as or- Blood or packed red cells may be INTERVENTIONS RATIONALES
dered. required to maintain adequate Evaluate complaints of pain- Pain may be perceived in differ-
oxygen-carrying capability, and type, location, intensity based ent ways by each individual and
adequate circulating volume for on 0- 10 scale. Compare preoper- is important to differentiate
cellular activity. Platelet func- ative pain perceptions with post- incisional pain from other types
tion and count is decreased operative pain. of chest pain. CABG patients
with use of cardiopulmonary by- usually do not have severe dis-
pass and proportional to the comfort to the chest incision
duration of bypass and depth but may have increased discom-
of hypothermia during surgery. fort with donor sire pain.
Severe pain should be investiga-
ted for possibility of compli-
Information, Instruction, cations.
Demonstration
Monitor vital signs. Heart rates usually increase
INTERVENTIONS RATIONALES with pain but bradycardia may
occur especially in severely
Attempt to reverse any contrib- These may precipitate a low CO damaged myocardium. Blood pres-
uting factor such as untreated state. sure may be increased with in-
DKA or endocrine dysfunction. cisional pain, but can also be
labile or decreased when chest
Prepare patient for placement Promotes knowledge and pain is severe or if myocardial
on IABP. decreases fear. ischemidnecrosis occurs.
Evaluate complaints of pain in May be indicative of develop-

Discharge or Maintenance Evaluation legs or abdomen, or vague non- ment of thrombophlebitis, infec-
specific complaints, especially tion or GI dysfunction.
Patient will have maximal cardiac output and if associated with changes in
mental status or vital signs.
stable hemodynamic pressures.
Monitor for complaints of pain May result from stretching of
Patient will have adequate perfusion of all body and/or paresthesia to ulnar the brachial plexus during posi-
systems. area of the hand, and possibly tioning of the arms during sur-
pain to shoulders and arms. gery and generally resolves over
Patient will be able to recall instructions time without specific treatment.
correctly.
Observe for anxiety, irritabili- Nonverbal cues may indicate the
Alteration in comfort ty, crying, restlessness, or in- presence of pain.
somnia.
Related to: mediastinal, leg, or arm incisions,
myocardial infarction, angina, inflammation, Administer analgesics as soon as Pain results in muscle tension,
tissue damage discomfort is noticed, or pro- which can decrease circulation
phylactically prior to painful and intensify pain perception.
Defining characteristics: communication of dis- procedures. Medication given prior to pro-
cedures known to cause pain may
comfort or pain, restlessness, irritability, increased facilitate cooperation with pro-
heart rate, increased blood pressure
INTERVENTIONS RATIONALES Defining characteristics: dyspnea, tachypnea,

apnea, ventilation/perfusion mismatching, abnor-
cedures and allow for easier
chest movement with respiratory mal ABGs, pain, increased hemodynamic
therapy. pressures, oxygen saturation less than 90%, adven-
titious breath sounds, hypoxia, hypoxemia
Provide back rubs, position chan- Promotes relaxation and helps to
ges, and diversionary activities. redirect attention away from
discomfort, thereby reducing the Outcome Criteria
amount of analgesic required.
Patient will be eupneic with clear breath sounds,
Encourage deep breathing, visu- Promotes decrease in stress
alization, or guided imagery. and may reduce analgesic need. and have no evidence of hypoxia/hypoxemia.
Information, Instruction, Monitor respiratory rate and Respiratory rates may be in-
depth, presence of dyspnea, use creased by pain, fever, blood
Demonstration of accessory muscles, nasal flar- loss, fluid loss, anxiety, hy-
ing, and increasing respiratory poxia, or gastric distention.
INTERVENTIONS RATIONALES work effort. Decreases in rate may occur
Instruct on methods to reduce Supporting extremities and the with use of narcotic analgesics.
strain on muscles when position- maintenance of good body align- Prompt recognition of potential
ing. ment reduce muscle tension and complications can promote
provide comfort. prompt treatment.
Auscultate lung fields for di- Breath sounds are frequently di-
minished or absent breath sounds minished immediately post-op as
Discharge or Maintenance Evaluation or for adventitious sounds. a result of atelectasis. Loss
of breath sounds in a previously
Patient will be comfortable, pain-free, and be ventilated lung may indicate a
able to recall methods for stress reduction and partid or total lung collapse,
pain coiitrol accurately. especially when chest tubes have
recently been discontinued. Ad-
Patient will be able to identify differences ventitious breath sounds may in-
dicate fluid or secretions have
between postoperative and preoperative chest accumulated in the interstitial
pain. spaces or airways resulting in
a partial occlusion of the air-
Patient will be able to maintain optimal body way.
alignment and minimize muscle tension.
1
Evaluate chest expansion for Unilateral incomplete chest ex-

Risk for inefective breathing symmetry. pansion may indicate that air or
patternhmpaired gas exchange fluid is preventing complete
expansion of the pleural space,
Related to: inadequate ventilation, possibly a pneumothorax.
ventilatiodperfusion mismatching, abnormal
Administer oxygen by cannula Provides supplementd oxygen to
ABGs, pain, blood loss, atelectasis, pneumothorax, or mask as warranted. decrease the workload on the
hemothorax, increased pulmonary vascular resis- heart and to maximize oxygen de-
tance, increased capillary permeability, chemical livery to under-perfused tis-
sues.
mediators, decrease in surfactant

Observe for pallor or cya- Cyanosis of lips, nailbeds, or port post-CABG due CO their me-
nosis, especially to mucous earlobes, or generalized duski- chanism of breathing. Ventila-
membranes. ness may indicate hypoxia as a tors provide controlled amounts
result of heart failure or pul- of oxygen and tidal volumes, and
monary dysfunction. Pallor is C O P D patients have their inert
frequently noted immediately drive to breathe removed by the
postoperatively due to blood use of ventilation. Occasion-
loss or insufficient blood re- ally with use of the cold car-
placement. dioplegic solution, the phrenic
nerve is injured resulting in a
Observe for presence of cough Endotracheal tube intubation loss of function of the dia-
and sputum character. may promote throat irritation phragm which is necessary for
which can result in coughing, 60% of the spontaneous tidal
but cough may also indicate volume for the patient.
impending pulmonary congestion
or infection. Purulent sputum Suction patient every 2-4 hours Removes mucous thar may occlude
may reflect pneumonia. and prn. Use pulmonary toilette airways. Saline instillation
and hyperoxygenate prior to and helps to liqueg secretions to
Encourage deep breathing ex- Promotes expansionlre-expansion after suaioning. facilitate easier removal. Oxy-
ercises, inspiratory spirometer, of airways. Adventitious breath gen concentration drops drastic-
or coughing exercises. sounds may indicate presence of ally with suaioning procedures
secretions or fluid in lungs. and leaves the patient compro-
mised with an increased oxygen
Observe for signs of respiratory May indicate impending pneumo- consumption.
distress, tachycardia, extreme thorax or hemothorax, expecially
restlessness and feeling of im- after chest tube removal. May Auscultate breath sounds pre- Provides for comparison of
pending doom. require reinsertion of chest and post-suctioning. breath sounds to evaluate for
tubes. improvement. Occasionally,
suctioning will move secretions
Monitor respiratory status and CABG patients are placed on me- up the bronchial tree and may
ventilatory settings every 1-2 chanical ventilation support cause a partial or total occlu-
hours while on ventilator. until awake from anesthesia. sion of an airway. Decreases in
F I 0 2 is initially 100% and then previously venrilated lung
gradually decreased, while main- fields may indicate this pheno-
raining an adequate PaO2 above menon has occurred.
90. FIO2 should be decreased to
.50 as rapidly as possible to Monitor use of amiodarone and Some drugs can exacerbate pul-
prevent actual pulmonary changes protamine sulfate. Observe for monary problems by their method
that occur with high levels of respiratory impingement. of action.
oxygen. Tidal volumes are usu-
ally maintained between 10-15
cclKg of ideal body weight to
allow for less interference with
venous return.
Assist with weaning from ven- Weaning is usually performed by

tilatory support. Monitor for reducing the rate and then a
hemodynamic instability and de- trial on a T-bar or CPAP mode.
creasing oxygen saturation. Patients who have a history of
Monitor ABGs as ordered. smoking or C O P D often have
prolonged need for ventilatory sup-
Information, Instruction, Patient will be compliant with respiratory regi-

Demonstration men, and will be able to recall all instructions
accurately.
Prepare patient for placement Lengthy instruction may not be
Alteration in skin integrity
on mechanical ventilation if prudent or possible depending Re1ate:dto: insertion of temporary or permanent
warranted. on the severity of the situa-
tion. If oxygenation cannot be pacemaker, alteration in activity, surgical incisions,
maintained with the use of sup- puncture wounds, drains
plemental oxygen, the only al-
ternative is intubationlventi- Defining characteristics: disruption of skin tissue,
lation. insertion sites
Prepare patient for insertion Prolonged endotracheal intuba-
of tracheostomy after 10 days tion may result in tracheal or Outcome Criteria
of ETT intubation/ventilation. nasal necrosis or rupture of
cuff. Tracheostomy is con- Patient will have healed wound sites without
sidered to prevent ulceration
into arteries or other vital
signs/symptoms of infection.
tissues, but may need to be INTERVENTIONS RATIONALES
avoided due to potential for
contamination of sternotomy Inspect pacemaker insertion Prompt detection of problems
wound from secretions. site for erythema, edema, warmth, promotes prompt treatmenr.
drainage, or tenderness.
Instruct patient on need for Promotes lung expansion and
ambulation, movement, change prevents pulmonary congestion.
in position. Observe all incisions for heal- Chest incisions usually heal
ing and progress. Notify MD first due to minimal amounts
Instruct on need for respira- Reassures patient that com- for incision4 areas that are of muscle tissue involved. Do-
tory treatments, coughing, deep plying with aggressive pul- not healing, areas that have nor sites have more muscle tis-
breathing. monary regimen will not Cause reopened or dehisced, edema- sue, usually are more lengthy
injury to surgical sites. tous and erythematous tissues, incisions and have poorer cir-
bloody or purulent drainage, or culation thereby requiring a
Prepare patient for reinsertion Promotes re-expansion of lung hot painful areas. longer healing process. Signs
of chest tubes as warranted. by removing accumulated fluid, may indicate a failure to heal,
blood, or air, and restores or the development of complica-
normal negative pressure in the tions that require further in-
pleural cavity. tervention.
Culture drainage from wound as Identifies causative organism

warranted. that may result in local or
Discharge or Maintenance Evaluation systemic infection, and allows
for identification of suitable
Patient will be free of dyspnea with adequate antimicrobial therapy.
ABGs and oxygenation, and without evidence of
cyanosis or pallor.
Change dressings daily, or per Allows for observation of site
Patient will have clear breath sounds to all lung hospital protocol, using sterile and detection of inflammation
technique. or infection. Sterile technique
fields with no lung collapse. is recommended due to the close
proximity of the portal to the
heart increasing the potential
for systemic infection.
INTERVENTIONS RATIONALFB Potential for injury

Utilize steri-strips to sup- Maintains approximation of heal-
[See Pacemakers]
port incisions when sutures are ing wound edges to facilitate
Related to: pacemaker failure, hemothorax or
removed. healing of skin tissues.
pneumothorax after insertion, bleeding, lead
migration, heart perforation
Provide adequate nutritional Maintains adequate circulating
and fluid intake. volume, assists to meet energy Defining characteristics: decreased cardiac output,
requirements to facilitate hemorrhage, diaphoresis, hypotension, restlessness,
tissue healing and perfusion.
dyspnea, cyanosis, chest pain, muscle twitching,
hiccoughs, muffled heart sounds, jugular vein dis-
Information, Instruction, tention, pulsus paradoxus
Demonstration Anxiety
INTERVENTIONS RATIONALES [See MI]
Instruct on wound care to wound Promotes compliance with care Related to: change in health status, fear of death,
sites. to decrease potential for infcc- threat to body image, threat to role functioning,
tion. Moisture can promote bac-
terial growth. pain
Instruct to observe for and re- Provides for prompt recognition

port to M D the following symp- of complications and facilitates anorexia, increased respirations, increased heart
toms: redness, drainage, temper- prompt treatment. rate, increased blood pressure, difficulty concen-
ature greater than 100 degrees,
pain or tenderness to site, or
swelling at site. energy, irritability, crying, feelings of helplessness
Instruct to avoid constrictive May cause discomfort at incision Knowledge &+it

clothing until site has healed. site from pressure and rubbing [See MI]
against skin.
Instruct to avoid tub baths Effort needed to get in and out standing of medical condition, lack of recall
until allowed by M D . of tub requires use of pectoral
and arm muscles which may con- Defining characteristics: questions regarding prob-
tribute to placing undue stress lems, inadequate follow-up on instructions given,
on suture lines of sternotomy.
misconceptions, lack of improvement of previous
Discharge or Maintenance Evaluation cations
Patient will have well-healed incision with no Impairedphysical mobility

signs/symptoms of infection. [See Pacemakers]
Patient will be able to recall accurately all Related to: pain, limb immobilization
instructions given. Defining characteristics: inability to move as
Patient will be able to demonstrate appropriate desired, imposed restrictions on activity, decreased
wound care prior to discharge. muscle strength and coordination, limited range of
motion
Disturbance of body image

[See Pacemakers]
Related to: presence of pulse generator, loss of
control of heart function, disease process, presence
of scarslwounds
Defining characteristics: fear of rejection, fear of
reaction from others, negative feelings about body,
refusal to participate in care, refusal to look at
wound
Aortic Aneurysm The goal for treatment is to remove or repair the

aneurysm and restore vascular circulation.
An aneurysm is a localized dilation of an artery Aneurysms are generally monitored until their size
that may occur as a congenital anomaly or as a reaches 6 cm or greater, and then surgical
result of arteriosclerosis and high blood pressure. intervention is indicated to prevent complications
There are three types of aneurysms found-saccu- such as rupture, stroke, or organ ischemia. Dacron
lar in which the vessel distention protrudes from grafts are used to help establish blood flow.
one side; fusiform in which the distention involves
the entire circumference of the vessel; and dissect- MEDICAL CARE
ing in which a tear occurs in the intimal layer of
the artery and with pressure, blood splits the wall Oxygen: to increase available oxygen supply
producing a hematoma that separates the medial Electrocardiography: used to monitor heart
layers of the aortic wall. In dissecting aneurysms, rhythm and rate for changes associated with
generally the separation of the layers does not decreases in perfusion, dysrhythmias, and for signs
completely encircle the lumen but may run the of left ventricular hypertrophy
entire length of the vessel.
Chest x-ray: used to observe for increase in aortic
Factors that may precipitate aneurysm formation diameter, right tracheal deviation, and pleural effu-
include atherosclerosis, hypertension, syphilis, sions
Marfan’s syndrome, cystic medial necrosis, trauma,
congenital abnormalities, and pregnancy. Abdomiinal x-ray: used to visualize aneurysm
Aneurysms that result from Marfan’s syndrome CT scans: used to visualize vessel wall thickness,
usually involve the first portion of the aorta, and lumen size, length of the aneurysm, and any mural
result in aortic insufficiency. Syphilitic aneurysms thrombi
usually occur in the ascending thoracic aorta. Angio-aortography: used to visualize lumen,
Abdominal aortic aneurysms ( M A )usually involve extent of disease, extent of collateral circulation,
that part of the aorta between the renal and iliac arteriovenous fistulas, extent of dissection, and
arteries, and thoracic aortic aneurysms (TAA) double I umens
occur mainly in the ascending, transverse or Ultrasound: used to visualize the vessels and
descending aorta with a prevalence toward men aneurysm non-invasively, amount of blood flow,
between 60 and 70 years of age. Mycotic and velocity of blood flow
aneurysms occur as a result of weakness in the
vessel from an infective process, such as endocardi- Laboratory: CBC used to monitor for decreases in
tis, and usually involve the peripheral arteries, but hemoglobin and hematocrit and for increases in
have been known to affect the aorta. leukocytes; BUN and creatinine used to monitor
for renal dysfunction; urinalysis used to monitor
AAA as a result of arteriosclerosis may be asympto- hematuria and proteinuria to detect renal compro-
matic until they become large enough to palpate, mise
large enough to cause pressure and pain, or until
leaking or rupture occurs. Frequently, rupture of Surgery: necessary to replace aneurysm with
the AAA leads to vascular collapse and shock, and dacron graft andlor repair the aneurysm
ultimately, death if not treated.
NURSING CARE PLANS INTERVENTIONS RATIONALES

Monitor for pain especially onsei Abrupt severe tearing pain in
Alteration in tissue pe&ion: of sudden sharp pain, and notify chest radiating to shoulders,
cardio ulrnonary, cerebral, gastrointestinal,
R
MD. neck, back, and abdomen is in-
per+ erad renal dicative of aortic dissection
and requires prompt interven-
Related to: arterial occlusion, aneurysm, dissecting tion. Low back pain may in-
dicate impending rupture.
aneurysm, or operative complications
Observe for dysphagia. Aneurysm may exert pressure
Defining characteristics: pulsating mass, bruits, on esophagus.
thrills, abdominal pain, low back pain, nauseahorn-
iting, syncope, chest pain, cough, hoarseness, Observe for voice weakness, Aneurysm may exert pressure
dysphagia, dyspnea, shortness of breath, pallor, loss hoarseness, paroxysmal cough, on laryngeal nerve or on the
or dyspnea. trachea.
of pulses, paresthesias, paralysis
Auscultate for bruits over ar- Indicates diminished blood
teries; observe and palpate gent- flow indicative of aneurysm.
Outcome Criteria ly for thrill over abdomen. A large aneurysm will have
Auscultate for cardiac murmurs. a palpable mass and thrill.
Patient will achieve and maintain hernodynamic An aortic murmur will be
stability, with all body systems adequately perfused, present if the aneurysm in-
and in the absence of pain, volves the aortic ring.
INTERVENTIONS RATIONALES Administer antihypertensives as Hypertension may exacerbate

ordered to maintain BP within decreased tissue perfusion
Monitor blood pressure in upper Normally systolic BP in thigh acceptible parameters. and compromise cardiovascular
and lower extremities. is greater than in the arm, but status.
is reversed much of the time
with abdominal aneurysms. Prepare patient for surgery as Surgical intervention may be
indicated. mandatory if circulation is
Monitor other vital signs and Hypertension may exacerbate compromised.
hemodynamic parameters. cardiac and peripheral perfusion
instabiliry.
Monitor pulses in both wrists Pulse differences may be noted

as well as in both legs. between wrists and between legs Demonstration
if the aneurysm interferes with
circulation to that particular INTERVENTIONS RATIONALES
extremity.
Instruct on disease process, Reduces anxiety and promotes
need for surgery, postoperative knowledge and compliance.
Observe for the 5 P’s-pain These may be associated with
care.
to extremity, pallor, pulse- thrombosis of the AAA.
lessness, paresthesia, and
Monitor vital signs and hemo- Hypertension may exacerbate
paralysis. Notify M D .
dynamic parameters. Maintain bleeding due to pressure on
blood pressure at MD-ordered suture lines, and hypotension
parameters. may not provide enough blood
flow to keep graft open.
Hypotension, tachycardia,
and decreased hemodynamic
pressures may indicate hypo-
volemia or hemorrhage.
~ ~~ ~~~

Auscultate lung fields for ad- Bedrest promotes atelectasis
Patient will have stable vital signs and hemody-
ventitious breath sounds. As- and decreased lung expansion
sist patient with cough, deep which may lead to pneumonia. namic pressures.
breathing exercises, incentive
spirometry. Patient will be pain free.
Monitor oxygen saturation by Maintenance of adequate Patient will be alert, oriented, and able to verbal-
oximetry. Administer oxygen oxygenation necessary for ade- ize instructions accurately.
as ordered. quate tissue perfusion.
Patient will have adequate perfusion to all body
Monitor peripheral pulses every Pulselessness indicates de- systems.
hour for 24 hours, then every 4 creased or no blood flow.
hours, for color, temperature, Occlusion of peripheral ar- Lung fields will be clear and patient eupneic.
capillary refill, and presence teries leads to ischemia and
of pulses. Notify M D if absent. necrosis. Alteration in comfort
Measure circumference of abdo- Significant differences be- Related to: pressure exerted on various structures
men or legs and notify M D of tween extremities or from day by aneurysm, infringement on nerves, surgical pro-
significant changes. to day may indicate hemorrhage.
cedures
Monitor EKG for changes and dys- Decreases in tissue perfusion Defining characteristics: pain to abdomen, lower
rhythmias. may cause cardiac decompensa-
tion, MIs, and dysrhythmias. back, hips, scrotum, chest, shoulders, neck, and
back; nauseahomiting, increases in blood pressure,
Monitor I&O every hour and Surgical procedures may result increased heart rate, facial grimacing, moaning,
notify M D if < 30 cdhr. in decreased renal blood flow
due to length of cross damp
shortriess of breath
time during aneurysm repair.
Higher flexion may cause flex-

Outcome Criteria
Do not elevate head of bed >
30-45 degrees. ion at femoral artery site and
may impede blood flow. Patient will be free of pain, with no associated
deviations of vital signs.
Auscultate abdomen for bowel Most major thoracoabdominal
sounds. Monitor NG aspirate surgical patients develop an INTERVENTIONS RATIONALES
for amount and characteristics. ileus and require decompression Monitor vital signs, and notify Pain may increase heart rate,
of bowel with nasogastric tube. M D for unstable vital signs that increase blood pressure or de.
do not change with analgesia. crease blood pressure, but
Monitor patient for diarrheal May indicate bowel ischemia due instability may occur from
stools and notify MD. to length of surgical procedure a variety of other causes.
and decreased perfusion to gut.
Assess for dull abdominal pain, May indicate impending rupture
Observe for mental changes, May be due to repair of lower backache, lower badc pain. of abdominal aortic aneurysm.
confusion, restlessness, and ascending and thoracic aortic
headache. aneurysms.
Assess fOr sudden severe pain to May indicate aortic dissection or
abdomen that may radiate to back, rupture of AAA and
hips, or scrotum, and is associ- requires immediate surgical
ated with nausea, vomiting, and intervention. MI should also be
hypotension. ruled out.

Demonstration
Assess for sudden tearing-type May indicate thoracic aortic
of pain to chest that may ra- aneurysm.
diate to shoulders, neck, and
back. Instruct in relaxation tech- Helps to decrease pain and
niques, deep breathing, guided anxiety and provides dis-
Observe for difficulty in swal- May indicate that aneurysm imagery, visualization, etc. traction from pain.
lowing or talking. Assess for is placing pressure against
voice hoarseness or cough. esophagus, laryngeal nerve, Instruct in activity alterations Decreases myocardial oxygen
Observe for shortness of breath. or trachea. and limitations. demand and workload.
Instruct in medication effects, Promotes knowledge and com-

Assess for pain to extremities, May indicate claudication of side effects, contraindications, pliance with therapeutic
with mottling/cyanosis/pallor, peripheral arteries as a result and symptoms to report. regimen. Alleviates fear.
pulselessness, or paralysis. of enlarged aneurysm placing
pressure on vasculature. Para-
lysis may indicate acute throm- Instruct patient to request Pain promotes muscle tension,
bosis of the AAA. pain medication when pain be- and may impair circulatory
comes noticeable and not to status and impair healing
Assess for complaints of pain May be an early sign of impen- wait until pain is severe. process.
that are vague or involve unre- ding complications, such as
lated areas of body. thrombophlebitis or ulcer. Instruct in methods of splinting Supports surgical incision
abdomen when coughing or deep to allow patient to expand
Administer analgesics as ordered. Provides pain relief/reduction, breathing. lungs to prevent atelectasis,
Medicate prior to painful proce- decreases anxiety, and reduces and minimizes pain level.
dures as warranted. the workload on the heart and
vasculature. Comfort and coop- Instruct in using pillows to Promotes comfort and reduces
eration with painful procedures maintain body alignment and muscle tension and strain.
may be enhanced by prior medi- support extremities.
cation administration.
Maintain bedrest with position Reduces oxygen consumption Discharge or Maintenance Evaluation
of comfort. and demand.
Maintain relaxing environment Reduces competing stimuli which

Patient will report pain being absent or relieved
to promote calmness. reduces anxiety and assists with with medication administration.
pain relief.
Medication will be administered prior to pain
Provide back rubs, reposition- Promotes relaxation and may re- becoming severe.
ing every 2 hours and prn, and direct attention from pain.
encourage diversionary activity. Analgesics may be reduced in Patient will be able to recall instructions on
dosage and frequency by mini- medications accurately.
mizing pain level.
Activity will be modified in such a way as to pre-
vent increased pain.
Risk for impaired skin integrity

[See Thrombophlebitis]
Related to: edema, bedrest, surgery, pressure,
altered circulation and blood flow, altered
metabolic states
Defining characteristics: skin surhce disruptions,
incisions, ulcerations, wounds that do not heal
Knowledge &ficit
[See MI]
Defining characteristics: questions regarding prob-
lems, inadequate follow-up on instructions given,
misconceptions, lack of improvement of previous
cations
AORTIC ANEURYSM
Degeneration of artery
J,
Weakening of arterial wall
3
Blood pressure increases tension and weakened areas
3 3
Loss of smooth muscle cells Thrombi line the surface of the aneurysm
3 J,
Dissection of artery Lumen decreases

3 J,
Increased pressures Pressure increases

3 4
Intima tears Aneurysm ruptures
3
Blood enters artery media
3
Media continues to tear further
3
Thin-walled channel created
3
Channel ruptures
I
3
Hemorrhage
3
Cardiovascular compromise and collapse
J,
Death
RESPIRATORY SYSTEM 83
Adult Respiratory Distress Syndrome (ARDS)

Chronic Obstructive Pulmonary Disease (COPD)
Pulmonary Embolism
Pneumonia
Pneumothorax
Status Asthmaticus
Mechanical Ventilation
Adult Respiratory problems, and chest x-rays may be normal or

show minimal diffuse haziness. The fluid leakage
Distress Syndrome CARDS) increases and lymphatic flow increases with the
acute phases with widespread damage to
Adult respiratory distress syndrome (ARDS) is also pulmonary capillary membranes and
known as shock lung, wet lung, white lung, or inflammation. Increases in intra-alveolar edema
acute respiratory distress syndrome, and occurs leads to capillary congestion and collagen forma-
frequently after an acute or traumatic injury or ill- tion. Surfactant production and activity decreases,
ness involving the respiratory system. The body which causes decreased functional residual capac-
responds to the injury with life-threatening respi- ity, increased pulmonary shunting with widening
ratory failure and hypoxemia. A-a gradients, decreased pulmonary compliance,
and ventilation/perfusion mismatching results.
ARDS is usually noted 12-24 hours after the ini- Chest x-rays will then show the ground glass
tial insult or 5- 10 days after sepsis occurs. appearance and finally a complete white-out of
Dyspnea with hyperventilation and hypoxemia are the lung.
usually the first clinical symptoms. Adventitious
breath sounds frequently are not present initially. The chronic phases occurs when the endothelium
thickens; Type I cells, which are the gas-exchange
Some of the most common precipitating factors pneumocytes, are replaced by Type I1 cells, which
are trauma, aspiration, pneumonia, near-drown- are responsible for producing surfactant, and
ing, toxic gas inhalation, sepsis, shock, DIC, along with fibrin, fluid and other cellular material
oxygen toxicity, coronary artery bypass, pancreati- form a hyaline membrane in place of the normal
tis, fat or amniotic embolism, radiation, head alveoli.
injury, heroin use, massive hemorrhage, smoke
inhalation, drug overdose, or uremia. Mortality is The goals of treatment are to improve ventilation
high (60-70%) despite treatment and often, and perfusion, to treat the underlying disease
patients who do survive, may have chronic resid- process that caused the lung injury, and to prevent
ual lung disease. In some cases, patients may have progression of potentially fatal complications.
normal pulmonary function after recovery. Oxygen therapy with high levels of oxygen,
mechanical ventilatory support with PEEE and
The latent phase of ARDS begins when the pul- fluid and drug management are required.
monary capillary and alveolar endothelium
become injured. The insult causes complement to
be activated, as well as granulocytes, platelets, and
MEDICAL CARE
the coagulation cascade. Free oxygen radicals, Laboratory: cultures to identify causative organ-
arachidonic acid metabolites and proteases are isms when bacterial infection is present and to
released into the system. Humoral substances, identify proper antimicrobial agent; C5A levels
such as serotonin, histamine and bradykinin, are increase with disease process; fibrin split products
released. This results in red blood cell and high increase; platelets decrease; lactic acid levels
plasma protein leakage into the interstitial spaces, increase
due to increased capillary permeability and Chest x-ray: used to evaluate lung fields; early x-
increased pulmonary hydrostatic pressure. Initially, rays may be normal or have diffuse infiltrates;
there may be little evidence of respiratory later x-rays will show bilateral ground glass
appearance or complete whiting-out of lung fields; Inefective airway clearance

assists with differentiation between ARDS and [See Mechanical Ventilation]
cardiogenic pulmonary edema since heart size is
Related to: interstitial edema, increased airway
normal in ARDS
resistance, decreased lung compliance, pulmonary
Oxygen: to correct hypoxia and hypoxemia secretions
Arterial blood gases: to identify acid-base prob- Defining Characteristics: dyspnea, tachypnea,
lems, hypocapnia, hypercapnia, and hypoxemia, cyanosis, use of accessory muscles, cough with or
and to evaluate progress of disease process and without production, anxiety, restlessness, feelings
effectiveness of oxygen therapy of impending doom
Ventilation: to provide adequate oxygenation and Anxiety
ventilation in patients who are unable to maintain [See Mechanical Ventilation]
even minimal levels
Related to: health crisis, effects of hypoxemia, fear
Pulmonary function studies: used to evaluate of death, change in health status, change in envi-
lung compliance and volumes which are normally ronment
decreased; physiologic dead space is increased and
Defining characteristics: apprehension, restless-
alveolar ventilation is compromised
ness, fear, verbalized concern
Knowledge deficit
[See Mechanical Ventilation]
Ineffective breathing pattern
Related to: lack of information, inability to
process information, lack of recall
Related to: decreased lung compliance,
Defining characteristics: verbalized concerns and
pulmonary edema, increased lung density,
questions
decreased surfactant
Defining characteristics: use of accessory muscles,
dyspnea, tachypnea, bradypnea, altered ABGs Related to: increased positive airway pressures,
sepsis, dysrhythmias, increased intrapulmonary
Impaired gas excbange
edema, left ventricular failure
Defining characteristics: tachycardia, cardiac
Related to: intra-alveolar edema, ateleccasis, venti-
output less than 4 L/min, cardiac index less than
lation/perfusion mismatching, decreased arterial
PO,, decreased amount and activity of surfactant, 2.5 Llminlm2, cold clammy skin, decreased blood
pressure
alveolar hypoventilation, formation of hyaline
membranes, alveolar collapse, decreased diffusing
capacity, shunting Outcome Criteria
Defining characteristics: tachypnea, cyanosis, use Patient will be hemodynamically stable.
of accessory muscles, tachycardia, restlessness,
mental changes, abnormal arterial blood gases,
intrapulmonary shunting increased, A-a gradient
changes, hypoxemia, increased dead space

Monitor vital signs every 1-2 Mechanical ventilation and the Monitor for peripheral or depen- May indicate fluid excess that
hours, and prn. use of PEEP increase the dent edema, or distended neck results in venous congestion and
intrathoracic pressures which veins. leads to respiratory failure.
results in compression of the
large vessels in the chest and this Auscultate lung fields for adven- Bronchovesicular sounds heard
causes decreased venous return to titious breath sounds. over entire lung fields result
the heart and decreased blood when lung density increases.
pressure. Crackles and rhonchi may be
auscultated in pulmonary edema.
Obtain PA pressures every hour, PA pressures will be elevated but
cardiac output/index every 4 wedge pressure will be normal. Monitor intake and output every Identifies fluid imbalances and
hours, and calculate other hemo- This is the classic marker to dif- hour. Notify MD if urine less possible sources.
dynamic values. ferentiate between cardiogenic than 30 cclhr.
and non-cardiogenic pulmonary Weigh every day. Weight gains of > 2 Ibs./day or 5
edema. Most ARDS patients Ibs.lweek indicate fluid reten-
have adequate cardiac function at tion.
least initially, unless decreases in
COlCI are due to PEEP. Monitor for vocal fremitus. May be present due to increased
lung density resulting from pul-
Monitor for mental changes, May indicate decreased cardiac monary. edema.
decreased peripheral pulses, cold output and decreased perfusion.
or clammy skin. Monitor vital signs. Tachycardia and elevated blood
pressure may result from fluid
excess and heart failure.
Restrict fluids as warranted. May be required to help with

fluid balance regulation.
. Patient will have adequate perfusion and cardiac
output/index within normal limits for physio-
Paiient will have no edema or weight gain.
logic condition.
Patient will have no mental status changes or
breath sounds to auscultation.
peripheral perfusion impairment.
Risk for fluid volume excess Risk for fluid volume &+kit
Related to: fluid shifts, diuretics, hemorrhage
Related to: interstitial edema, increased
pulmonary fluid with normal intravascular Defining characteristics: decreased blood pressure,
volume, transfusions, resuscitative fluids oliguria, anuria, low pulmonary artery wedge pres-
sures
Defining characteristics: edema, dyspnea, orthop-
nea, rales, wheezing
Outcome Criteria
Outcome Criteria Patient will achieve and maintain a normal and
balanced fluid volume status and be hemodynami-
Patient will be hemodynamically stable, with no
cally stable.
signs of pulmonary edema.
Monitor vital signs every 1-2 Tachycardia, hypotension and
hours, and prn. decreases in pulse quality may
indicate fluid shifting has
resulted in volume depletion.
Temperature elevations with
diaphoresis may result in
increased insensible fluid loss.
Monitor intake and ouput every Continuing negative balances

hour, and notify MD of signifi- may result in volume depletion.
cant fluid imbalances.
Weigh daily. Changes in weight from day to

day may correlate to fluid shifts
that may occur.
Observe skin turgor and hydra- Decreases in skin turgor, tenting

tion status. of skin, and dry mucous mem-
branes may indicate fluid volume
deficits.
Administer IV fluids as ordered. Replaces fluids and maintains

circulating volume.
Monitor labwork for sodium and Diuretic therapy may result in

potassium levels. hypokalemia and hyponatremia.

Patient will achieve normal fluid balance.
Patient will be hemodynamically stable, with no

weight change.
Patient will have urine output within normal
limits.
~
ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)
Triggering event
c
Cellular damage
3
Increased capillary permeability
3
Plasma proteins leak into interstitial spaces
I
Inflammatory !ells aggregate
Fibrin and cell debris aggregate
Lymph flb blocked
3 c
Hyaline membrane formed Increased interstitial fluid
c c
Decreased oxygen diffusion Non-cardiogenic pulmonary edema
4 c
Hypoxemia J-receptors activated
c 3
Alveolar collapse Tachypnea
c 3
Decreased lung compliance Decreased PaC02
3 3
Shunting through non-ventilated Hypoxemia
areas of lungs
3 c
Increased A-a gradient Decreased PaO2
3 3
Increased work of breathing Increased dyspnea
I
I Worsening hypoxemia
c
Circulatory collapse
3
Organ failure
c
DEATH
Chronic Obstructive bouts of cor pulmonale, or right-sided heart fail-

ure, resulting in peripheral edema.
Pulmonary Disease The most common precipitating factors for
COPD include cigarette smoking, air or environ-
(I:0 P D) mental pollution, allergic response, autoimmunity,
and genetic predisposition. Treatment is aimed at
Chronic obstructive pulmonary disease (COPD) avoidance of respiratory allergens and irritants,
is irreversible condition in which airways become controlling bronchospasms, and improving airway
obstructed and resistance to air flow is increased
clearance.
during expiration when airways collapse. COPD is
usually further subdivided into other diseases such
as bronchitis and emphysema, and actually COPD
refers to these simultaneous disease entities. Laboratory: cultures used to identify causative
organisms and determine appropriate antimicro-
Emphysematous changes include enlarging of the
bial therapy; CBC used to identify presence of
air spaces distally to the terminal bronchioles, and
infection with elevated white blood cell count,
concurrent changes in alveolar walls. Capillary
and to monitor for increases in RBCs and hemat-
numbers decrease in the remaining walls and may
ocrit as the body tries to compensate for oxygen
sclerose. Gas exchange is decreased due to the
transport requirements; alphal-antitrypsin levels
reduction in available alveolar surfaces as well as
used to identify deficiency that may be present if
decreased perfusion to non-ventilated areas.
patient has heredity predisposition; theophylline
Ventilation/perfusion mismatching occurs and
levels used to monitor for therapeutic levels
functional residual capacity is increased. The
and/or toxicity
anteroposterior diameter of the chest is often
enlarged due to the loss of elasticity and increased Pulmonary function studies: used to evaluate pul-
air trapping in the airway supportive structures. monary status and function, and to identify
These type A patients are often called “pink airway obstruction, increased residual volume,
puffers” because of the increased response to total lung capacity, compliance, decreased vital
hypoxemia. Symptoms include dyspnea and capacity, diffusing capacity, and expiratory
increase in breathing effort, which result in a volumes with emphysema patients; increased
well-oxygenated, or pink, patient who displays residual volume, decreased vital capacity and
overt dyspnea, or puffing. forced expiratory volumes with normal static com-
pliance and diffusion capacity with bronchitis
Bronchitis is usually associated with prolonged
patients
exposure to lung irritants, which results in inflam-
matory changes and thickening of bronchial walls, Chest x-ray: used to identify hyperinflation of
and increases in mucous production. The patient lungs, flattened diaphragm, or pulmonary hyper-
exhibits a chronic productive cough due in part to tension; used to identify barotrauma that may
the increase in size of mucous glands and decrease occur, increased antero-posterior chest diameter,
in cilia. These type B patients are often called large retrosternal air spaces, or secondary cardio-
“blue bloaters” because their response to vascular complications with right-sided heart
hypoxemia is reduced, with increasing PaC02 failure
levels and cyanosis. These patients frequently have
Electrocardiography: used to identify Defining characteristics: dyspnea, tachypnea,

dysrhythmias associated with this disease; tall p bradypnea, bronchospasms, increased work of
waves in inferior leads, vertical QRS axis, atrial breathing, use of accessory muscles, increased
dysrhythmias, right ventricular hypertrophy, sinus mucous production, cough with or without pro-
tachycardia, and right axis deviation ductivity, adventitious breath sounds
Oxygen: used to improve hypoxemia; liter flow Inefective breathing pattern
should be low in order to maintain the patient's [See Mechanical Ventilation]
respiratory drive; PaO, may be acceptable at 55-
Related to: pain, increased lung compliance,
60 mmHg to avoid hypoventilation and maintain
decreased lung expansion, fear, obstruction,
function
decreased elasticity/recoil
IV fluids: used to maintain hydration and for
Defining characteristics: dyspnea, tachypnea, use
administration of medical therapeutics
of accessory muscles, cough with or without pro-
Bronchodilators: xanthines and sympathomimet- ductivity, adventitious breath sounds,
ics are used to relieve bronchospasms and help to prolongation of expiratory time, increased
promote clearance of mucoid secretions mucous production, abnormal arterial blood gases
Antibiotics: used to treat respiratory infections Impaired gas exchange
Arterial blood gases: used to identify acid-base
disturbances, presence of hypoxemia and hyper- Related to: obstruction of airways, bronchospasm,
capnia, and to evaluate responses to therapies air-trapping, right-to-left shunting,
ventilation/perfusion mismatching, inability to
Chest physiotherapy: percussion and postural
move secretions, hypoventilation
drainage are used to facilitate mobilization of
secretions and promote clearance of airways Defining characteristics: hypoxemia, hypercapnia,
mental changes, confusion, restlessness, dyspnea,
Corticosteroids: used to decrease secretions and
vital sign changes, inability to tolerate activity, res-
reduce inflammation in the lungs; use of steroids
piratory acidosis
is controversial
Psychological treatment: use of anti-anxiety
Anxiev
agents to decrease fear and anxiety related to dysp-
nea, without sedation to depress the respiratory Related to: threat of death, change in health
drive; psychotherapy may be required to enable status, life-threatening crises
patients to cope with their ongoing disease process
Defining characteristics: fear, restlessness, muscle
tension, helplessness, communication of
NURSING CARE PLANS uncertainty and apprehension, feeling of
Ingective airway clearance suffocation
Activity intolerance
Related to: bronchospasm, fatigue, increased work Related to: fatigue, weakness, increased effort and
of breathing, increased mucous production, thick
work of breathing, inadequate rest, hypoxia,
secretions, infection hypoxemia
Defining characteristics: dyspnea, decreased Information, Instruction,

oxygen saturation levels with movement or activ- Demonstration
ity, increased heart rate and blood pressure with
movement or activity, feelings of tiredness and INTERVENTIONS RATIONALES
weakness
Instruct on techniques to save Helps CO decrease energy expen-
energy expenditure: shower diture and fatigue, which may
Outcome Criteria stools, arm and leg rests, gather- result in increased dyspnea.
ing required articles and
placement within reach, etc.
Patient will be able to tolerate minimal activity
without respiratory compromise. Provide patient with exercise Promotes independence and self-
regimen protocol. worth; increases tolerance to
exercises.
~~~ ~
INTERVENTIONS RATIONALES Instruct on breathing exercises to Promotes effective respiratory

be performed with activicy. patterns during exertion.
Monitor for patient’s response to Identifies patient’s ability to
activity changes. , compensate for increases in activ-
ity and provides baseline date
from which to plan care.
Patient will be able to tolerate activity without
Monitor vital signs before, Increases in heart rate greater
excessive dyspnea or hemodynamic instability,
during, and after increased activ- than lolminute or respiratory
ity levels. rate greater than 32 may Patient will be able to perform ADLs within
indicate that patient has reached
his maximal activity limit and limits of disease process.
further activity may result in
circulatorylrespiratory
Patient will be able to recall information accu-
dyshnction. rately, and will be able to utilize relaxation and
breathing techniques effectively.
Plan activities to ensure patient Decreases potential for dyspnea
obtains adequate amounts of rest and provides rest to prevent
Patient will be compliant with prescribed exer-
and sleep. excessive fatigue.
cise regimens.
Assist patient with activities as Conserves energy and decreases
warranted. oxygen consumption and dysp- Ineffective individuaUfamily coping
nea. [See Mechanical Ventilation]
Increase activity gradually and Gradual increases facilitate
Related to: changes in lifestyle and health status,
encourage patient participation. increased tolerance to activity by
balancing oxygen supply and sensory overload, fear of death, physical
demand, and patient cooperation Gmitations, inadequate support system, inadequate
may facilitate feelings of self- coping mechanisms, continual dyspnea
worth and adequacy.
Administer inhalers as ordered Helps prevent dyspnea by per-

Defining characteristics: inability to meet role
prior to activities. forming activities at peak time of expectations, inability to meet basic needs,
medication effects. constant worry, apprehension, fear, inability to
problern-solve, anger, hostility, aggression, inap-
propriate defense mechanisms, low self-esteem,
insomnia, depression, destructive behaviors, vacil-
lation when choices are required, delayed
decision-making, muscle tension, fatigue
Risk for infiction food, increased metabolism due to disease process,

decreased level of consciousness, fatigue, increased
Related to: disease process, inability to move sputum, medication side effects
secretions, decreased cilia function, immunosup-
pression, poor nutrition Defining characteristics: actual inadequate food
intake, altered taste, altered smell sensation,
Defining characteristics: increased temperature, weight loss, anorexia, absent bowel sounds,
chills, elevated white blood cell count, inability to decreased peristalsis, muscle mass loss, changes in
move secretions bowel habits, abdominal distention, nausea, vom-
iting
INTERVENTIONS RATIONALES Knowledge &+it

Monitor for increased dyspnea, Yellow or green sputum, with Related to: lack of information, lack of recall of
sputum color and character increased viscosity usually
changes, cough, and temperature indicates infection. Prompt
information, cognitive limitations
elevation. recognition facilitates prompt
Defining characteristics: request for information,
treatment.
statement of misconception, statement of
Obtain sputum specimen for Identifies the causative organism concerns, development of preventable complica-
culture and sensitivity as ordered. and provides information regard-
ing appropriate antimicrobial
tions, inaccurate follow-through with instructions
agent required.
Administer antibiotics as Controls and clears the infection Outcome Criteria

ordered. and any secondary infections in
che bronchial tree. Improvement Patient will be able to recall information
should be noted within 24-48 accurately and will follow through with all instruc-
hours after antimicrobial agent
has begun. tions.
Monicor for abrupt changes in May indicate presence of
other body systems; cardiac secondary infeccion or resistance
abnormalities and alteration in to ordered antibiotics. INTERVENTIONS RATIONALES
heart sounds, increasing pain, Superinfections, systemic bac-
Assess knowledge of COPD dis- Identifies level of knowledge and
changes in mental status, recur- teremia, inflammatory cardiac
ease process, medicacions, and provides baseline from which CO
ring temperature elevations. conditions, meningitis or
treatments. plan teaching.
encephalitis may occur.
Instruct on medication effects, Promotes knowledge and com-
Provide adequace rest time for Helps to facilitate healing and
side effects, contraindications, pliance with treatment regimen.
patient. natural immunity.
and signslsymptoms to report.
Discharge or Maintenance Evaluation Instruct in proper technique for Proper technique, including
using and cleaning inhalers. appropriate time intervals
Patient will exhibit no signs/symptoms of sec- between puffs, facilitates effective
delivery and therapeutic effect.
ondary infection.
Instruct on need to avoid smok- May initiate and exacerbate
Altered nutrition: less tban body ing and other respiratory bronchial irritation which can
requirements irritants. resulr in increased mucous pro-
[See Mechanical Ventilation] duction and airway obstruction.
Instruct on effective coughing Effective coughing reduces

Related to: dyspnea, inability to take in sufficient
INTERVENTIONS RA'IIONALES INTERVENTIONS RATIONALES

techniques; postural drainage, fatigue and facilitates removal of Assist patientlfamily to set redis- Provides a plan for patient and
chest physiotherapy, etc. secretions. Percussion and pos- tic goals for long- and facilitates self-involvement with
tural drainage help to mobilize short-term. realistic goals and methods to
tenacious secretions. meet them. Fosters independence
and reduces anxiety.
Instruct to drink 10-12 glasses of Maintains hydration and pro-
water per day. motes easier mobilization of
secretions. Discharge or Maintenance Evaluation
Instruct on use of supplemental COPD patients will rarely
oxygen at low flow rates, and require more than 2-3 Llmin to
Patient will be able to recall information regard-
reasons to avoid increasing flow maintain their optimum oxy- ing disease process and treatment regimen.
indiscriminately. genation levels. Increasing flow
rates will increase their PaOz but Patient will be able to recall accurately the
may decrease their respiratory signs/symptoms for which to notify MD, the
drive and may result in drowsi- effects and side effects of medications, and
ness and confusion.
proper procedure for using inhalers.
Instruct on oxygen safery: avoid- Promotes physical and environ-
ing flammable objects, use of mental safety. Patient will be able to demonstrate accurately
vaseline or other petroleum proper cough techniques, pursed-lip breathing,
products, and ambulation with and proper positioning to facilitate breathing.
tubing.
Instruct on avoiding sedative or Sedative may result in respiratory Patiendfamily will be able to access support sys-
antianxiety drugs as warranted. depression and impair cough tems effectively.
reflexes.
Instruct on avoiding people with Prevents exposure to other infec-

infections; encourage patient to tions, and decreases potential for
obtain influenza and pneumonia incidence of upper respiratory
vaccinations as warranted. infections.
Instruct on activity limitations, Helps decrease fatigue, optimizes

methods to conserve energy and activity level within range of
promote rest, pursed-lip breath- disease process, and reduces dys-
ing, etc. pnea and oxygen consumption.
Instruct on signslsymptoms to Provides for prompt recognition

notify MD: increased tempera- of infection to facilitate prompt
ture, change in sputum color or intervention prior to respiratory
character, increasing dyspnea. failure.
Instruct to continue with follow- Provides for monitoring of pro-

up medical care. gression of disease, presence of
complications, or exacerbations,
and facilitates changes in medical
regimen to concur with current
medical condition.
Provide patient/family with Support groups may be required

information regarding support to provide emotional assistance
groups, such as the American and respite for caregiver(s).
Lung Association, etc.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (C 0 P D)
(smoking,pollution, infection)
4
Inff ammation
4
Alphal-antitrypsin inhibited
s
Elastase production
4
Lung elastin broken down
I
1 I
EMPHYSEMA CHRONIC BRONCHITIS
(Pink Puffers) (Blue Bloaters)
Increased response to hypoxemia Decreased response to hypoxemia

c c
Terminal air spaces enlarged Hypertrophy and hyperplasia of mucus glands
4 s
Destruction of alveolar walls Goblet cell metaplasia
s s
Loss of elastic recoil Increased mucus production and viscosity
J, c
Increased air trapping Mucus plugs in airways decrease airway size
s 4
Airways collapse, decreasing gas exchange surface Bronchial wall thickening increased
s s
Decreased resistance to lung expansion Increased airway resistance, decrease
Increased lung volumes in vital capacity and expiratory flow rates
4 4
Ventilationlperfusion mismatching Hypoxemia
4
Air sacs replaced by bullae
c
Increased PaCO2
4 s
Increased dyspnea and work of breathing Increased pulmonary constriction
Hypoxia
4
Further pulmonary constriction
Increased pulmonary artery pressures
4
(See Next Page)
C 0 P D continued
Pulmonary hypertension
4
Right ventricular strain
4
Right ventricular hypertrophy
4
Right ventricular failure
Cor Pulmonde
4
Left ventricular failure
4
Circulatory collapse
J
Death
chest pain, and cough with hemoptysis. Other

symptoms may be present, such as
A pulmonary embolus (PE) usually results after a lightheadedness, diaphoresis, cyanosis, pleural fric-
deep vein thrombus partially or totally dislodges tion rubs, S, split, tachypnea, tachycardia, anxiety,
from the pelvis, thigh, or calf. The clot then lodges mental changes, gallops, dysrhythmias, rales, and
hypot:ension, but are dependent on the size of the
in one or more of the pulmonary arteries and
obstructs forward blood flow and oxygen supply to embolus and presence of infarction or complica-
the lung parenchyma. Pressure is backed up and tions.
results in increased pulmonary artery pressures and
vascular resistance, right ventricular failure, tachy- MEDICAL CARE
cardia, and shock. Alveolar dead space is increased Laboratory: PTTs done daily to monitor heparin
which results in ventilation/perfusion mismatching therapy; LDH may be elevated in pulmonary
and decreased PaO,. The embolus releases chemi- embolus, but other diagnoses must be ruled out;
cals that decrease surfactant and increase fibrin split products usually increase consistently
bronchoconstriction. Hyperventilation due to with PE; CBC may show increased hematocrit
carbon dioxide retention results in decreased due to hemoconcentration, and increased RBCs
PaCO,. Fat embolism, septic embolism, or amni-
otic fluid embolism are rarely causes of PE and Chest x-ray: used to rule out other pulmonary
when they are, usually occlude smaller arterioles or diseases; shows atelectasis, elevated diaphragm and
capillaries. A pulmonary embolus is classified as pleural effusions, prominence of pulmonary artery,
being massive when more than half the pulmonary and occasionally, a wedge-shaped infiltrate com-
artery circulation is occluded. monly seen in pulmonary embolism
Infarction of the pulmonary circulation occurs less Nuclear radiographic testing: lung scans are used
than 10 per cent of the time and usually results to show perfusion defects beyond occluded vascu-
when the patient has an underlying chronic car- lature; xenon ventilation scans are used to
diac or pulmonary disease. Pulmonary infarcts differentiate between pulmonary embolism and
may be reabsorbed and fibrosis may cause scar COPD, and together with perfusion scans, will
tissue formation. Usually collateral pulmonary cir- reveal ventilation/perfusion mismatchl:;
culation maintains lung tissue viability. Pulmonary angiography: used as a definitive test
The main risk factors that may predispose when other tests do not ensure the diagnosis in
pulmonary embolism formation are bedrest, high-risk patients; identifies intra-arterial filling
immobility, cardiac disease, venous disease, preg- defects and obstruction of pulmonary artery
nancy, malignancy, fractures, estrogen branches
contraceptives, obesity, burns, blood dyscrasias, Electrocardiography: used to reveal right axis
surgery, and trauma. Thrombus formation occurs deviation, right-sided heart strain, right bundle
with blood flow stasis, coagulopathy alterations, branch block, tall peaked P waves, ST segment
and damage to the endothelium of the vessel walls, depression and T wave inversion, as well as
and these three factors are known as Virchow’s supraventricular tachydysrhythmias
triad.
Phlebography: used to identifj. deep vein throm-
The most common signs/symptoms are dyspnea, bosis in legs
Oxygen: to provide supplemental oxygen to main- Defining characteristics: dyspnea, use of accessory
tain oxygenation muscles, shallow respirations, tachypnea, increased
Pulmonary artery catheterization: used to place work of breathing, decreased chest expansion on
catheter to enable hemodynamic monitoring and involved side, cough with or without productivity)
to assess response to therapies adventitious breath sounds
Arterial blood gases: used to assess for hypoxemia

Outcome Criteria
and acid-base imbalances
Thoracentesis: may be used to rule out empyema Patient will be eupneic with clear lung fields and
if pleural effusion is noted on chest x-ray arterial blood gases within normal limits.
Beta-blockers: used in pulmonary hypertension to

dilate the pulmonary vasculature to increase tissue INTERVENTIONS RATIONALES
per fusion
Monitor respiratory status for In PE, respiratory rate is usually
Cardiac glycosides: used only if absolutely manda- changes in rate and depth, use of increased. The effort of breath-
accessory muscles, increased ing is increased and dyspnea is
tory during the acute hypoxemia phase due to the
work of breathing, nasal flaring, ofien the first sign of PE.
potential for lethal dysrhythmias or cardiac failure and symmetrical chest expansion. Depending on the severity and
location of the PE, depth of res-
Analgesics: used to alleviate pain and discomfort pirations may vary. Chest
expansion may be decreased on
Anticoagulants: heparin is used initially in the the affected side due to atelecta-
treatment of PE, with change to coumadidwar- sis or pain.
farin PO for 3-6 months
Provide supplemental oxygen via Provides oxygen and may
Thrombolytics: streptokinase or urokinase nasal cannula or mask. decrease work of breathing.
enhances conversion of plasminogen to plasmin to Monitor for presence of cough Bloody secretions may result
prevent venous thrombus and character of sputum. from pulmonary infarction or
abnormal anticoagulation. A dry
Antiplatelet drugs: aspirin and dipyridamole used cough may result with alveolar
congestion.
to prevent venous thromboembolism
Auscultate lung fields for adven- Breath sounds may be dimin-
Surgery: embolectomy may be performed to titious breath sounds andlor ished or absent if airway is
remove the clot; umbrella filter may be placed or rubs. obstructed due to bleeding, clot-
surgical interruption of the inferior vena cava may ting, or collapse. Rhonchi or
wheezing may result in conjunc-
be performed to prevent migration of clots into tion with obstruction.
the pulmonary vasculature
Auscultate heart sounds. Splitting of S, may occur with
pulmonary embolus.
NURSING CARE PLANS Encourage deep breathing and Improves lung expansion and
Inefective breathing pattern effective coughing exercises. helps to remove secretions which
may be increased with PE.
Related to: increase in alveolar dead space, physio-
logic lung changes due to embolism, bleeding,
increased secretions, decreased lung expansion,
inflammation
Information, Instruction, 4 L/min or cardiac index less than 2.7 L/min/m2,

Demonstration cold, pale extremities, EKG changes, hypotension,
S, split sounds, S3 or S4 gallops, dyspnea, crackles
INTERVENTIONS RA'TIONALES (rales), chest pain
Prepare patientlfamily for place- May be required if respiratory Risk f i r altered tissue p&ion: cardiopuL-
ment on mechanical ventilation. distress is severe.
monaly, peripheral, cerebral
Instruct on avoiding shallow Eupnea decreases potential for
respirations and splinting. atelectasis and improves venous Related to: impaired blood flow, alveolar
return. perfusion and gas exchange impairment, occlusion
Prepare patiendfamily for bron- May be required to remove of the pulmonary artery, migration of embolus,
choscopy as warranted. mucous plugs andlor clots in hypoxemia, increased cardiac workload
order to clear airways.
Defining characteristics: dyspnea, chest pain,
Discharge or Maintenance Evaluation tachycardia, dysrhythmias, productive cough,
hemoptysis, edema, cyanosis, syncope, jugular vein
Patient will be able to maintain his own respira- distention, weak pulses, hypotension, convulsions,
tions without mechanical assistance. loss of consciousness, restlessness, hemiplegia,
coma
Patient will be eupneic, with no adventitious
lung or heart sounds.
Outcome Criteria
Patient will be able to recall all information
accurately. Patient will be hemodynamically stable, eupneic,
with no alterations in perfusion to any body
system.
Related to: atelectasis, airway obstruction, alveolar
collapse, pulmonary edema, increased secretions, INTERVENTIONS RA'TIONALES
active bleeding, altered blood flow to lung, shunt- Monitor vital signs and notify Hypoxemia will result in
ing MD for significant changes. increased heart rate as the body
tries to compensate for the
Defining characteristics: dyspnea, restlessness, decrease in perfusion.
anxiety, apprehension, cyanosis, arterial blood gas Monitor EKG for rhythm distur- Hypoxemia, right-sided heart
changes, hypoxemia, hypoxia, hypercapnia, bances and treat as indicated. strain, and electrolyte imbalances
decreased oxygen saturation may induce dysrhythmias.
Auscultate for S, or S4 heart Increases in heart workload may

Risk for decreased cardiac output sounds. result in heart strain and failure
[See Heart Failure] as perfusion decreases, and may
result in gallop rhythm.
Related to: dysrhythmias, cardiogenic shock, heart
failure Monitor for presence of periph- Presence of deep vein thrombus
eral pulses and notify MD for may occlude the circulation and
Defining characteristics: elevated blood pressure, significant changes. result in diminished or absent
pulses.
elevated mean arterial blood pressure, elevated sys-
temic vascular resistance, cardiac output less than Assess for Homan's and Pratt's Presence of these signs may or
signs. may not be related to PE.
Assess skin color, temperature Impairment of blood flow may
and capillary refill. induce pallor or cyanosis to the
slun or mucous membranes.
Cool clammy skin or mottling
may indicate peripheral vasocon-
strictiodshock.
Monitor for restlessness or May indicate occlusion, impaired

changes in mental status or level cerebral blood flow, hypoxia, or
of consciousness. development of stroke.
Demonstration
Prepare patient for insertion of May be required to monitor
pulmonary artery catheter. hemodynamic status and assess
response to therapy.
Prepare patient for surgery as Surgical intervention may be

warranted. required if patient develops
recurrent emboli in spite of treat-
ment, or if anticoagulant therapy
cannot be given. Ligation of the
vena cava or insertion of an
umbrella filter may be necessary.
Instruct on thrombolytic agents Streptokinase, urokinase, or

as warranted. alteplase (t-PA) may be required
if the pulmonary embolus is
massive and compromises hemo-
dynamic stability.

body systems.
Patient will have stable hemodynamic parame-
ters and vital signs will be within normal limits.
Oxygenation will be optimal as evidenced by
pulse oximetry greater than 90% and adequate
ABGs.
PULMONARY EMBOLISM
Embolus obstructs blood flow
Chemicals released Pulmonary pressures increased Alveolar dead space increased

4 4 c
Bronchoconstriction Pulmonary vasoconstriction Ventilation perfusion
Pulmonary hypertension mismatch
4 J, J,
Decreased P a 0 2 Right ventricular failure Increased airway resistance

4 Decreased lung compliance
Decreased cardiac output 4

Hypotension
4
-
Pulmonary vasoconstriction
c
W Decreased tissue perfusion Decreased PaOZ
c
Cardiopulmonary collapse
c
Death
influenza, malnutrition, smoking, alcoholism,

immuriosuppressive therapy, aspiration, sickle cell
Pneumonia is an acute infection of the lung's ter- disease, head injury or coma.
minal alveolar spaces and/or the interstitial tissues Aspiration pneumonia occurs after aspiration of
which results in gas exchange problems. The gastric or oropharyngeal contents, or other chemi-
major challenge is identification of the source of cal irritants into the trachea and lungs. Stomach
the infection. Pneumonia ranks as the sixth most acid damages the respiratory endothelium and
common cause of death in the United States. may result in non-cardiogenic pulmonary edema,
When the infection is limited to a portion of the hemorrhage, destruction of surfactant-producing
lung, it is known as segmental or lobular pneumo- cells, and hypoxemia. The p H of the aspirated
nia; when the alveoli adjacent to the bronchioles material determines the severity of the injury with
are involved, it is known as bronchopneumonia, p H less than 2.5 causing severe damage.
and when the entire lobe of the lung is involved, it Morbidity is high even with treatment.
is known as lobar pneumonia. In pneumonia's early stages, pulmonary vessels
Pneumonia may be caused by bacteria, viruses, dilate and erythrocytes spread into the alveoli and
mycoplasma, rickettsias, or fungi. The causative cause a reddish, liver-like appearance, or red hepa-
organism gains entry by aspiration of oropharyn- tization, in the lung consolidation area.
geal or gastric contents, inhalation of respiratory Polymorphonuclear cells then enter the alveolar
droplets, from others who are infected, by way of spaces and the consolidation increases to a grey
the blood stream, or directly with surgery or hepatization. The leukocytes trap bacteria against
trauma. the alveolar walls or other leukocytes so that more
organisms are found in the increasing margins of
Viral types are more common in some areas, but the consolidation. The macrophage reaction
identification of causative organisms may be diffi- occurs when mononuclear cells advance into the
cult with limited technology. alveoli and phagocytize the exudate debris.
Patients who develop bacterial pneumonia usually Diagnosis may be assisted with the observation of
are immunosuppressed or compromised by a sputum characteristics, with bacterial pneumonia
chronic disease, or have had a recent viral illness. having mucopurulent sputum, viral and mycoplas-
The most common type of bacterial pneumonia is mic pneumonias having more watery secretions,
pneumococcal pneumonia, in which the organism pneurnococcal pneumonia having rust-colored
reaches the lungs via the respiratory passageways sputum, and Klebsiella noting dark red mucoid
and result in the collapse of alveoli. The inflam- secretions.
matory response that this generates causes
The initial signs/symptoms are sudden onset of
protein-rich fluid to migrate into the alveolar
shaking chills, fever, purulent sputum, pleuritic
spaces and provides culture media for the organ-
chest pain that is worsened with respiration or
ism to proliferate and spread.
coughing, tachycardia, tachypnea, and use of
Frequently pneumonia is predisposed by upper accessory muscles.
respiratory infections, chronic illness, cancer,
Staphylococcal pneumonia is frequently noted
surgery, atelectasis, chronic obstructive pulmonary
after influenza or in hospitalized patients with a
disease, asthma, cystic fibrosis, bronchiectasis,
nosocomial superinfection following surgery, Chest x-ray: used to demonstrate small effusions
trauma, or immunosuppression. Pleural pain, dys- and abscesses, pulmonary consolidations, and
pnea, cyanosis, and productive coughing with empyema; may be clear with mycoplasma pneu-
copious pink secretions are common symptoms. monia
Streptococcal pneumonia occurs rarely with the
Oxygen: used to supplement room air, and to
exception as a complication after measles or
treat hypoxemia that may occur
influenza. Klebsiella pneumonia is virulent and
necrotizing, and is usually seen with alcoholic or Antibiotics: used in the treatment after culture
severely debilitated patients. Pneumonia that is results are obtained to eradicate the infective
caused by Hemophilus influenzae occurs after organ ism
viral upper respiratory infections, or concurrently
Thoracentesis: used to remove fluid if pleural
with bronchopneumonia, bronchitis, and bronchi-
fluid is present; assists in the diagnosis of pleural
olitis. Sputum is usually yellow or green, and
empyema
patients have fever, cough, cyanosis, and arthral-
gias. Viral pneumonia may be caused by influenza, Surgery: may be required for open lung biopsy or
adenoviruses, respiratory syncytial virus, treatment of effusions and empyema;
rhinoviruses, cytomegalovirus, herpes simplex bronchoscopy with bronchial brushing may be
virus, and childhood diseases; it is usually milder. indicated for progressive pneumonias that are
Symptoms include headache, anorexia, and occa- unresponsive to medical treatment
sionally mucopurulent sputum that is bloody.
Nerve blocks: intercostal blocks may be required
to control pleuritic pain
MEDICAL CARE
Laboratory: white blood cell count may be NURSING CARE PLANS
normal or low but usually is elevated with poly-
morphonuclear neutrophils; cultures of sputum,
Inefective airway clearance
blood, and CSF may be obtained to identify the Related to: inflammation, edema, increased secre-
causative organism and antimicrobial agent best tions, fatigue
suited for eradication; electrolytes may show
decreased sudium and chloride levels; serology and Defining characteristics: adventitious breath
cold agglutinins may be done for identification of sounds, use of accessory muscles, cyanosis, dysp-
viral titers; sedimentation rate is usually elevated nea, cough with or without production
Pulmonary function studies: used to evaluate ven- Outcome Criteria

tilation/perfusion problems; volumes may be
decreased due to alveolar collapse; airway pressures Patient will maintain patency of airway, have clear
may be increased; lung compliance may be breath sounds, and will be able to effectively clear
decreased secretions.
Arterial blood gases: to evaluate adequacy of
oxygen and respiratory therapies, as well as to
identify acid-base imbalances and
acidotic/alkalotic states
INTERVENTIONS RATIONALES Alteration in comfort

[See MI]
Monitor respiratory status for Tachypnea and hyperpnea are
changes, increased work of frequently noted with Related to: inflammation, dyspnea, fever,
breathing, use of accessory mus- pneumonia. coughing
cles, and nasal flaring.
Defining characteristics: pleuritic chest pain wors-
Observe for symmetrical chest Unilateral pneumonia will result
expansion. in asymmetrical chest movement ened with respiration or cough, muscle aches,
due to decreased lung compli- joint pain, restlessness, communication of
ance on the affected side and pain/discomfort
because of pleuritic pain.
Observe for cyanosis andlor May indicate impending or pre-

Risk for altered nutrition: less than body
mental status changes. sent hypoxemia. requirements
Assess vocal fremitus. Increased fremitus is noted over
consolidated areas in pneumonia.
Related to: increased metabolic demands, fever,
Decreased or absent fremitus
may indicate that a foreign body infection, abnormal taste sensation, anorexia,
is obstructing a large bronchus. abdominal distention, nausea, vomiting
Percuss chest for changes. Percussion may be dull over Defining characteristics: actual inadequate food
consolidated areas or in areas of
atelectasis.
weight loss, anorexia, nausea, vomiting, abdominal
Auscultate lung fields. Fine crackles or bronchial breath
distention, decreased muscle mass and tone
sounds are noted in lobar pneu-
monia; in other types of
pneumonia, bronchial sounds are
Risk f i r fluid volume d$cit
rarely heard. Wheezes may indi-
[See ARDS]
cate aspiration of a solid object.
Inspiratory stridor may indicate
Related to: fluid loss from fever, diaphoresis, or
the presence of an obstruction to vomiting, decreased fluid intake
a large bronchus.
Assist with bronchoscopy as May be required to remove oliguria, anuria, low pulmonary artery wedge
warranted. mucous plugs and prevent or
improve atelectasis.
pressures
Assist with thoracentesis as May be required to drain puru- Risk for fluid volume excess
warranted. lent fluid. [See ARDS]
Related to: inflammatory response, pulmonary
Impaired gas exchange edema
Defining characteristics: rales, crackles, wheezing,
Related to: inflammation, infection, pink ftothy sputum, abnormal arterial blood gases
ventilation/perfusion mismatching, fever, changes
in oxyhemoglobin dissociation curve Knowledge de$cit
Related to: lack of information, competing stim-
Defining characteristics: dyspnea, tachycardia,
uli, misinterpretation of information
cyanosis, hypoxia, hypoxemia, abnormal arterial
blood gases Defining characteristics: request for information,
failure to improve, development of preventable
complications
Outcome Criteria
Patient will be able to verbalize and demonstrate
understanding of information.
Instruct on need for vaccines for Influenza increases the chance of
influenza and pneumonia. secondary pneumonia infection;
vaccinations help to prevent the
occurrence and spread of infec-
tive process.
Instruct in continued need for Patient is at risk for recurrence of

coughing and deep breathing. pneumonia for 6-8 weeks follow-
ing discharge.
Instruct in importance of contin- Helps prevent complications and

uing with follow-up medical recurrence of pneumonia.
care.
Instruct in need to quit or avoid Smoking destroys the action of

smoking. the cilia and impairs the lungs’
first line of defense against
infection.

Patient will be able to accurately verbalize
understanding of all instructions.
Patient will be compliant in avoiding smoking.
Patient will not have preventable complications
from illness.
PNEUMONIA
t
Defect in defense and immunity
Airborne pathogenic or direct contact spread
c
Virulent microorganisms
1 Overwhelming exposure
I I
I
Infectious organism lodges in bronchioles
c
Alveolar collapse
4
Inflammation of interstitial
tissues of lungs
c
Vascular engorgement of alveoli with fluid
c
RBCs and fibrin move into alveoli
c
Fibrin accumulates
Disintegration of RBCs and fibrin
c
Exudate digesjed by enzymes
4
Action provides excellent culture media to increase spread of organisms
c
Consolidation
Removal of pathogenic mucus by Continued infection despite use of

coughing, suctioning, or macrophagic action antimicrobial therapy
4 JI
RESOLUTION Abscess formation
c
Necrosis of pulmonary tissues
c
Overwhelming sepsis
c
DEATH
A hemothorax not only results in

cardiopulmonary effects, but also may involve
A pneumothorax occurs when free air accumulates problems with hemorrhagic shock. The rate at
in the pleural cavity benveen the visceral and pari- which shock may occur depends on the source
etal areas, and causes a portion or the complete and rapidity of bleeding.
lung to collapse. Pressure in the pleural space is The severity of a pneumothorax, no matter what
normally less than that of atmospheric pressure the origin, relates to the degree of collapse. A
but following a penetration injury, air can enter small partial pneumothorax may resolve by itself
the cavity from the outside changing the pressure when the air is reabsorbed. In cases where collapse
within the lung cavity and causing it to collapse. is more than 20-30 percent, a closed, water-seal
Air can also migrate to the area when the esopha- drainage system and insertion of a chest tube via a
gus is perforated or a bronchus ruptures, leaking lateral intercostal space is required. In cases where
air into the mediastinum (pneumomediastinum). rapid re-expansion is desired, 15-25 cm H 2 0 suc-
Barotrauma related to mechanical ventilatory sup- tion may be added to the drain system.
port using high levels of PEEP leads to alveoli
rupture and collapse. Gas formation from gas- A pneumothorax may result spontaneously or
forming organisms can also result in with trauma, such as a penetrating chest wound,
pneumothorax. gunshot wound, knife wound, or after a procedure
such as insertion of a centrally placed venous
Pneumothorax may occur spontaneously in cases catheter line. Some symptoms of pneumothorax
where a subpleural bleb or emphysematous bulla include abrupt onset of pleuritic chest pain, short-
ruptures due to chronic obstructive pulmonary ness of breath, decreased or absent breath sounds,
disease, tuberculosis, cancer, or infection and this tachycardia, tachypnea, hyperresonant percussion,
is the most common reason in otherwise healthy shock, and hypotension.
individuals. A tension pneumothorax is a life-
threatening emergency and occurs when air is
permitted into the pleural cavity but not allowed
MEDICAL CARE
to escape, resulting in increased intrathoracic pres- Laboratory: hemoglobin and hematocrit may be
sure and complete collapse of the lung. It decreased with blood loss
compromises the opposite lung because of increas- Chest x-ray: used to evaluate air or fluid accumu-
ing pleural pressures and causes a mediastinal shift lations, collapse of lungs, or mediastinal shifts; a
which interferes with ventilation and venous visceral pleural line may be visualized
return. Severe shortness of breath, hypotension,
and shock ensues, and emergent treatment of Arterial blood gases: vary depending on the sever-
needle thoracentesis must be performed to relieve ity of the pneumothorax; oxygen saturation
the pressure until a chest tube can be placed. usually decreases, P a 0 2 is usually normal or
decreased, and PaCOz is occasionally increased
A hemothorax occurs when the lung collapse is
due to accumulation of blood. Blood accumula- Chest tube: placement required to facilitate re-
tions usually occur from the pulmonary expansion of the collapsed lung and to permit
vasculature, the intercostal and internal mammary drainage of fluid from lung
arteries, the mediastinum, the spleen or the liver. Thoracentesis: needle thoracentesis is required for
the immediate management of a tension INTERVENTIONS RATIONALES

pneumothorax to relieve the pressure in the pleura
Application of a dressing seals
by removing air and/or fluid
the chest wall defect, while the
Surgery: thoracotomy with excision or oversewing valsalva maneuver helps to
expand the lung.
of the bullae may be required if the patient devel-
ops 2 or more pneumothorax on one side Observe for paradoxical move- May indicate flail chest and
ments of the chest during impaired ventilation. Procedures
respiration; if present, stabilize help to stabilize the area to facili-
NURSINQ CARE PLANS the flail area with a sandbag or tate improved respiratory
pressure dressing, and turn to the exchange.
lnefective breathing pattern affected side.
Related to: air andlor fluid accumulations, pain, Place patient in semi-sitting Promotes lung expansion and
position. improves ventilatory efforts.
decreased lung expansion
Prepare patient for and assist Intercostal tube placement is
Defining characteristics: dyspnea, tachypnea, use with insertion of chest tube. required when a pneurnothorax
of accessory muscles, nasal flaring, decreased chest is greater than 20-30% in order
expansion, cyanosis, abnormal arterial blood gases to facilitate re-expansion of the
lung. Instruction, when feasible,
reduces patient anxiety and
Outcome Criteria improves cooperation.
Once chest tube is inserted, Prevents air leaks and disconnec-

Patient will be eupneic, with adequate ensure that connections are tight- [ions at the connector sites.
oxygenation, and will maintain adequate ABGs. ened and taped securely per
hospital protocol.
Monitor water-seal drainage bot- Fluid must be maintained above

INTERVENTIONS RATIONALES tles to ensure fluid level is above the end of the tube to prevent air
drain tube. from being sucked into lung and
Monitor respiratory status for Physiologic changes that result resulting in further collapse.
increase in rate, decrease in from the lung collapse may cause
depth, dyspnea, or cyanosis. respiratory distress and may lead Maintain prescribed level of suc- Usually 15-25 cm H,O pressure
to hypoxia. tion to drainage system. suction is sufficient to maintain
intrapleural negative pressure and
Auscultate breath sounds. Breath sounds may be absent in facilitate fluid drainage and re-
areas where atelectasis occurs, expansion of the lung.
and may be decreased with par-
tially collapsed lung fields. Observe the water-seal drainage Bubbling should occur during
system for bubbling. expiration and demonstrates that
Observe for symmetrical chest Moderate to severe pneumotho- the pneumothorax is vented
expansion. rax will result in asymmetrical through the system. Bubbling
chest expansion until the lung is should diminish and finally cease
fully re-expanded. as the lung re-expands. If no
Observe for position of trachea. Tracheal deviation away from the bubbling is present in system,
afTected lung occurs in tension this may indicate either complete
pneumothorax. re-expansion of the lung or
obstruction in the chest
Listen for sucking sounds with Indicates an open pneumothorax tubeldrainage system.
inspiration; if present, apply which impairs ventilation.
occlusive dressing over wound During inspiration air moves Monitor drainage system for Continuous bubbling may result
while patient performs valsalva into the pleural space and col- continuous bubbling and ascer- from a large pneumothorax or
maneuver. lapses lung; with expiration, air tain if the problem is patient- or from air leaks in the drainage
moves out of the pleural space.
~~

system-centered. Clamp chest system. When the tube is Place chest drainage system Promotes drainage of air and
tube near the patient's chest. clamped as described and bub- below the level of the chest, and fluid, and prevents kinking and
bling ceases, the problem is coil tubing carefully to avoid occlusion of tubing.
patient-centered with potential kinking.
air leak at the insertion site or
within the patient. If the bub- Obtain chest x-rays daily. Identifies the presence of pneu-
bling continues, the le& is mothorax and resolution or
within the drainage system. deterioration.
If patient has insertion site air Provides a seal and corrects the If chest tube is accidentally Provides a seal over chest wound
air leak problem. removed, apply vaseline-impreg- to prevent pneumothorax from
leak, apply vaseline-impregnated
nated gauze and pressure recurring or worsening. Prompt
gauze around site, and reassess
dressing, and notify MD. treatment may prevent
the problem.
cardiopulmonary impairment.
If patient has drainage system air Determines the location of the
problem and corrects air leaks at If chest tube becomes acciden- Disconnection may result in
leak, ascertain the location by
the connectors. tally disconnected from tubing, atmospheric air entering the
clamping the tube downward
reconnect as cleanly and quickly pleural space and worsening or
toward the system by increments.
as possible. causing pneumothorax.
Secure connections.
Observe dressing over chest tube Excessive drainage on dressing
Observe for fluid tidaling. Fluctuation of the fluid within
insertion site for drainage and may indicate malposition of the
!he tubing, or tidaling, demon-
notify MD for significant chest tube, infection, or other
strates pressure changes during
inspiration and expiration, and is drainage. problem.
normally 2-10 cm during inspi- Assure that chest tube clamps (2 Provides for emergencies which
ration. Increases may occur for each tube) are present in may require clamping of the
during coughing or forceful expi- patient's room and are taken tube.
ration but continuous increases with patient when transported
in tidaling may indicate a large out of unit.
pneumothorax or airway
obstruction. Assist with removal of chest tube Once lung is re-expanded and
as warranted, and apply vaseline- fluid drainage has ceased, chest
Monitor fluid drainage for char- Provides for prompt detection of impregnated gauze and dry tubes are removed. Gauze pro-
acter and amount, and notify hemorrhage and prompt inter- sterile dressing over site, and vides a seal over the open wound
MD if drainage is greater than vention. Some drainage systems change per hospital protocol. to prevent recurrence of pneu-
100 cc/hr for more than 2 hours. have the potential for auto- mothorax.
transfusion, and this should be
done per hospital policy. Monitor patient for changes in May indicate recurrent pneu-
respiratory status, oxygenation, mothorax and requires prompt
Strip chest tubes gently, if at all, Some facilities and physicians chest pain, dyspnea, or presence intervention and reinsertion of
per hospital protocol. avoid milking, or stripping, of of subcutaneous emphysema. intercostal tube.
the tubes due to the potential for
suction to draw lung tissue into
the orifice of the tube and
damage the tissue, as well as rup- Demonstration
turing of small blood vessels. The
procedure changes intrathoracic INTERVENTIONS RATIONALES
pressure which may result in
chest pain or coughing. Instruct on function of chest Provides knowledge and
Stripping may be required to tubeldrainage system. decreases patient anxiety
maintain drainage when large
Instruct patient to avoid pulling Prevents obstruction of tube and
blood clots or fibrin strands are
or lying on tubing. facilitates drainage.
present or if the drainage is
viscid or purulent.
Instruct on signslsymptoms to Promotes prompt recognition of
report to nurse: dyspnea, chest problems that may require
pain, changes in sounds of bub- prompt intervention.
bling from drainage system.

breath sounds.
Patient will have symmetrical chest expansion
and midline tracheal placement with no
episodes of dyspnea.
Patient will achieve and maintain re-expansion
of lung with no recurrence or complications.
PNEUMOTHORAX
Air enters pleural cavity

J,
Pleural pressure increased above atmospheric pressure

J,
Lung collapses
J,
High pressure gradient between alveolus and adjacent vascular sheet

4
Decreased P a 0 2
Increased PaC02
4
Air moves along pulmonary vessels to mediastinum
44
Mediastinal shifting
4
Interference with ventilation and venous return
J,
Increased pulmonary pressures

Low P C W , high CVP
4
Shock
J,
4
DEATH
Status Asthmatieus Wheezing may occur not only with asthma, but
with chronic obstructive pulmonary disease, con-
gestive heart failure, pulmonary embolism, and
Status asthmaticus is a critical emergency that tuberculosis, and these diagnoses should be ruled
requires prompt intervention to avoid acute and out.
possibly fatal, respiratory failure. In this condition,
the asthmatic attacks are unresponsive to medical Patients who have status asthmaticus suffer pro-
therapeutics, with severe bronchospasms creating nounced fatigue due to the continuous efforts of
decreased oxygenation and perfusion. breathing, and they easily become dehydrated due
to the hyperpnea. The patient usually has dysp-
During an acute asthmatic attack, the individual nea, tachypnea, wheezing, tachycardia, pulsus
may demonstrate varying degrees of respiratory paradoxus, and severe anxiety. The goals of treat-
distress depending on the duration of the attack, ment include ventilatory support and
and the severity of spasm. The underlying cause of maintenance of adequate airways, and the preven-
asthma is still as yet unknown, but is thought to tion of respiratory failure or barotrauma.
be due to imbalances in adrenergic and cholinergic
control of the airways, and their response to the
allergens, infections, or emotional factors with
which they come in contact. Intrinsic asthma Laboratory: CBC and sputum specimens usually
occurs when the triggering factors are irritation, show eosinophilia
infection, or emotions, and extrinsic asthma
Chest x-ray: used to observe for infiltrates or
occurs when precipitated by allergic or
hyperinflation to the lungs; may be used to visual-
complement-mediated factors. Asthma may be
ize pneumothorax, hemothorax, or
drug-induced by aspirin, indomethacin, tartrazine,
pneumomedias tinum
propranolol, and timolol.
Arterial blood gases: to identify problems with
In asthma, the airways are narrowed due to the
oxygenation and acid-base balance
bronchial muscle spasms, edema, inflammation of
the bronchioles, and thick, tenacious mucous pro- Spirometry: to provide information about severity
duction. The narrowing leads to areas of of an attack, and to assess for improvement with
obstruction and these become hypoventilated and therapy; FEV, is the forced expiratory volume for
hypoperfused. Eventually a ventilation/perfusion 1 second and is usually < 1500 cc during an asth-
mismatch occurs and may lead to hypoxemia and matic attack and will increase 500 cc or more if
an increasing A-a gradient. When PaCO, rises to treatment is successful
the point of respiratory acidosis, the patient is
Oxygen: to provide supplemental available oxygen
then considered to be in respiratory failure.
Bronchodilators: used to relax bronchial smooth
The three most common causes of status asthmati-
muscle to dilate bronchial tree to facilitate air
cus are allergen exposure, noncompliance with
exchange
medication regime, and respiratory infection expo-
sure. Environmental factors, such as excessively Beta-adrenergic agents: ephedrine, epinephrine,
hot, cold, or dusty areas, may initiate status asth- isoproterenol, metaproterenol, terbutaline; used to
maticus because of the effect they have on the air relax bronchial smooth muscle
that is breathed.
Corticosteroids: used to decrease inflammatory INTERVENTIONS RATIONALES

response and decrease edema
and maintenance of therapeutic 10-20 mcg/ml. Symptoms may
Antibiotics: used when infective process is docu- levels. Observe patient for indicate theophylline toxicity,
anorexia, nausea, vomiting, which will require titration of the
mented; usually bacterial infection is not a abdominal pain, nervousness, drug dosage.
common precipitating factor restlessness, and tachycardia.
Mechanical ventilation: necessary when respira- Administer sympathomimetics as Epinephrine is usually given S Q
ordered. every 20-30 minutes for 3 doses
tory failure is present and hypoxemia persists
as needed to relieve broncho-
despite medical therapy constriction. Terbutaline is
usually not the first drug of
IPPB: used to assist the patient with deep inspira- choice in acute situations due to
tion to facilitate more productive coughing of the delayed onset of action, but
thick mucous and to deliver medication by an is frequently used after the
patient shows improvement.
aerosol route
Assist/administer inhalation ther- Nebulizers and intermittent posi-
apy as ordered. tive pressure breathing
treatments may be used in mild
Inefective airway clearance to moderate episodes but should
not be used during acute attacks
because of the potential for bron-
Related to: airway obstruction, edema of bronchi-
chospasm in response to the
oles, inability to cough or to cough effectively, aerosol agent.
excessive mucous production
Defining characteristics: adventitious breath
Demonstration
sounds, dyspnea, tachypnea, shallow respirations,
cough with or without productivity, cyanosis, anx- INTERVENTIONS RATIONALES
iety, restlessness
Monitor for side effects, such as May occur as adverse reactions
tachycardias, tremors, nausea, from medications. May require
Outcome Criteria vomiting, or bronchospasm. change in specific drug used.
Patient will maintain patency of airway and will

be able to effectively clear secretions. Discharge or Maintenance Evaluation
Patient will maintain patent airway and be able
INTERVENTIONS RATIONALES to cough and clear own secretions.
Patient will have clear breath sounds with no
Administer bronchodilators as Nebulizers are usually the first
ordered. line treatment for asthma. adventitious sounds or airway compromise.
Aminophylline is frequently pre-
scribed to relax bronchial smooth
Patient will have adequate oxygenation.
muscle and mediates histamine
release and cAMD degradation,
Impaired gm excbange
which facilitates improved air [See Mechanical Ventilation]
flow.
Related to: bronchospasm, inflammation to
Monitor lab levels for attainment Therapeutic levels range between
bronchi, hypoxemia, fatigue
Defining characteristics: dyspnea, tachypnea,

hypoxia, hypoxemia, hypercapnia, restlessness,
anxiety, abnormal ABGs, dysrhythmias, decreased
oxygen saturation
Anxiety
Related to: dyspnea, change in health status,
threat of death
Defining characteristics: fear, restlessness, muscle

tension, apprehension, helplessness, sense of
impending doom
STATUS ASTHMATICUS
Hyperactive airways
11
Mucosal edema + bronchial musde constrictionhpasm
4
Mucus plugs
4
Inflammatory response
J,
Decreased Pa02
Hypoxia
4
Increased airway resistance
Increased work of breathing
Dehydration CO2 retention Tachypnea

4 11 Wheezing
Decreased PaCO2
Increased mucus plugs
-
4 4
Hypoxia Increased CO2 production Respiratory alkalosis
J, J, s
Decreased PaO2 Respiratory acidosis Hypoxemia
J, I
Bght ventricular strain Reactive pulmonary hypertension
11
Ventricular failure
4
Cardiac dysrhythrnias
Cardiovascularcompromise d
c
Cardiopulmonary collapse
4
DEATH
Mechanical Ventilation FIO, and exhaled tidal volumes are more

accurate.
Mechanical ventilation is used as an artificial High-frequency ventilation is used when other
adjunct to maintain and optimize ventilation and methods have not been successful in oxygenation
oxygenation in those patients that are unable to and ventilation of the patient. It uses lower tidal
do so on their own for whatever the reason. It is volumes and increased respiratory rates to decrease
utilized when other adjuncts are ineffective to reg- the incidence of barotrauma and cardiac decom-
ulate oxygen and carbon dioxide levels and pensation. Frequencies range from 60-200
provide for an adequate acid-base balance. timedmin, and in high-frequency oscillation,
movement of air to and from the airway is
Major types of ventilators include negative exter-
nal pressure and positive pressure ventilators. The performed at 600-3000 cycledmin.
external type is very rarely seen today, such as the PEEC or positive end-expiratory pressure, is used
“iron lung” used for the treatment of polio and to improve oxygen exchange in persistent hypox-
the chest ventilator used for home treatment of emia when increases in FIO, have not improved
neuromuscular diseases. These ventilators apply the situation. PEEP produces an increased func-
pressure against the thorax that is less than room tional residual capacity (FRC) which increases the
air, in order to accomplish ventilation by changes available lung alveoli surface for oxygenation by
in lung pressures. There are no requirements for maintaining the alveoli in an open position. High
artificial airways and are fairly easy to use. The levels of PEEP may contribute to the incidence of
patient must remain in or under the unit and, as barotrauma and hemodynamic compromise, and
such, activity is limited, and the negative pressure is most effective when maintained for lengthy
exerted may result in venous pooling and periods of time. To this end, a special PEEP ambu
decreased cardiac output. bag must be used to maintain the pressure in
order to maintain the beneficial effects.
Positive pressure ventilators are further subclassi-
fied according to the factor that initiates the
inspiratory phase, and what factor causes the MEDICAL CARE
inspiratory phase to cease. Pressure-cycled ventila- Laboratory: CBC, transferrin, albumin, prealbu-
tors use oxygen or compressed air valves to deliver min, electrolytes used to monitor infection,
a gas volume until a preset pressure limit is imbalance, and nutritional status; cultures done to
achieved. As the lung compliance and airway resis- identify infective organism and specify antimicro-
tance changes, inspired tidal volumes, alveolar bial agent required for eradication
ventilation and FIO, changes also. The alarm sys-
tems for this ventilator are sometimes inadequate Intubation: artificial airway is required for
and the ventilator cannot compensate for leaks mechanical ventilation
that may occur in the system. Arterial blood gases: used to determine levels of
Volume-cycled ventilators, currently the most oxygen, carbon dioxide, and p H to identify acid-
common found in intensive care settings, deliver a base disturbances, hypoxemia, and to monitor for
preset gas volume to the patient regardless of changes in respiratory status
airway resistance or compliance. Most have safety Respiratory treatments: used to instill varied
features to limit excessive airway pressures, and agents into the lungs to reduce spasm, increase
hydration and liquification of secretions, and to INTERVENTIONS RATIONALES

facilitate removal of secretions
obrurator airways are useful only
Ventilatory management: ventilator settings are in emergency situations and
changed periodically based on patient condition must be replaced as quickly as
possible. These are easier to
and arterial blood gas analysis to ensure optimum insert than endotracheal tubes,
ventilation and oxygenation but stimulate vomiting and
cannot be used in conscious
Tracheostomy performed when nasal or oral intu- patients. The trachea may acci-
bation is impossible, or after significant time of dentally be intubated and the
nasal/oral intubation on a prolonged ventilator esophagus may be perforated.
Endotracheal intubation requires
patient advanced training and skill, and
may be accidentally placed in rhe
NURSING CARE PLANS esophagus, develop leaks that
may decrease oxygenation, and
Inefectiue airway clearance over time, may necrotize tissues.
Artificial airways may become
Related to: thick tenacious secretions, airway occluded by mucous, blood, or
other secretions; endotracheal
obstruction, edema of bronchioles, inability to tubes may become twisted or
cough or to cough effectively, presence of artificial compressed, or severe spasms
airway may occlude airway.
Defining characteristics: adventitious breath Monitor tube placement for Tube migration may occur with
migration; place marking on coughing, re-taping, or acciden-
sounds, dyspnea, tachypnea, shallow respirations, tube and note length and posi- tally, with the potential for
cough with or without productivity, cyanosis, tion at least every 8 hours; tube improper placement resulting in
fever, anxiety, restlessness should be adequately secured to hypoxia. Comp’arison of previous
maintain placement. placement guidelines will provide
prompt recognition of differ-
Outcome Criteria ences and changes, and facilitate
prompt intervention.
Patient will maintain patency of airway, have clear Prepare for placement on If routine medical therapeutics
breath sounds, and will be able to effectively clear mechanical ventilation as war- are not effective in controlling
secretions. ranted. the spasms, hypoxemia, and
hypoxia, respiratory failure will
ensue, and mechanical ventila-
tion will be required to assure
INTERVENTIONS RATIONALES adequate oxygenation and
perfusion.
Monitor airway for patency and Artificial airways will be required
provide artificial airways as war- if patient cannot maintain Auscultate lung fields for pres- Proper tube placement will result
ranred. Prepare for mechanical patency. Oropharyngeal airways ence of breath sounds, changes in equal bilateral breath sounds
ventilation. hold tongue anteriorly but may in character, and presence to all and symmetrical chest expansion.
precipitate vomiting if lengrh is lobes; observe for symmetrical Adventitious breath sounds, such
nor accurately measured. chest expansion. as rhonchi and wheezes, may
Nasopharyngeal airways are more indicate airflow has been
easily tolerated i n conscious obstructed by occlusion of the
patients but may cause tube or migration into an inap-
nosebleeds and may easily propriate position. Absence of
become occluded. Esophageal breath sounds to left lung fields
INTERVENTIONS RATIONALES Patient will have clear breath sounds with no

adventitious sounds or airway compromise.
may indicate intubation of the
right main stem bronchus. Patient will not have any aspiration
Suction patient every 2-4 hours Patients who are intubated fre- complications.
and prn, being sure to hyperoxy- quently have ineffective cough
genate patient prior to, during, reflexes or are sedated and have Patient will be able to adequately perform
and after procedure; limit active some muscular involvement that coughing.
suctioning to 15 seconds or less may impair coughing, and suc-
at a time; use pulmonary toilette tioning is required to remove Impaired gas exchange
instillation as needed. their secretions. Suctioning time
should be minimized and hyper- Related to: bronchospasm, mucous production,
oxygenation performed to reduce edema, inflammation to bronchial tree,
the potential for hypoxia.
hypoxemia, fatigue
Position patient in high-Fowler’s Promotes maximal lung expan-
or semi-Fowler’s position. sion. Defining characteristics: dyspnea, tachypnea,
hypoxia, hypoxemia, hypercapnia, confusion, rest-
Turn patient every 2 hours and Repositioning promotes drainage
prn. of pulmonary secretions and lessness, cyanosis, inability to move secretions,
enhances ventilation to decrease tachycardia, dysrhythmias, abnormal ABGs,
potential for atelectasis. decreased oxygen saturation by oximetry
Administer bronchodilators as Promotes relaxation of bronchial
ordered. smooth muscle to decrease
spasm, dilates airways to improve
Outcome Criteria
ventilation, and maximizes air
exchange. Patient will have arterial blood gases within
normal range for patient, with no signs of ventila-
Information, Instruction, tion/perfusion mismatching.
Demonstration
Instruct on splinting abdomen Promotes increased expiratory Monitor pulse oximetry for Oximetry readings of 90 corre-
with pillow during cough efforts. pressure and helps to decrease oxygen saturation and notify late with PaO, of 60. Levels
discomfort. MD if .c 90. below 60 do not allow for ade-
quate perfusion to tissues and
Instruct on alternative types of Minimizes fatigue by assisting
vital organs. Oximetry uses
coughing exercises, such as quad patient to increase expiratory
light waves to identify differ-
thrusts, if patient has difficulty pressure and facilitates cough.
ences between saturation and
during coughing.
reduced hemoglobin of the
Instruct on deep breathing Promotes full lung expansion tissues and may be inaccurate in
exercises. and decreases anxiety. low blood flow states.
Perform chest percussion and Mobilizes secretions and facili- Monitor transcutaneous oxygen Measures the oxygen concentra-
postural drainage as warranted. tates ventilation of all lung fields. tension if available. tion of the skin, but may cause
burns if monitor site 1s nor
rotated frequently. Slun, blood
Discharge or Maintenance Evaluation flow and temperature may
affect these readings.
Patient will maintain patent airway and be able
to cough and clear own secretions.
INTERVENTIONS RATIONALES INTERSENTIONS RATIONALES

Provide oxygen as ordered. Provides supplemental oxygen to Use PEEP ambu bag when SUC- despite increasing levels of
benefit patient. Low flow oxy- tioning patient. oxygen by producing an
gen delivery systems use some increased functional residual
room air and may be inadequate capacity which then increases the
for patient's needs if their tidal available lung alveoli surface for
volume is low, respiratory rate is oxygenation. PEEP may predis-
high, or if ventilation status is pose the patient to barotrauma
unstable. Low flow systems with elevated levels. Ambu bags
should be used in patients with that are capable of maintaining
COPD so as to not depress their PEEP levels are required because
respiratory drive. High levels of short intervals minimize the ben-
oxygen may cause severe damage eficial effects of PEEP.
to tissues, oxygen toxicity,
increases in A-a gradients, Information, Instruction,
microatelectasis, and ARDS.
Demonstration
Monitor for changes in mental May indicate impending or pre-
status, restlessness, anxiety, sent hypoxia and hypoxemia. INTERVENTIONS RATIONALES
headache, confusion, dysrhyth-
mias, hypotension, tachycardia, Prepare patient for placement on May be necessary to maintain
and cyanosis. mechanical ventilation as war- adequate oxygenation and acid-
ranted. base balance.
Monitor ABGs for changes Provides information on mea-
andlor trends. sured levels of oxygen and Assist with respiratory Provides information to
carbon dioxide as well as acid- therapists measurements of facilitate early detection of
base balance. Promotes prompt oxygen analyzing, lung compli- oxygen toxicity.
intervention for deteriorating ance, viral capacity, and A-a
airway status. PaO, alone does gradients.
not reflect tissue oxygenation;
ventilation must be adequate to Discharge or Maintenance Evaluation
provide gas exchange.
Patient will have arterial blood gases within
Administer oxygen as ordered. Oxygen by itself may not always
correct hypoxia of tissues and
normal limits for patient.
restore perfusion.
Patient will be eupneic with adequate oxygena-
Monitor for signs/symptoms of Oxygen toxicity may result when tion and no signslsymptoms of oxygen toxicity.
oxygen toxicity (nausea, vomit- oxygen concentrations are greater
ing, dyspnea, coughing, than 40% for lengthy durations Inefective breathing pattern
retrosternal pain, extremity of time, usually 8 to 24 hours,
paresthesias, pronounced fatigue, and may cause actual physiologic Related to: fatigue, dyspnea, secretions,
or restlessness). changes in the lungs. Progressive inadequate oxygenation, respiratory muscle weak-
respiratory distress, cyanosis, and
ness, respiratory center depression, decreased lung
asphyxia are late signs of toxicity.
Oxygen concentrations should be expansion, placement on mechanical ventilation
maintained as low as possible in
order to maintain adequate Defining characteristics: dyspnea, tachypnea,
PaO,. bradypnea, apnea, cough, nasal flaring, cyanosis,
Limit PEEP (positive end-expira- PEEP is used to improve oxygen
shallow respirations, pursed-lip breathing, changes
tory pressures) to 5-20 cm H,O. exchange in persistent hypoxemia in inspiratorylexpiratory ratio, use of accessory
muscles, diminished chest expansion, barrel chest,
abnormal arterial blood gases, fremitus, anxiety,
decreased oxygen saturation
Outcome Criteria INTERWNTIONS RATIONALES

the tube should be 2-3 cm above
Patient will be eupneic, with adequate
the carina.
oxygenation, and will maintain adequate ABGs
within normal limits. If E T T is placed orally, daily Prevents tissue necrosis from
changes from side to side of pressure of tube against teeth,
mouth should be routinely lips, and other tissues. Oral tubes
performed. promote saliva formation, cause
INTERVENTIONS RATIONALES nausea and vomiting if rnove-
ment of tube stimulates retching,
Prepare patient for placement on Promotes knowledge and
and prevents the patient from
mechanical ventilation and intu- reduces fear. May promote
closing his mouth without biting
barion procedures. cooperation.
down on the tube.
Assist with intubation of patient; Placement of an artificial airway
Suction patient as needed, Suctioning is required to remove
auscultate all lung fields for (endotracheal tube [ETT] or
making sure to hyperoxygenate secretions because the patient is
breath sounds. tracheostomy) is required for
before, during, and after proce- unable to d o so on his own.
mechanical ventilation support.
dure. Utilize sterile normal saline Effective coughing is decreased
Nasotracheal intubation may be
for pulmonary toilette instilla- because of the inability to
preferred to prevent oral discom-
tion prior to suctioning increase intrathoracic pressure
fort and necrosis, but is
procedures as warrantedlordered. when the glortis is restricted
associated with a high incidence
from air. Suctioning places
of sinus disease.
patient at risk for inadequate
Hyperoxygenate patient and aus- Prolonged difficulty in place- oxygenation and decreased perfu-
cultate for bilateral breath sounds ment of the tube may result in sion. Hyper-oxygenation helps to
and observe for bilateral symmet- hypoxia. If symmetrical chest limit this sudden decrease in
rical chest expansion. expansion is not observed, or if available oxygen. Mucous pro-
breath sounds cannot be heard duction is usually increased with
bilaterally, this may indicate placement of E T T due to ciliary
improper placement of the tube movement being impaired and
into the right main bronchus or the body's response to the foreign
esophagus, and correction of this tube. Pulmonary toilette is con-
problem must be addressed troversial but may be helpful to
promptly. liquefy secretions to facilitate
easier removal.
Utilize low pressure endotracheal High pressure cuffed tubes may
tubes for intubation. promote tracheal necrosis or Restrain patient as warranted and Prevents accidental extubation in
result in a tracheal fistula. as per hospital protocol. sedated or confused patients.
Maintain airway; secure tube Artificial airways may become Monitor ventilator settings at Ventilator settings are adjusted
with tape or other securing occluded by mucous or other least every 2-4 hours and prn; based on the disease process and
device. secretory fluids, may develop a FIO, should be analyzed periodi- patient's condition to maintain
cuff leak resulting in inability to cally to ensure correct amount is optimal oxygenation and ventila-
maintain pressures suficient for being maintained; tidal volume tion while the patient is unable
ventilation, or may migrate to a should ideally be 10-15 cc/Kg to do so o n his own. Oxygen
position whereby adequate oxy- body weight; airway pressures percentages may not be corn-
genation is impaired. Tubes (peak inspiratory pressure and pletely accurate and analysis
should be adequately secured to plateau pressure) should be noted must be performed to ensure
prevent movement, loss of for identification of trends; inspi- proper amounts arc being deliv-
airway, and tracheal damage. ratory and expiratory ratio; sigh ered. Exhaled tidal volumes
volume and rate. should be monitored and
Obtain chest x-ray afrer ETT is Radiographic confirmation of changes may indicate changes in
inserted. tube placement is mandatory; lung compliance or problems
with delivering specific volumes.

Increases in airway pressures may Increasing volumes of air
indicate bronchospasm, presence required to maintain ventilatory
of mucoid and other secretions, pressures, or increasing cuff pres-
obstruction of the airway, pneu- sures may indicate cuff leak and
mothorax, or ARDS with high will require replacement of
pressure levels and disconnection airway to maintain oxygenation.
of tubing, inadequate cuff pres-
sure or non-synchronous Auscultate for adventitious May indicate migration of
breathing with low pressure breath sounds, subcutaneous airway tube. Movement from
levels. I:E ratio should be 1:2 but emphysema, or localized whea- trachea into tissue may cause
may be altered to improve gas ing. mediastinal or subcutaneous
exchange. Sighs, when used, are emphysema and/or pneumotho-
commonly 1 112 times the rax. Intubation of the bronchus
volume of a normal breath, 2-6 may result in decreased unilateral
times per hour to facilitate chest expansion with decreased
expansion of alveoli to reduce the breath sounds, and localized
potential for atelectasis. wheezing. Movement of the tube
Ventilator settings may be inad- to the level of the carina may
vertently changed, or due to result in excessive coughing,
forgetfulness, increased oxygena- diminished breath sounds, and
tion used for suctioning inability to insert suction
procedure may not be turned catheter.
down to ordered amounts. This Monitor ABGs for trends, and Maintains adequate oxygenation
may result in oxygen toxicity or change ventilator settings as and acid-base balance.
inadequate ventilation. ordered.
Observe for temperature of ven- Intubation bypasses the body’s Observe breathing patterns and Increased or decreased ventila-
tilator circuitry; drain tubing natural warminglhumidifying note if patient has spontaneous tion may be experienced by
away from the patient as action, and requires increased breaths in addition to ventilatory ventilator patients who may try
warranted. temperature and moisturizing breaths. to compensate by competing
of the delivered oxygen. The wirh ventilatory breaths.
temperature of the ventilator Tachypnea may result in respira-
circuitry (and the delivered tory alkalosis; bradypnea may
oxygen) should be maintained at result in acidosis with increased
approximately body temperature PaC02.
to avoid hyperthermic reactions.
Temperature increases and Observe patient for non-synchro- Asynchrony with the ventilator
humidification promote conden- nous respirations with ventilator decreases alveolar ventilation,
sation of water in tubing which (“fighting the ventilator”). increases intrathoracic pressures,
may restrict adequate volume Administer sedation or and decreases venous return and
delivery. Drainage of fluid sedationlneuromuscular block- cardiac output. Pavulon paralyzes
toward the patient or toward the ade, as ordered. all muscles in body to facilitate
reservoir may promote bacterial synchrony with ventilation sup-
infestations. port. Patients may be completely
alert when paralyzed, so sedation
Monitor airway cuff for leakage, Proper cuff inflation is done with is MANDATORY prior to
noting amount of air volume in the least amount of air to ensure administration of Pavulon.
cuff and cuff pressures at least a minimal leak with maintenance Often, a sedation cocktail of
every 4-8 hours and prn. of adequate ventilatory pressures narcotics andlor benzodiazepines
and tidal volumes. Cuff pressures may be titrated wirh better
should be less than 25 cm H,O results to achieve adequate seda-
to prevent tracheal necrosis. tion.
RESPIRATORY SYSTEM - 127
Information, Instruction, Impaired verbal communication

Demonstration
~
Related to: intubation, artificial airway, muscular
INTERVENTIONS RATIONALES paralysis
Prepare patient for placement of Prolonged ventilatory support via Defining characteristics: inability to speak, inabil-
rracheostomy as warranted. nasal or oral endotracheal tube ity to communicate needs, inability to make
may lead to necrosis of tissues
due to pressure exerted by the
sounds
tube. Tracheostomy is more com-
fortable for the patient, decreases
the airway resistance, and may
Outcome Criteria
reduce the amount of dead space.
Patient will achieve a method to communicate his
Observe for pulsarion of May indicate close proximity to needs.
tracheostomy with neck vein innominate vessels that may lead
pulsation and notify MD. to necrosis and erosion into ves-
sels and result in hemorrhage.
Assess for cuff l e h g e and Cuffs which have leaks that
changelnorify MD for change of enable a patient to have the Evaluate patient’s ability to speak Patient may be fluent in sign
airway. ability to speak, in which air may or communicate by other means. language, or able to communi-
be felt at the nose andlor mouth, cate in wriring to make needs
changing pressures with ventila- known.
tion, andfor decreased exhaled
volumes require change in order Ensure that call lighr is placed Provides patient with concrete
to maintain adequate oxygena- within easy reach of patient at all evidence that he may call for
tion and ventilation. times, and that the light system assistance and that the nurse will
is flagged to denote patient‘s be available to meet his needs.
Obtain chest x-rays every day Facilitates recognition of tube impairment. Flagging system ensures that
and prn while patient is migration, atelectatic changes, personnel not familiar with the
intubated. presence of pneumothorax, or patient will be alerted ro his
other significant changes. inability to speak.
Insure that neostigmine bromide These reverse effects of Make eye contact with patient at Communication may be possible
or edrophonium chloride is pancuroniurn. all times; ask questions that may if patient is able to nod head yes
available. be answered by nodding of the or no, or blink eyes in sequence.
head; provide paper and Writing may be illegible due to
writing utensils, magic slate, or disease process or sedation, and
Discharge or Maintenance Evaluation communication board for may frustrate and farigue patient.
communication.
Patient will be able to maintain own airway and
expectorate sputum.
Patient will have arterial blood gases within Demonstration
normal limits of patient disease process.
Patient will be eupneic with no adventitious ~ ~~
Instruct patient in using tongue Provides alternate merhod to

breath sounds. to make clicking noise, or in communicate with nurse and
tapping table or side rails to gain helps to allay fear of abandon-
Patient will have artificial airway intact with no
nurse’s attention as a secondary menr.
signs/symptoms of complications. means of calling for assistance.
INTERVENTIONS RATIONALES INTERVENTIONS

~
RATIONALES
~~~ ~~ ~~
Instruct family members in talk- Promotes understanding for the concerns. Do not give false sively begin work on emotional
ing with patient to provide family and assists in incorpor- reassurance. barriers. False reassurance tends
information about issues of con- ating family into the patient's to minimize patient's feelings
cern to patient, and help them to care to mainrain contact with resulting in impaired trust and
deal with the awkwardness of a reality. increased anxiety.
one-sided conversation.
Provide support and encourage- Family's anxiety may be commu-
menr to family members and nicated to the patient and result
Discharge or Maintenance Evaluation assist them in dealing with their in increased anxiery levels.
own fearslconcerns.
Patient will be able to speak or make needs Discuss safety precautions Provides concrete answers to help
known. involved with ventilatory sup- decrease anxiety and fear of the
port; emergency power source, unknown, and to relay emer-
Patient will develop an adequate alternative emergency oxygen and equip- gency plans for patient.
means of communication and be able to utilize ment, alarm systems, etc.
communication to make needs known. Ensure that patient's call light is Provides reassurance that nurses
placed within easy reach at all will be available to assist with
Patient's family will be able to recognize their times, and that alternative meth- patient's needs, and decreases
own contribution to the patient's recovery. ods of summoning assistance anxiety.
have been discussed.
Anxiety
Administer antianxiery medica- Helps to reduce anxiety to a
Related to: ventilatory support, threat of death, tions as ordered. manageable level when other
techniques have failed.
change in health status, change in environment,
life-threatening crises
Defining characteristics: fear, restlessness, muscle Demonstration
tension, apprehension, helplessness, communica-
tion of uncertainty, sense of impending doom, INTERVENTIONS RATIONALES
worry Instruct in use of relaxation tech- Promotes reduction in stress and
niques and guided imagery. anxiety, and provides opportu-
nity for patient to control his
Outcome Criteria situation.
Patient will have decreased anxiety and be able to Consult psychiatrist, psycholo- Patient may require further inter-
gist, or counselor as warranted. vention for dealing with
function at acceptable levels with anxiety-produc-
emotional problems.
ing stimuli.
INTERVENTIONS EWTIONALES Discharge or Maintenance Evaluation
~ ~~
Evaluate patient's perception of Identifies problem base and facil- Patient will be able to verbalize concerns and
crisis or threat to self. itates plan for intervention. fears and be able to rationally deal with them in
Monitor for changes in vital May indicate patient's level of appropriate ways.
signs, restlessness, or facial response to stressors and level of
tension. anxiety. Patient will be able to function with anxiety
Encourage patient to express Promotes verbalization of con-
reduced at a manageable level.
fears and concerns and provide cerns, and allows time for
information pertinent to those identification of fears to progres-
~~
Patient will be able to utilize methods to reduce INTERVENTIONS RATIONALES

anxiety. ~~
Provide opportunities for patient Provides opportunity to gain

Inefective individ~ul...amiiy
coping to make decisions regarding his some sense of control of his life,
care, when feasible. decreasing anxiety, and assisting
Related to: change in health status, change in abil- in coping skills.
ity to communicate, sensory overload, change in Discuss current problems and Identifies actual problems and
environment, fear of death, physical limitations, assist with problem-solving to assists patiendfamily ro find real
inadequate support system, inadequate coping find solutions. solutions to facilitate increasing
self-control and self-esteem.
mechanisms, threat to self, pain
Discuss feelings of blame, either Blaming oneself or others pro-
Defining characteristics: inability to meet role on self, or on others. longs inability to cope and
expectations, inability to meet basic needs, worry, increases feelings of hopelessness.
apprehension, fear, inability to problem solve, hos- Remain non-judgmental of Anger and hostile feelings may
tility, aggression, inappropriate defense choices patiendfamily may make. promote resolution of stages of
mechanisms, low self-esteem, insomnia, Adopt a non-threatened attitude grief and loss, and should be
when anger and hostility are regarded as an important step in
depression, destructive behaviors, vacillation when expressed. Set limits on unac- that process. Limits must be set
choices are required, delayed decision making, ceptable behaviors. to prevent destructive behavior
muscle tension, headaches, pain that will impair patienr’s self-
esteem.
Discuss feelings of anger at God, Spiritual beliefs are questioned

Outcome Criteria religious alienation, lack of when threats of death occur, and
meaning to life, etc. may affect patient’s ability to
Patient will be able to recognize problems with cope with and problem-solve
coping and be able to problem-solve adequately. during crises.
INTERVENTIONS RATIONALES Demonstration
Evaluate patient’dfamily’s coping Provides baseline information to
skills and ability to verbalize establish interventions best suited INTERVENTIONS RATIONALES
problems. to the patient/family/situation.
Assess rapport of family members Actions of the family may be
Coping abilities that the patient
with patient. Involve the family helpful, but the patienr may per-
has utilized previously may be
members in the care of the ceive these as being
used in the current crisis to pro-
patient when feasible. over-prorective or smothering.
vide a sense of control.
Helping with patient’s care may
Discuss concerns and fears of loss Identifies needs for intervention enhance the family’s feelings of
of control with patient, and pro- and helps to establish a trusting importance and control of the
vide feedback. relationship. situation.
Monitor for dependence on May indicate patient’s need to Provide information to the Identifies opportunities for other
others, inability to make deci- depend on others to allow time patient and family regarding resources that may be available,
sions, inability to involve self in to regain ability for coping with other agencies and personnel and provides means of control
care, or inability to express con- crises, and promotes feeling of who may assist them with their over situation.
cerndquestions. safety. Patient may be afraid to crisis.
make any decision in which his
tenuous condition could be com-
promised.
Patient/family will be able to recognize ineffec- Maintain good handwashing Handwashing is the most
technique and isolation precau- important step in preventing
tive coping behavior and regain emotional tions when warranted. nosocomial infection. Patients
equilibrium. may require isolation based on
their diagnosis to prevenr trans-
Patient/family will be able to adequately prob- mission of infection to or from
lem-solve during crises. the patient.
Patiendfamily will be able to recognize options Screen visitors who are ill Patients are already immuno-
themselves. compromised and at risk for
and resources for use post-hospitalization. development of infection.
Patient/family will be able to make appropriate, Maintain sterile technique for all Reduces spread of infection.
informed decisions and be satisfied with dressing changes and suctioning.
choices. Administer antibiotics as Required to treat infective organ-
POtent i d for infection ordered. ism.
Related to: intubation, disease process, immuno- Information, Instruction,

suppression, compromised defense mechanisms Demonstration
Defining characteristics: increased temperature, INTERVENTIONS RATIONALES
chills, elevated white blood cell count, purulent Instruct patientlfamily in proper Reduces risk of transmission of
sputum handwashing and disposal of infection to others.
contaminated secretions, tissues,
etc.
Outcome Criteria
Instruct family to avoid visiting Patient is already immuno-com-
Patient will have no evidence of infective process. if they have upper respiratory promised and is at risk for
infections. infection.
Instruct patientlfamily on antibi- Provides knowledge and

otics: effects, side effects, enhances cooperation with
contraindications, and treatment.
Evaluate risk factors that would Intubation and prolonged foodsldrugs to avoid.
predispose patient to infection. mechanical ventilation predis-
pose patient to nosocomial Discharge or Maintenance Evaluation
infection. Age, nutritional status,
chronic disease progression and
invasive procedures and lines also Patient will be free of fever, chills, purulent
predispose patient to infection. drainage, or other indicators of infective
Monitor sputum for changes in Purulent, malodorous sputum
process.
characteristics and color; culture indicates infection. Cultures may Patient will be able to recall information accu-
sputum as warranted. be required to identify causative
organism and to prescribe appro- rately regarding antibiotics and infection control
priate antibiotics. procedures.
Monitor trachcostomy site for Purulenr drainage indicates infec- Patiendfamily will be able to recognize risk fac-
redness, foul odor, or purulent tion. Cultures may be required to
drainage; culture site as identiFy causative organism and
tors and avoid further compromise of patient.
warranted. to prescribe appropriate antibi-
otics.
Altered oral mucous membrane Information, Instruction,

Demonstration
Related to: oral intubation, increased or decreased
saliva, inability to swallow, antibiotic-induced INTERVENTIONS RATIONALES
fungal infection
Instruct on antifungals as Provides knowledge.
Defining characteristics: oral pain or discomfort, warranted.
stomatitis, oral lesions, thrush Instruct patient in utilizing oral Provides a sense of control CO the
suction equipment when feasible, patient, and facilitates removal of
if patient has copious oral excessive secretions.
Outcome Criteria secretions.
Patient will be free of oral pain and mucous mem-

branes will remain intact.
Patient will have intact oral mucous
membranes, with no evidence of infection.
Patient will be able to recall instructions accu-
0bserve mouth for missing, Teeth may be chipped or
knocked out during intubation
rately.
loose, or chipped teeth; bleeding,
sores, lesions, necrotic areas, or process and loose teeth may pose
Patient will be able to adequately remove secre-
reddened areas. a potential for aspiration.
Identification of lesions or other tions by use of suction equipment.
problems may facilitate prompt
intervention. Patient will be compliant with performance of
oral care.
Move oral endotrached tube to Decreases potentid for pressure
other side of mouth at least daily and ultimately, ulceration of lips Altered nutrition: less than body
and prn. or mucous membranes.
requirements
Provide oral care at least every 8 Promotes cleanliness, reduces
hours and prn. odor, and reduces potential envi- Related to: intubation, inability to swallow, inabil-
ronment for bacterial invasion. ity to take in food, increased metabolism due to
Removes transient bacteria,
disease process, surgery, decreased level of
Swab mouth with mouthwash
every 4-8 hours and prn. reduces odor, and helps to consciousness
stimulate circulation to oral
membranes. Defining characteristics: actual inadequate food
Apply lip balm every 2-4 hours Prevents drying and cracking of
and pm. lips. weight loss, anorexia, absent bowel sounds,
decreased peristalsis, muscle mass loss, decreased
Suction patient’s ord cavity fre- Removes excessive saliva and
mucous which may facilitate
muscle tone, changes in bowel habits, nausea,
quently if patient is unable to
handle secretions. bacterial growth. vomiting, abdominal distention
Observe for white patches on May indicate presence of fungal
tongue and mucous membranes, infection (thrush) which will Outcome Criteria
and notify MD. require anti-fungal solution, such
as Nystatin. Patient will have adequate nutritional intake with
no weight or muscle mass loss.

Evaluate ability to eat. Some patients with water every 8 hours, before and tube maintains patency.
tracheostomies are able to eat, after medication administration
while those patients who are via the tube, and prn.
endouacheally intubated must
be kept NPO due to the posi- Aspirate gastric residuals every 4- Increasing residuals may indicate
tioning of the epiglottis, and will 8 hours, and decrease or hold decreased or absent peristalsis
require enteral or parenteral feedings per hospital protocol. and lack of absorption of
alimentation. required nutrients which may
require another form of nutri-
Weigh every day. Continued weight loss will result tional support.
in catabolic metabolism and
impaired respiratory function. Use food coloring to tint feed- Helps to identifj aspiration of
ings. Do not use red coloring. feedings when suctioned. Be
Observe for muscle wasting. May indicate muscle stores aware that the food coloring may
depletion which can impair res- cause false readings on occult
piratory muscle function. blood tests on stools. Red color-
ing should be avoided due to
similarity of blood color and this
Observe for nausea, vomiting, Ventilator patients may develop may impair ability to differenti-
abdominal distention and palpa- GI dysfunction from ate bleeding problems.
bility, and stool characteristics. analgesicslsedatives,bedrest,
trapped air, and stress, which Instill warm cranberry juice, Helps to dissolve clogged partic-
may result in ileus formation. carbonated cola, or mixture of date matter to maintain patency
monosodium glutamate and of tube.
Test stools and gastric contents Stressors of ventilation and pres- water in enteral tube for signs of
for guaiac. ence in ICU may predispose occlusion.
patient to the formation of a
stress ulcer resulting in GI bleed- Administer antidiarrheal medica- Osmolality imbalances may
ing. tions as warranted. result in diarrhea requiring
antidiarrheds for control.
Obtain calorie count and assess- Establishes imbalances between
Changing strengths or types of
ment of metabolic demands actual nutritional intake and
feedings may be helpful.
based on disease process. metabolic needs.
Administer metodopramide as Medication helps to stimulate
Monitor lab work as warranted; Evaluates need for andlor ade-
ordered. gastric motility and may be help-
electrolytes, BUN,creatinine, quacy of nutritional support.
ful to increase absorption.
albumin and prealbumin, glucose
levels. Administer parenteral alimenta- Provides complete nutritional
tion fluids as warranted via support without dependence on
Administer enteral solutions at Bolus feedings may result in
infusion pump. GI function for absorption.
continual rate by infusion pump dumping syndrome. Continuous
Additives are based upon lab
as warranted. infusion feedings are generally work and patient requirements.
better tolerated and have better Increases in protein and nitrogen
absorption. Enteral feeding for-
may be prescribed for increased
mulas vary depending on the
metabolic demands of the
nutritional needs of the patient.
patient.
The use of enteral formulas
require a functioning GI system. Administer intralipids as ordered, Provides additional caloric bene-
if not admixed with TPN soh- fits as well as a source of essential
Determine patency of enteral Oral or nasal tubes may migrate
tion. fatty acids. Lipids may be uti-
feeding tubes at least every 8 with coughing, resulting in lized for respiratory failure to
hours. Flush with 20-30 cc of improper placement and poten- help decrease CO, retention.
tial for aspiration. Flushing of
~

Change solution at least every 24 Some additives may be unstable Patient will maintain baseline weight with no
hours, as well as tubing. after 24 hours, and prolonged
infusion with same solution may loss of muscle mass.
promote bacterial growth.
Patient will maintain adequate nutritional status
Monitor lab work per hospital Requirements for electrolyte with use of nutritional support, and will experi-
protocol; general chemistry, renal replacement or alteration in for-
ence no complications from support.
profile, CBC, urine or blood mula may be changed based on
glucose levels. this information. High dextrose
Patient will show no signs of malnutritional
content in TPN solutions may
require additions of insulin to status.
meet metabolic demands if pan-
creatic disease, hepatic disease, or
diabetes are present. rately.
Do not stop T P N abruptly; Rebound hypoglycemia may Patient will maintain a normal nitrogen balance
taper over several dayslhours per result if dextrose concentrations
and immunity will not be compromised.
protocol. are abruptly changed.
Dysfinctionud ventihtory wean response
Demonstration Related to: fever, pain, muscle fatigue, sedation,
anemia, electrolyte imbalance, sleep deprivation,
INTERVENTIONS RATIONALES poor nutrition, cardiovascular lability, psychologi-
cal instability
Insert nasogastric feeding tube as Smaller lumen is less irritating
warranted, utilizing small to nasal mucosa, and decreases
Defining characteristics: inability to wean, lack or
weighted tube. Obtain chest the incidence of gastroesophageal
x-ray or KUB post procedure. reflux. Radiographic inadequacy of spontaneous respirations, negative
confirmation of placement is inspiratory force or pressure < -20 cm H,O, PaO,
necessary due to the potential for < 60 mmHg on FIO, > 50%, PaCO, > 40
aspiration when patients may
have impaired gag reflex.
mmHg, tidal volume < 5 cc/Kg, vital capacity <
10 cc/Kg, minute ventilation > 10 L/min
Maintain elevation of the head of Helps prevent potential
the bed at least 30 degrees at all aspiration.
times. Outcome Criteria
Assist with placement of central Centrally-placed intravenous
venous catheter for TPN admin- lines may enable higher Patient will be able to be weaned from ventilatory
istration. Obtain chest x-ray post concentrations of amino acids to support successfully with arterial blood gases
procedure. be utilized. Radiographic confir- within normal limits.
mation of placement, as well as
ruling out hemo- or pneumotho- INTERVENTIONS RATIONALES
rax post procedure, is mandatory.
Monitor vital signs. Temperature elevations increase
Instruct in need for supplemental Promotes knowledge, decreases metabolism and oxygen demand.
nutritional support, procedures fear of the unknown, and facili- Unstable heart rate and rhythm
to be performed, and tests that tates cooperation with results in increased workload on
will be required. procedures. Provides opportunity the heart, increased oxygen con-
for patient to make informed sumption and demand. Process
choices. of weaning will increase work-

load and may compromise an Attempt to wean only during the Crises that may occur with
already-stressed body and should day and after the patient has had respiratory deterioration and
not be attempted until these a resthl sleep period. Avoid failure to wean may be handled
factors have been corrected. activity during weaning. more efficiently when sufficient
Once weaning process has medical personnel are available,
begun, significant changes in usually during the day. Fatigue
heart rate and rhythm, respira- may predispose patient to failure
tory rare, and blood pressure due to the need for stamina to
may indicate a need to slow or withstand the effort of sponta-
discontinue weaning due to res- neous breathing. Activity
piratory compromise. increases oxygen demand and
consumption.
Monitor EKG for dysrhythmias Ventilatory support decreases
and treat as warranted. venous return to the heart, Evaluate patient’s emotional Weaning process may result in
increases PVR and SVR. status and ability to cope with anxiety due to fear of failure to
Hypoxemia and p H imbalances weaning. wean andlor ability to breathe
may result in dysrhythmias from spontaneously.
cardiac compromise.
Prior to attempt, assess weaning Attainment of parameters facili-
Monitor nutritional status. Protein, carbohydrate and fat parameters to ensure patient tate best chance for successful
Evaluate labwork: CBC, transfer- concentrations can alter the abil- meets requirements for successful weaning and ensures that neuro-
rin, albumin, prealbumin, ity to maintain oxygenation. weaning: NIF > -20 cm H,O, muscular control is adequate for
electrolytes, etc. Increased fat concentration prior vital capacity > 10-15 cclKg, maintenance of spontaneous
to weaning may assist in decreas- PaO, > 60 mmHg on FIO, < ventilation. If carbon dioxide
ing potential for CO, retention 40%, resting minute ventilation retention is chronic, pH is more
and decrease in respiratory drive. < 10 L/min, PaCO, c 40 indicative of weaning readiness.
Labwork may be used to verify mmHg, tidal volume > 5 cdKg.
adequacy of nutritive state.
Assess patient for resolution of Factors may promote respiratory
Calcium imbalances can decrease
the function of the diaphragm, disease process, absence of inspi- insufficiency and compromise
and phosphorus may affect 2, 3- ratory muscle fatigue, absence of which may result in unsuccessful
DPG and ATP function, affect fever, absence of hemodynamic weaning.
instability, absence of sedative
respiratory muscle function and
red cell membrane stability. agents or respiratory suppres-
sanrs, presence of spontaneous
Stay with patient until stable, Respiratory deterioration may respirations, pulmonary shunt <
once weaning process has begun. occur rapidly and physical pres- 20%, and adequate hemoglobin
Observe for use of accessory ence is required to observe and hematocrit.
muscles, non-synchronous respi- patient to facilitate prompt inter-
Suction patient and perform Removes secretions that may
ratory pattern, or skin color vention. May indicate
deterioration in respiratory
chest physiotherapy, percussion compromise weaning process and
changes.
status, resulting in inability to and postural drainage as war- promotes improved pulmonary
wean. ranted prior to disconnection conditions.
from ventilator.
Monitor oxygen saturation per Oximetry provides identification
Utilize T-bar/T-piece adaptor as Provides oxygen via endotracheal
oximetry and notify MD if read- of tissue oxygen desaturation
which usually coincides with ordered. (Usually on T-bar for tube or tracheostomy with
ing less than 90% per pulse
decreases in arterial blood gases. 10-30 minutes per hour patient spontaneously breathing.
oximetry, or sustained reading
Oximetry does not give indica- initially.)
less than 60% per mixed venous
oxygen oximetry; obtain ABGs tion of increased CO, levels and Utilize SIMV/IMV mode on Provides ventilatory support to
per protocol. these must be verified with ventilator as ordered. (Usually patient with gradually decreasing
ABGs. rate decreased by 1-2 ventilator breaths and increase of
breathslminute every 15-30 spontaneous breaths. Facilitates
minutes.) gradually increasing respiratory

workload. If weaning is not the peak of the inspiratory effort. lungs so that patient will exhale
tolerated, may increase PaCO, or cough as tube is removed ro
and decrease pH. prevent aspiration of any secre-
tions that may be remaining after
Utilize PS (pressure support) as Assists patient to overcome suctioning.
ordered. (Usually 3-5 initially airway resistance and support
and may increase to 20, with spontaneous breathing by Administer humidified oxygen at Provides moisture and oxygen to
gradual lowering as IMV/SIMV increasing respiratory muscle prescribed amount. increase available oxygen, helps
rate lowered.) function. to reduce swelling, and facilitates
liquification of secretions for
Utilize CPAP (continuous posi- Patient exhales against continu- easier removal.
tive airway pressure) as ordered. ous positive pressure to prevent
(Usually 2-5 cm H,O.) atelectasis and improve arterial Monitor for dyspnea, May indicate partial obstruction
oxygen tension. bronchospasm, laryngospasm, or of airway. Deep breathing helps
stridor. Encourage deep breaths to expand lungs and facilitates
Monitor for MD-set parameters Alterations in vital signs and and coughing. movemenr of secretions.
or respiratory rate > 30, increas- hemodynamic may result from
ing PA pressures, heart rate > insufficient ventilation and respi- Monitor for persistent hoarseness Transient hoarseness and sore
110 with new or increased ratory compromise and indicates and sore throat. throat is normal post-extubarion
ectopic activity, blood pressure > intolerance of attempts to wean. but persistent symptoms may
20 mmHg from baseline, indicate vocal cord paralysis or
SaO, < 90%, tidal volumes c glottis edema.
250 cc; if significant changes
occur, place back on ventilator as
per protocol.
Gradually increase time off venti- The patient's progress will

lator with each successful increase as fatigue decreases,
attempt. Once patient is able to respiratory muscle function
improves, and patient is emo-
tolerate 1-2 hours off ofventila-
Demonstration
tor at a time, weaning may be
advanced more rapidly.
tionally ready to wean.
-
Determine patient's emotional Weaning may result in excessive
sratus and ability to cope with anxiety due to fear of failure Instruct on weaning process Decreases fear and anxiety, pro-
weaning process. and/or the ability to breathe and procedures based on M D motes cooperation, and increases
spontaneously. protocol. potential for successful weaning
attempt.
Extubate patient when he is able Emergency equipment should
to maintain an airway and his be easily available in case
spontaneous respirations are able reintubation is required due to
Knowledge deficit
to maintain oxygenation and bronchospasm, laryngospasm, or Related to: change in health status, situational
ventilatory status per protocol. respiratory deterioration.
Intubation equipment should
crisis, lack of information, misinterpretation of
remain at the bedside post-extu- information, stress, inability to recall information,
bation for 4-24 hours or per lack of understanding
protocol.
Defining characteristics: verbalized questions
To extubate, increase oxygen and Removes secretions that may
suction secretions from trachea, potentially be aspirated upon regarding care, inadequate follow-up on instruc-
nose and mouth. removal of tube. tions given, misconceptions, lack of improvement,
Promotes full inflation of the
development of preventable complications
Deflate cuff and remove tube at
Patient will be able to verbalize and demonstrate Instruct family on ventilatory Reduces fear, enables the family
understanding of information given regarding support procedures-function of to have sense of security about
all equipment, how to trouble- problems that may arise, and
condition, treatment regimen, and medications. shoot problems, and personnel to assures them that medical assis-
contact in case of an emergency. tance can be easily obtained in
an emergency.
Demonstration Instruct family on procedures for Promotes knowledge, enhances
suctioning, tracheostomy care, proper technique for care, and
INTERVENTIONS RATIONALES and administration of breathing decreases fear.
treatments as ordered.
Determine patient’s baseline of Provides information regarding
Instruct family on infection con- Decreases potential for infection
knowledge regarding disease patient’s understanding of condi-
trol techniques. and/or spread of biohazardous
process, normal physiology and tion as well as a baseline from
materials.
function of body systems, and which to plan teaching.
medical treatment regimens. Instruct patientlfamily on Promotes prompt recognition of
signslsymptoms to notify MD or potentially dangerous problems
Monitor patient’s readiness to Patient’s physical condition may
medical personnel. to facilitate prompt intervention.
learn and determine best meth- not facilitate participation in
ods to use for teaching. Attempt learning, with cognition af€‘ected Have patientlfamily perform Provides assurance that care is
to incorporate family members by high stress levels or disease return demonstration of all tasks able to be performed with proper
in learning process. Reinstrucd process. Family members may be instructed. technique, and allows for correc-
reinforce information as needed. fearful of equipment and envi- tion of erroneous methods.
ronment which may hamper
their ability to learn. Instructions Ensure that prior to discharge, all Reduces anxiety with discharge.
may require repetitive teaching equipment required will be set
due to competition with other up in home.
stimuli.
Instruct on all safety concerns; Promotes sense of security that
Provide time for individual inter- Promotes relationship between back-up power and equipment. emergency situations can be
action with patient. patient and nurse, and establishes handled.
trust.
Instruct on specific disease Provides knowledge to enable

process that has required ventila- patient to make informed
tory support, procedures that choices, and provides knowledge Patiendfamily will be able to accurately recall
may be required, diagnostic tests base on which to build for fur- instructions.
to be performed, and plans for ther teaching.
weaning off ventilator. Patient/family will be able to demonstrate all
Instruct on medications perti- Provides knowledge and facili-
tasks with appropriate proper methods.
nent to patient‘s care. tates compliance with regimen.
Patiendfamily will be able to recall emergency
Discuss potential for ventilator Unsuccessful weaning attempts numbers, and signs/symptoms for which to
dependence and alterations that may foster depression and atti-
notify medical personnel, and can accurately
may be required in lifestyle. tude of “giving up.” Practical
Encourage setting of short- and solutions and trouble-shooting demonstrate back-up power and equipment.
long-term goals. problems that may arise, as well
as participation in setting of real-
Patiendfamily will be able to follow infection
istic goals may enhance control procedures.
self-worth and self-control.
Patiendfamily will be able to problem-solve and
set realistic goals.
NEUROLOGICAL SYSTEM 137
NEUROLOGICAL SYSTEM
CYA
Head Injuries
Spinal Cord Injuries
Guillain-Bard Syndrome
Status Epilepticus
Meningitis
VentriculostomylICP Monitoring
Endarterectomy
CUA In addition to the disease processes discussed ear-

lier, cardiac dysrhythmias, alcohol use, cocaine or
A cerebrovascular accident, or stroke, occurs when other recreational drug use, smoking, and the use
a sudden decrease in cerebral blood circulation as of oral contraceptives may predispose patients to
a result of thrombosis, embolus, or hemorrhage strokes.
leads to hypoxia of brain tissues, causing swelling Strokes may cause temporary or permanent losses
and death. When circulation is impaired or inter- of motor function, thought processes, memory,
rupted the small area of the brain becomes speech,,or sensory function. Difficulty with swal-
infarcted and this changes membrane permeability lowing and speaking, hemiplegia, and visual field
resulting in increased edema and intracranial pres- defects are stations of this disease. Treatment is
sure (ICP). The clinical symptoms may vary aimed at supporting vital functions and ensuring
depending on the area and extent of the injury. adequate cerebral perfusion, and prevention of
Thrombosis of small arteries in the white matter major complications or permanent disability.
of the brain account for the most common cause
of strokes. A history of hypertension, diabetes MEDICAL CARE
mellitus, cardiac disease, vascular disease, or ather- CT scans: used to identify thrombosis or hemor-
osclerosis may lead to thrombosis, which causes rhagic stroke, tumors, or hydrocephalus; may not
ischemia to the brain supplied by the vessel reveal changes immediately
involved.
Skull x-rays: may show calcifications of the
Embolism is the second most common cause of carotids in the presence of cerebral thrombosis, or
CVA, and happens when a blood vessel is partial calcification of an aneurysm in subarach-
suddenly occluded with blood, air, tumor, fat, or noid hemorrhage; pineal gland may shift to the
septic particulate. The embolus migrates to the opposite side if mass is expanding
cerebral arteries and obstructs circulation causing
edema and necrosis. Brain scans: used to identify ischemic areas due to
CVA but usually are not discernible until up to 2
When hemorrhage occurs, it is usually the sudden weeks after injury
result of ruptured aneurysms, tumors, or AV mal-
formations, or involves problems with Angiography used to identify site and degree of
hypertension or bleeding dyscrasias. The cerebral occlusion or rupture of vessel, assess collateral
bleeding decreases the blood supply and blood circulation and presence of AV malforma-
compresses neuronal tissue. tions
Patients who have strokes frequently have had MRI: used to identify areas of infarction, hemor-
prior events, such as TIAs (transient ischemic rhage, and AV malformations
attacks) with reversible focal neurological deficits Ultrasound: may be used to gather information
lasting less than 24 hours or RINDS (reversible regarding flow velocity in the major circulation
ischemic neurological deficits) lasting greater than
24 hours but leaving little, if any, residual neuro- Lumbar puncture: performed to evaluate ICP and
logical impairment. to identify infection; bloody CSF may indicate a
hemorrhagic stroke, and clear fluid with normal
pressure may be noted in cerebral thrombosis, Outcome Criteria

embolism, and with TIAs; protein may be elevated
if thrombosis results from inflammation Patient will have improved or normal cerebral per-
fusion with no mental status changes or
EEG: may be used to help localize area of injury complications.
based on brain waves
Laboratory: CBC used to identify blood loss or INTERVENTIONS RATIONALES
infection; serum osmolality used to evaluate Measure blood pressure in both Cerebral injury may cause
oncotic pressures and permeability; electrolytes, arms. variations in blood pressure
readings. Hypotension may result
glucose levels, and urinalysis performed to identify
from circulatory collapse, and
problems and imbalances that may be responsible increased ICP may result from
edema or clot formation.
Surgery: endarterectomy may be required to Differences in readings between
remove the occlusion, or microvascular bypass arms may indicate a subclavian
may be performed to bypass the occluded area, artery blockage.
such as the carotid artery, aneurysm, or AV Maintain head of bed in elevated Helps to improve venous
malformation position with head in a neutral drainage, reduces arterial pres-
position. sure, and may improve cerebral
Corticosteroids: used to decrease cerebral edema perfusion.
Anticonvulsants: used in the treatment and pro- Provide calm, quiet environment Bedrest may be required to
with adequate rest periods prevent rebleeding after initial
phylaxis of seizure activity between activities. hemorrhage. Activity may
increase ICI?
Analgesics: used for discomfort and pain; aspirin
and aspirin-containing products are Administer anticoagulants as May be warranted to improve
contraindicated with hemorrhage ordered. blood flow to cerebral tissues and
to prevent further clotring and
TPA: use is controversial because of risks of embolus formation. These are
contraindicated in hypertension
uncontrolled bleeding due to the potential for hemor-
rhage.
NURSING CARE PLANS Administer antihypertensives as Hypertension may be transient
ordered. when occurring during the CVA,
Alteration in tissue perfusion: cerebral but chronic hypertension will
require judicious trearmenr to
Related to: occlusion, hemorrhage, interruption of prevent further tissue ischemia
'\\cerebralblood flow, vasospasm, edema and damage.
1
Oefining characteristics: changes in level of con- Administer vasodilators as Helps to improve collateral circu-
sciousness, mental changes, personality changes, ordered. lation and to reduce the
incidence of vasospasm.
memory loss, restlessness, combativeness, vital sign
changes, motor function impairment, sensory
impairment
Information, Instruction, INTERVENTIONS RATIONALES

Demonstration
Evaluate patient‘s response to Inability to follow simple com-
INTERVENTIONS RATIONALES simple commands. mands may indicate receptive
aphasia.
Instruct on use of stool softeners Valsalva maneuvers increase ICP
and avoidance of straining at and may result in rebleeding. Evaluate patient‘s ability to name Inability to do so indicates
stool. Stool softeners help to prevent objects. expressive aphasia.
straining.
Evaluate patient’s ability to write May indicate patient’s disability
Prepare patient for surgery as May be required to treat problem simple sentences or his name. with receptive and expressive
warranted. and prevent further complica- aphasia.
tions. Avoid talking down to patient or Intellect frequently remains
making patronizing comments. unimpaired after injury.
Impaired verbal communication When asking questions, use yes Provides for method of commu-
or no type questions initially, and nication without necessity of
Related to: weakness, loss of muscle control, cere- progress as patient is able. response to large volumes of
bral circulation impairment, neuromuscular information. As patient
progresses, the intricacy of ques-
impairment
tions may increase.
Defining characteristics: inability to speak, inabil- Provide a method of communi- Allows for communication of
ity to identify objects, inability to comprehend cation for patient, such as a needs and allays anxiety.
language, inability to write, inability to choose writing board, or communication
board to which patient may
and use appropriate words, dysarthria point.
Outcome Criteria Information, Instruction,

Demonstration
Patient will be able to communicate normally or
will be able to make needs known by some form INTERVENTIONS RATIONALES
of communication. Consult with speech therapy. May be required to identify cog-
nition, function, and plan
interventions for recovery.
Evaluate patient’s ability to speak Provides a baseline from which
Assist patientlfamily to Provides method for patient to
or understand language. to begin planning intervention.
identify and use methods for communicate his needs.
Determination of specific areas communication.
of brain injury involvement will-
preclude what type of assistance
will be required. Discharge or Maintenance Evaluation
Assess whether patient suffers Aphasic patients have dificulty
from aphasia or dysarthria. using and interpreting language, Patient will be able to communicate effectively.
comprehending words, and
inability to speak or make signs.
Patient will be able to understand communica-
Dysarthric patients can under- tion problem and access resources to meet needs.
stand language, but have
problems forming or pronounc- Impaired physical mobility
ing words as a result of weakness [See Head Injuries]
of paralysis of the oral muscles.
Related to: weakness, paralysis, paresthesias, INTERVENTIONS RATIONALES

impaired cognition
return to function level. Sensory
Defining characteristics: inability to move at will, impairment affects balance and
positioning.
muscle incoordination, decreased range of motion,
decreased muscle strength Evaluate environmene for safety Promotes safety and decreases
hazards, such as temperature potential for injury.
Senso y-perceptual alterations: visual, extremes.
kinesthetic, gustatory, tactile, oyactory
Related to: neurological trauma/deficit, stress,
altered reception of stimuli
Demonstration
~~ ~
Defining characteristics: behavior changes, disori- INTERVENTIONS RATIONALES

entation to time, place, self, and situation,
Instruct patient to observe feet Visual and tactile stimulation
diminished concentration, inability to focus, alter-
when standing or ambulating, helps to retrain movement and to
ation in thought processes, decreased sensation, and to make a conscious effort to experience sensations.
paresthesias, paralysis, altered ability to taste and reposition body parts. Assist with
smell, inability to recognize objects, muscle inco- sensory stimulation to non-use
side.
ordination, muscle weakness, inappropriate
communication
Outcome Criteria * Patient will be alert and oriented to all phases.
Patient will achieve and maintain alertness and Patient will be able to understand changes in
orientation with acceptable behavior and functional ability and residual neurological
motor/sensory function. deficits.
Patient will be able to compensate for dysfunc-
INTERVENTIONS RATIONALES tional abilities.
Risk for impaired swallowing
Assess patient’s perceptions and May help decrease distortions of
reorient as necessary. thought and identify reality. Related to: neuromuscular impairment
Assess for visual field defects, Visual distortion may prevent
Defining characteristics: inability to swallow
visual disturbances, or problems patient from having realistic
with depth perception. perception of his environment. effectively, choking, aspiration
Assist patienr by placing objects Allows for recognition of people
in his field of vision. and objects, and decreases Outcome Criteria
confusion.
Limit amount of stimuli. Avoid May create sensory overload and

Patient will be able to swallow effectively with no
excess noise or equipment. confusion. incidence of aspiration.
Observe patient for non-use of May create self-care deficiencies.
extremities. Test for sensatiod Loss of sensation or inability to
awareness and ability to discern recognize objects may impair
position of body.
INTERVENTIONS RATIONALES Self-care deficit: bdthing, dressing, feeding,

toileting
Evaluate patient’s ability to swal- Provides baseline information
low, extent of any paralysis, from which to plan interventions Related to: weakness, decreased muscle strength,
ability to maintain airway. for care.
muscle incoordination, paralysis, paresthesia,
Maintain head position and sup- Helps to prevent aspiration and pain, functional impairment
port, head of bed elevated at least facilitates ability to swallow.
30 degrees or more during and Defining characteristics: inability to perform
after feeding. ADLs, inability to feed self, inability to maintain
Place food in the unaffected side Allows for sensory stimulation personal hygiene, inability to dresdundress self,
of mouth. and taste, and may assist to trig- inability to take care of toileting needs
ger swallowing reflexes.
Provide foods that are soft and These types of foods are easier to
Outcome Criteria
require little, if any, chewing, or control and decrease potential for
provide thickened liquids. choking or aspiration.
Patient will be able to meet self-care needs within
Assist with stimulation of May help to retrain oral muscles own ability level.
tongue, cheeks, or lips as war- and facilitate adequate tongue -
ranted. movement and swallowing. INTERVENTIONS RATIONALES
Monitor intake and output, and Insufficient nutrient intake orally Evaluate level of neurological Provides baseline from which to
caloric intake. may result in the need for alter- impairment and patient’s abilities plan care for patient needs.
nate types of nutritional support. to perform ADLs.
Administer tube feedings/TPN May be required if oral intake is Assistance may reduce levels of
Assist patient with ADLs as
as warranted/ordered. insufficient. needed and encourage patient to frustration but patient will have
perform tasks he may be capable more self-esteem with tasks he
of doing. may complete.
Alter plans of care keeping in Assists patient with safety con-
Demonstration mind patient’s visual, motor, or cerns and allows for some degree
sensory deficits. of independence.
Utilize self-help devices and Allows patient to perform task
Instruct to use straw for drinking Helps to strengthen facial and instruct patient in their use. and improves his self-esteem.
liquids. Maintain swallowing oral muscles to decrease potential
Establish a bowel regime, using Medications may be helpful
precautions identified by speech for choking.
stool softeners, suppositories, etc. when establishing a bowel regime
therapists.
Offer bedpan or bedside com- and to regulate function.
Encourage family to bring Familiar foods may increase oral mode ar regular intervals. Retraining will allow the patient
patient’s favorite foods. intake. to gain independence and fosters
self-esteem.
Discharge or Maintenance Evaluation Information, Instruction,

Demonstration
Patient will be able to eat and swallow normally. ~~~ ~~
Patient will be able to ingest an adequate amount
of nutrients without danger of aspiration. Consult physicaVoccupationa1 May be required to assist wlth
therapist. development of therapy plan and
Patient will be able to follow instructions and to identify methods for patient
strengthen muscles used for eating/swallowing. to compensate for neurological
defi ci ts.

Patient will be able to perform self-care activi-
ties by himself or with the assistance of a
caregiver.
Patient will be able to understand and identify
methods to facilitate meeting self-care needs.
Patient will be able to access community
resources to meet continuing needs.
CVA
Cerebral hemorrhage Occlusion of major vessel Other causes of ischemia

by embolism
II c
Cerebral infarction t
e
Decreased flow of blood to brain
J,
Hypoxia
c
Cerebral edema
c
Vascular congestion
c
Compression of tissue
c
Impaired hnction
I
I I
Anterior cerebral artery Middle cerebral artery Posterior cerebral artery
4 e c
Confusion Arm paralysis Hemiparesis
Impaired thought Hemianopia Ataxia
Contralateral paralysis Aphasia Visual problems
Urinary incontinence Agnosia Dysphasia
Sensory deficits Perception deficits Dysphonia
Return of normal perfusion Continued inadequate blood flow

J, c
Decreased edema Further compression of tissues
4 c
Function improved Cerebral death
NEUROLOGICAL SYSTEM 1h7
When injury to the axons and neurons in the

hemispheres, brain stem, and diencephalon occur
Head injuries, both open and closed, are usually and result in diffuse shearing of white matter with
the result of some type of trauma, and include concurrent cerebral edema, dysfunction results in
skull fractures, concussions, lacerations, coma. More than half of these patients die, and
contusions, a n d o r cerebral hemorrhages. The those who do survive, have severe residual
injury can be the result of a direct blow to the dysfunction. Contusions of the brain stem result
head, or may involve acceleration/deceleration in coma, as well as cranial nerve dysfunction and
injuries. Acceleration, or coup, injuries occur cardiopulmonary instability.
when the brain is forced against the cranium. Skull fractures are normally classified as linear,
Deceleration, or contrecoup, injuries occur after basilar, or depressed. If a linear skull fracture does
the initial impact when the brain is rotated or not puncture the dura mater, the fracture will heal
thrown in the opposite direction of the force. without treatment. If the dura is torn, there is an
Closed head injuries (CHI) result when a blunt increased chance that the middle meningeal artery
trauma to the head causes a neurological deficit or is also punctured, and this will cause an epidural
loss of consciousness from bruising, hemorrhage, hematoma.
or laceration of brain tissues. This type of injury A basilar skull fracture can occur in the anterior or
may be further categorized into mild concussion, posterior fossa, and classic symptoms include cere-
classic concussion, diffuse injury with loss of con- brospinal fluid leakage from the nose or ears, or
sciousness greater than 24 hours, and diffuse ecchymoses over the mastoid projection or around
shearing and disruption of brain structures. the eyes. With basilar fractures, there exists a high
A mild concussion occurs when forces on the risk for cranial nerve injury and dysfunction,
brain stretch nerve fibers and result in impaired infection, and residual neurological impairment.
conduction of nerve responses. Neurological dys- Depressed skull fractures that are not depressed
function is temporary with no residual effects. In a more than the thickness of the skull are usually
classic concussion, the loss of consciousness is usu- not treated. A depression more than 5 millimeters
ally less than 24 hours in length and the patient or more in depth will require surgery in order to
experiences disorientation and a degree of retro- relieve the compression on structures. If the dura
grade amnesia when consciousness is regained. mater is punctured, the possibility of bone frag-
Some patients may experience residual personality ments entering the brain tissue is increased, as well
changes or impairment in memory recall. Patients as the potential for infection.
may exhibit a focal deficit caused by an injury that
occurs to a specific area. Lacerations of the scalp may occur with head
injury or skull fractures, and will potentiate the
With diffuse closed head injuries, the loss of con- danger of infection.
sciousness is greater than 24 hours and the coma
may last up to weeks. The patient can exhibit rest- Intracranial hematomas result after trauma to the
lessness, withdrawal from painful or noxious head, and frequently occur in conjunction with
stimuli, or purposeful movement. Disorientation scalp lacerations, skull fractures, contusions, or
and amnesia occur with the return of conscious- penetrating wounds to the head. Subdural
ness, and personality changes are permanent due hematomas (SDH) usually are caused by venous
to the widespread cerebrum disruption.
bleeding, most often from the superior sagittal

sinus, and involves the area between the dura
MEDICAL CARE
mater and the arachnoid space. It may be acute, CT scans: used to identify cerebral edema,
happening within 24-48 hours of injury, subacute, lesions, hemorrhage, ventricle size, tissue shifts, or
within 3-20 days of injury, or chronic, greater infarctions
than 20 days from injury, depending on the time
X-rays: skull x-rays may be used to identify frac-
elapsed from injury to the onset of symptoms.
tures or midline shifts, or presence of bone
SDH may occur spontaneously if the patient has a fragments, and to evaluate healing or resolution
blood dyscrasia or clotting problem.
MRI: used to reveal disruption of axonal
Epidural hematomas (EDH) are usually caused by
pathways and white matter shearing
arterial bleeding, generally from the middle
meningeal artery, and involve the area above the Angiography: cerebral angiograms may be used to
outer dura mater and below the skull. These occur identify circulatory anomalies, shifting of struc-
frequently when skull fractures cross the middle tures, hemorrhage, or edema
meningeal artery, or transverse or superior sagittal
Lumbar puncture: may be used in diagnosis of
sinus, and the bleeding causes the dura to be
subarachnoid hemorrhage; LP may be contraindi-
pulled away from the skull. A posterior fossa
cated in some cases
E D H is usually caused by a venous bleed and may
result in delayed symptoms due to the slow Laboratory: electrolyte imbalances may increase
oozing. With EDH, the patient may have a brief ICP or alter mental status; CBC to evaluate blood
episode of unconsciousness, followed by a varying loss and hydration status; drug toxicology studies
length of lucid behavior prior to neurological to identify drugs that may be responsible for con-
deterioration and increased intracranial pressure. sciousness level changes; anticonvulsant drug
levels to monitor therapeutic maintenance levels
Intracerebral hemorrhage (ICH) into the brain
may occur hours or days after a closed head injury, Arterial blood gases: used to evaluate hypoxemia
and many result after rupture of an aneurysm, AV and acid-base imbalances that can increase ICP;
malformation, tumor, or vessel that has been intracranial hematomas may result in respiratory
weakened from hypertension. If the hemorrhage alkalosis, or metabolic acidosis if patient is also in
occurs in the internal capsule of the brain, paraly- shock
sis will ensue. Symptoms vary depending on site,
Diuretics: may be used to draw water from brain
size, cerebral edema, and blood accumulation rate.
cells in order to decrease cerebral edema and ICP
Head injuries .can result in varying severity from
Steroids: may be used to decrease inflammation
absence of neurological dysfunction to death, and
and edema
each injury must be considered potentially critical.
Cervical spine injury evaluation may be required Anticonvulsants: may be required to treat and/or
depending on the mechanisms of the closed head prevent seizure activity
injury.
NURSlN6 CARE PLANS INTERVENTIONS RATIONALES

inability to stay awake unless
Alteration in tissue perfision: cerebral stimulared, or disorienration.
Related to: hemorrhage, hematoma, lesions, cere- Lack of response to stimuli may
indicate that damage has
bral edema, metabolic changes, hypoxia, occurred to the midbrain, pons,
hypovolemia, cardiac dysrhythmias and/or medulla. If a minimal
amount of damage has occurred
Defining characteristics: disorientation, in the cerebral cortex, the patient
confusion, changes in mental status, combative- may be uncooperative or drowsy.
ness, inability to focus o n topic, amnesia, memory Assess patient’s best verbal Identifies speech ability and ori-
loss, restlessness, inability to follow commands, response to questions and entation levels.
increased intracranial pressure, vital sign changes, whether wordslsentences are
appropriate.
impaired motor function, impaired sensory func-
tion Assess ability to follow simple Identifies ability to respond to
commands, noting purposeful stimuli when patient is unable to
and non-purposeful movements open eyes or cannot speak.
Outcome Criteria bilaterally. Purposeful movement, such as
holding up two fingers or
Patient will achieve and maintain consciousness, squeezing and releasing hands
when instructed to do so, can
and will have normal cognition and motor func- help identify awareness and the
tion. ability to respond appropriately!.
Abnormal posturing may indi-
INTERVENTIONS RATIONALES cate diffuse cortical damage, and
the absence of any movement to
Assess patient for cause of Establishes plan of care and iden- one side of the body usually indi-
impairment, problem with perfu- tifies appropriate choices for cates damage has been done to
sion, and potential for increased intervention. Depending on the motor tracts of the opposite
ICP patient’s conditiodproblem, side of the cerebral hemisph’ re
surgical intervention may be f .
required. Observe pupils bilaterally, noting Compression of the brain stem
equality, size, and reaction to and impairment of the second
Evaluate neurological status every Establishes a baseline from which light. Notify M D of significant and third cranial nerves will alter
hour initially, then every 1-2 to gauge changes or trends. changes. pupillary response.
hours, and notify M D for perti- Alterations in level of conscious-
nent changes. See Glasgow ness and behavior, as well as Observe position of eyes, noting Loss of doll’s eyes, or the oculo-
Coma Scale below. other symptoms may be helpful any deviation laterally or verti- cephalic reflex, indicates
to determine area of damage. cally. Observe for presence of impairment in the function of
doll’s eyes. the brain stem. Positions and
Assess patient’s arousal or lack of Establishes level of consciousness movement of the eyes may indi-
arousal to verbal and noxious which is the single most impor- cate which area of rhe brain has
stimuli. tant measure of the patient’s been involved. Problems with
status. Extensive damage involv- abduction of the eyes may be an
ing the cerebral cortex may result early indication of increased
in delayed responses to intracranial pressure.
commands, drowsiness and
Observe for presence of blink Loss of blinking reflex may indi-
reflex. cate injury to the pons and
medulla.

Monitor intracranial pressure at Provides immediate information Monitor EKG for rhyrhm and Bradycardia is frequently seen
leasr hourly, or use continuous about changes in pressure of the rate changes and treat per hospi- with brain stem injury.
monitoring per hospital policy. cerebrospinal fluid and blood to tal protocol. Dysrhyrhmias may become life-
facilitate detection of life- threatening and require emergent
threatening increases that can intervention.
lead to brain deterioration. ICP
fluctuates continuously and Assess for presence of cough and Injuries ro the medulla will resulr
gag reflexes. in impairment of these reflexes
maintained increases longer than
and may cause further complica-
10-15 minutes should be
reported. tions.
Observe for restlessness, moan- May indicate presence of discom-

Monitor ICP waves. Plateau, or A waves, have rapid
ing, or nonverbal changes in fort or pain and this may
increases and decreases of pres-
behavior. increase ICP
sure ranging from 15-50 mmHg,
last from 2-1 5 minutes, and are Observe for presence of seizure Cerebral injury and irritation,
usually noted in cerebral dys- activity and provide appropriate hypoxemia, hypoxia, and
function caused by shifting of safety precautions. increased ICP may result in
the brain. B waves last from 30 seizures. Seizure activity increases
seconds to 2 minutes, and are metabolic demands which can
usually less significant unless also increase ICI?
they occur in runs, which may
precede changes to A waves. C Observe for nuchal rigidity. May be present when meninges
waves are small and normally are irritated if dura mater has
occur at the rate of G/minute, been punctured, or if infection
and relate to variances in arterial develops.
blood pressure.
Elevate head of bed 15-30 Reduces inrracranial pressure and
Obtain CSF sample as ordered May be required for diagnostic degrees as indicated. cerebral congestion and edema.
and as per hospital protocol. testing or to relieve pressure.
Support head and neck in a neu- Movement of the head to either
Monitor vital signs; observe for Autoregulation may be impaired tral midline position utilizing side can compress jugular veins
widening pulse pressure, blood after cerebral vascular injury. pillows, sand bags, or towels. inhibiting venous drainage and
pressure changes, bradycardia, Temperature elevation may can result in increased ICI?
tachycardia, apnea, Cheyne- increase cerebral blood flow and
Limit suctioning to only when Suctioning procedures can
Stokes respiration, or fever. volume, which can increase ICI?
needed . increase intrathoracic, intraab-
Widening pulse pressure may
indicare increasing intracranial dominal, and intracranial
pressures.
pressure, especially when con-
sciousness level is deteriorating Administer oxygen as warranted. Reduces hypoxemia which may
concurrently. Hypotension from resulr in increased ICP
hypovolemia may occur when
patient has associated multiple If patient requires mechanical Hyperventilation results in respi-
trauma. Cardiac dysrhythmias ventilation, monitor hyperventi- ratory alkalosis, which results in
may result from brain stem pres- larory status. cerebral vasoconstriction and
sure or injury, or may be seen in decreases in ICP
cardiac disease. Increasing ICP or
Administer sedation and neuro- Paralping drugs may be ordered
compression of brain structures
muscular paralyzing agents as to prevent sudden rises in ICP
may result in loss of spontaneous
ordered and warranted. caused by coughing, suctioning,
respiration and may require
or other muscular acriviry, but
mechanical ventilation. Damage
should never be given without
to the hypothalamus may resulr
sedation of patient.
in hyperthermia which can result
in increased ICE!

Moniror pulse oximetry and Indicates respiratory insufficiency Patient will be alert, oriented in all phases, with
notify MD if levels remain below and impendinglpresent hypoxia. no speech or motor impairment.
90%.
Identifies acid-base imbalances
Patient will have no sensory impairment.
Monitor ABGs as warranted.
and presence of hypoxemia.
Patient will have stable vital signs and no
Elevations in PaCO, will cause
vasodilation in the cerebral vas- increase in ICI?
culature with a resultant increase
in I C P Risk f i r inefective breathing pattern
Monitor intake and output Reflects amounts of total body Related to: respiratory center injury, obstruction,
hourly. water which influences tissue structural shifting, surgical intervention
perfusion. Cerebral injury may
result in inappropriate A D H or Defining characteristics: dyspnea, Cheyne-Stokes
diabetes insipidus, and may lead
respirations, bradypnea, apnea, hypoxia,
to hypovolemia.
hypoxemia, abnormal arterial blood gases
Provide calm, quier environment Helps to reduce ICE Use of
without extraneous stimuli, and restraints may be required to
provide rest periods between care ensure the patient’s safety, but Outcome Criteria
activities. Use restraints only may cause irritation and fighting
when absolutely necessary. against the restraints which can Patient will maintain a patent airway with no evi-
increase ICE
dence of respiratory insufficiency.
Administer osmotic diuretics as Drugs remove water from areas
ordered. in the brain that maintain an -
intact blood-brain barrier, and Observe respiratory status for Changes from patient’s baseline
helps to reduce ICE rate, depth, rhythm, irregularity, may indicate pulmonary compli-
chest expansion and symmetry, cations or involvement of brain
Information, Instruction and absence. injured areas. Respiratory insuffi-
Demonstration ciency may require mechanical
ventilation.
Mainrain patency of airway. Depending on location of injury,
Instruct patient to avoid cough- Activities increase ICP by patient may not be able to main-
ing, straining, or any valsalva-like increasing intrathoracic and tain his own airway or
maneuvers. intra-abdominal pressures. ventilation and may require arti-
ficial means of doing so.
Prepare patiendfamily for place- Injury to certain areas of the
ment on mechanical ventilation brain may result in insufficient Auscultate breath sounds for May indicate hypoventilation,
as warranted. respiratory status and may changes and presence of adventi- obstruction, atelectasis, or infec-
require intubation and mechani- tious lung sounds. tion which may impair cerebral
cal ventilation to maintain life oxygenation.
support.
Observe for presence of gag, Lack of these reflexes may impair
Prepare parient/family for surgi- Craniotomy or burr holes may cough, and swallow reflexes. the parient’s ability to handle his
cal procedures. be necessary to remove bone secretions and may require an
fragmenrs, remove a hematoma, artificial airway. Nasopharyngeal
stop hemorrhage, remove airways are preferred to avoid
necrotic tissue, or elevate a stimulation of the gag reflex
depressed skull fracture. which can increase ICP
INTERVENTIONS RATIONALES Alteration in thoughtprocesses

Administer oxygen as warranted. Provides supplemental oxygen to Related to: injury, psychological problems, med-
reduce hypoxia and prevent ications
desaturation.
Defining characteristics: memory deficit, dimin-
Elevate head of bed as warranted. Promotes chest expansion and
ventilation. ished attention span, inability to focus,
disorientation to time, place, person, or situation,
Avoid suctioning unless manda- Suctioning may cause hypoxia
tory, and observe for changes in and decreases cerebral perfusion,
poor recall, distractibility, personality changes,
sputum color, consistency, or while increasing ICI? Changes in inappropriate behavior, inability to problem-solve
odor. sputum characteristics may indi-
cate impending or presence of
infection. Outcome Criteria
Patient will be oriented in all phases and will be
Information, Instruction, able to recall data.
Demonstration
INTERVENTIONS RATIONALES Provides a baseline on which to
Evaluate orientation status with
regard to time, place, person, begin and plan interventions.
Instruct patient in deep breath- Reduces potential for atelectasis circumstance, and recent events.
ing exercises. and/or pneumonia.
Observe patient for abiliry to Abiliry to concentrate may be
Avoid chest physiotherapy during C P T is concraindicated with
concentrate and attention span. diminished due to injury and
acute phases. patients with increased I C P
this further potentiates anxiety
because this potentiates the
for the patient.
increase.
Assist family members to under- Head injury recovery includes
Prepare patient/family for intu- As time and condition permits, stand patient’s aberrant behavior, agitation and hostility, anger, and
bation/mechanical ventilation as instruction may be given.
personality changes, and other disorganized thought sequences.
warranted. Provides knowledge and
responses. Family members may have diff-
decreases fear in patients who are
culty dealing with the patient’s
awake.
changed personaliry and behav-
ior.
Discharge or Maintenance Evaluation Encourage family to discuss news Helps to maintain contact with
and family occurrences with normal events and assists with
patient. orientation.
Patient will maintain his own airway and be
able to sustain spontaneous respiration. Explain all procedures with clear Patient may have lost the abiliry
concise explanations. to reason or conceptualize, and
Patient will be able to handle secretions and dis- may require repeated reinforce-
pose of them adequately. ment. Retention of information
may be decreased and result in
Arterial blood gases will be within normal limits further anxiety.
for the patient. Reduce competing stimuli when Brain injured patients may be
conversing with the patient. overly excitable and become vio-
Patient will be able to recall information accu- lent with excess stimulation.
rately and be able to demonstrate appropriate
Be consistent with srafFassign- Provides atmosphere of stability
deep breathing. ments as much as possible. and allows patient some control
in situation.
~~~~ ~ ~ ~ ~
INTERVENTIONS RATIONALES Defining characteristics: fever, tachycardia,

elevated white blood cell count, shift to the left on
Remain with patient during Offers support and helps to calm differential, redness to wounds, purulent drainage
episodes of fright or agitation. patient to reduce anxiety to pre-
or sputum, nuchal rigidity, bloody or purulent
vent loss of control and panic.
CSF
Assist patient/family to set realis- Helps to maintain a sense of
tic goals and instruct in ways to hope for improvement and to
control behavior. facilitate rehabilitation. Outcome Criteria
Patient will be free of signs/symptoms of infection.
Demonstration
Monitor temperature every 2-4 Elevation may indicate develop-
INTERVENTIONS RATIONALES hours. ment of infection.
Observe wounds, incision lines, Prompt identification of develop-

Consult rehabilitation counselor Assists patient with methods to invasive line sites, or other skin ing problems may result in
for assistance with cognitive compensate for problems with bre& for drainage, redness, or prompt intervention to prevent
training as warranted. concentration, memory, judg- edema. systemic sepsis.
ment, and problem-solving.
Observe for CSF leakage from Indicates a serious complication
Make appropriate referrals TO Additional help may be needed ears and nose, and report to from head injury and may result
support groups or counseling as to help with recovery. MD. in meningitis.
warranted.
Use aseptic or sterile technique Prevents spread of infection.
when changing dressings or pro-
viding wound care.
Utilize good handwashing Prevents nosocomial infections,
Patient will regain normal mental skills and be practices.
oriented in all phases. Monitor urine output for ade- May identify presence of bacrer-
quacy of amount, color, clarity, id infection.
Patient will be able to recognize aberrant behav- and presence of foul odor.
ior and control negative reactions.
Obtain cultures of wound, urine, Identifies the presence of infec-
Patient will participate in rehabilitation/counsel- blood, stool, sputum, or other tion and the causative agent, as
body fluidslsurfaces as well as identification of appropri-
ing for retraining.
warranted, and as per hospital ate antimicrobial agent to treat
protocol. infection.
Risk for infiction
Administer antibiotics as May be given prophylactically
Related to: trauma, lacerations, broken skin, open ordered. when trauma, surgery, or CSF
wounds, invasive procedures, surgery, use of leakage occurs. Appropriate
steroids, cerebrospinal fluid leakage, nutritional antibiotic may be ordered after
results of culture and sensitivity
deficiency are received.

Demonstration
INTERVENTIONS RATIONALES Evaluate patient’s ability and Identifies impairments and
function and injury. allows for identification of
Instruct on isolation procedures Isolation may be required based appropriate interventions.
as warranted. Instruct visitors on on type of organism grown.
Assess patient for degree of Provides a baseline on which to
avoiding patient if they have Restriction of ill visitors may
immobility. base interventions. Patient may
upper respiratory or other type of reduce exposure of an already
only require minimal assistance
infection. susceptible patient.
or be completely dependent on
Instruct on deep breathing and Promotes lung expansion and caregivers for all body needs.
pulmonary exercises as reduces potential for atelectasis
Observe skin for redness, May indicate pressure is being
warranted. and pneumonia. Postural
warmth, or tenderness. concentrated in one area and
drainage is contraindicated if
may predispose patient to decu-
patient has increased ICE
bitus formation.
Discharge or Maintenance Evaluation Provide kinetic bed or alternating Helps to promote circulation and
pressure mattress for patient. reduces venous stasis and tissue
pressure to prevent formation of
Patient will be normothermic with normal
pressure sores.
white blood cell count.
Maintain good body alignment Prevents further complications
Patient will exhibit no signs/symptoms of infec- and use pillows/rolls to support and contractures. Use of tennis
tion. body. Use high-top tennis shoes shoes helps prevent footdrop.
and removelreapply every 4-8
Wounds will heal without complications. hours.
Perform range of motion exer- Helps to maintain mobility and

Impaired physical mobility
cises every 4 hours. function of joints.
Related to: trauma, immobilization, mental Provide skin care every 8 hours Helps to promote circulation and
impairment, decreased strength, paralysis and prn. Change wet clothing reduces potential for skin break-
and linens prn. down.
Defining characteristics: inability to move at will,
Instill artificial tears or lubrica- Prevents eye tissues from drying
inability to transfer or ambulate, decreased range tion ointment to eyes every 4 out. If patient is unable to main-
of motion, decreased muscle strength, muscle hours and prn as ordered. tain closed eyes, eye patches or
incoordination, footdrop, contractures, decreased tape may be required.
reflexes
Demonstration
Outcome Criteria
Patient will achieve and maintain an optimal level
of motor function. Instruct patient/family in range Helps patient to regain some
of motion exercises and mobility control and allows family some
aids. involvement in reconditioning
program.
Instruct patiendfamily in reasons Promotes understanding and

for impairment and realistic goals compliance with treatment regi-
for changes in patient’s lifestyle men.
as warranted.

Consult physical andlor occupa- Assists patient with identihing Encourage family to assist with Involves family in parient’s plan
tional therapy, as warranted. methods to compensate for feeding a s warranted. of care and provides opportunity
impairments and provides for for socialization that may
post-discharge care. improve intake.
Administer tube feedings as Tube feedings may be required

Discharge or Maintenance Evaluation required. during the initial phase after
injury until the patient is able to
Patient will be able to maintain skin integrity swallow without danger of aspi-
with no complications. ration.
Elevate the head of the bed at Helps to prevent aspiration

Patient will be able to increase muscle strength least 30 degrees while eating or
and tone and achieve a functional level of giving tube feedings.
muscle function. Auscultate bowel sounds every 4 Quality of bowel sounds may
hours. indicate response to feedings or
Patient will be able to demonstrate exercise pro-
development of an ileus.
gram.
Consult dietitian as warranted. Provides additional resources to
Patient and family will become involved in establish nutrient needs based on
recovery programs. many factors including metabolic
deman ds .
Risk for alteration in nutrition: less tban Monitor serum albumin, preal- Assists in identification of nutri-
body requirements bumin, transferrin, iron, renal tional problems, body function,
profiles, and glucose levels. and response to nutritional sup-
*Relatedto: inability to take in sufficient nutrients, port.
inability to chew or swallow, decreased level of
consciousness, intubation, increased metabolism Information, Instruction,
Demonstration
Defining characteristics: weight loss, muscle wast- ~
ing, catabolism
Consult speech or occupational May be required ro establish a
therapy For mechanical problems. functional method of eating for
Outcome Criteria the patient.
Patient will be able to ingest sufficient nutrients to Check gastric contents, vomitus, Bleeding may occur from srresses
meet metabolic demands, and will experience no and stools for occult blood. resulting from injury or from
mechanical erosion.
weight loss.
Patient will maintain optimal weight.
Evaluate patient’s ability to eat, Identifies problems and estab-
swallow, chew, etc. lishes data for choices of
Patient will be in a positive nitrogen balance,
interventions.
with laboratory values within normal limits.
Weigh every day. Establishes trends and helps to
evaluate effectiveness of Patient will be able to ingest food in sufficient
interventions. amounts to meet and maintain metabolic
Provide small, frequent meals. Improves patient compliance and demands.
facilitates digestion.
HEAD INJURIES
Brain trauma
c
Bleeding
-1 JI I
Bruising of brain Small petechial hemorrhages Laceration of brain tissue
c
Brain edema Neuronal pathways disrupted
c s
Compression of blood vessels Cranial nerve dysfunction
Blood flow decreased
c
Brain ischemia
c
Tissue hypoxia
c
Arteriolar dilatation
Increased capillary pressure
Decreased venous return
c
Celular metabolism impaired
c
Cellular transport decreased
Sodium and water increased
c
Increased cerebral edema
Increased ICP
c
Shifting of brain structures
c
Brain tissue destruction
Herniation/cornpression of brain and brainstem
J.
Cardiovascular and respiratory impairment
4
Cardiopulmonary failure
c
DEATH
HEAD INJURIES
CONCUSSION DIFFUSE INJURY WITH DIFFUSE WHITE MATTER

LOG24 HOURS SHEARING W I T H DISRUPTION
OF AXON/NEURON PATHS
MILD CLASSIC
c c c c
Stretching of Axonal disruption Coma with purposhl move- Coma with brainstem and
nerve fibers ment and restlessness autonomic dysfunction
c c c c
Loss of nerve Cortical dysfuntion Disorientation Cardiovascular collapse
conduction
c c c
Temporary neuro- Disorientation Retrograde and post-traumatic DEATH
logical dysfunction amnesia
J, J, J,
Retrograde amnesia Retrograde and post- Increased cerebral edema

traumatic amnesia
J, JI e
Return to normalcy Potential subtle Increased ICP
personality and c
memory changes Brain tissue
destruction/compression
J,
J,
DEATH
Spinal Cord Injuries In central cord syndrome, the central gray matter
of the cord is contused, compressed, or
Spinal cord injuries are traumatic injuries to the hemorrhaged. This results in varying degrees of
spinal cord caused by contusion, compression, or sensory loss and bowel/bladder dysfunction, and
transection of the cord as a result of dislocation of there is more motor loss in the arms than in the
bones, rupture of ligaments, vessels, or vertebral legs. In anterior cord syndrome, the injury has
discs, stretching of neuron tissue, or impairment occurred to the anterior horn and spinothalamic
in blood supply. These lesions are classified as areas resulting in a loss of motor function and
being complete or incomplete. Complete lesions painltemperature below the lesion. Sensations of
involve the total loss of sensation as well as volun- touch, position, pressure and vibration may be
tary motor function, and incomplete lesions maintained. In Brown-Sequard syndrome, as a
involve mixed losses of sensation and voluntary result of a transverse hemi-transection of the cord,
motor function. motor loss, touch, vibration, pressure, and posi-
tion are involved ipsilaterally, with a contralateral
The flexion, hyperextension and/or rotational loss of pain/temperature sensation. Posterior cord
types of injury that result in spinal cord injury are syndrome is exceedingly rare and results in the loss
usually caused by trauma, motor vehicle accidents, of light touch below the level of injury, with
falls, gun shot wounds, stab wounds, and diving motor function and sensation of pain and temper-
injuries, The severity of the injury can vary ature maintained intact.
depending on the amount of pathologic changes
that are produced. Injury without intervention When spinal lesions at or above T6 level block
results in ischemia, edema, hemorrhage, and pro- sensory impulses from reaching the brain, an
gressive destruction. After the initial cord excessive and critical autonomic response to a
compression, small hemorrhages occur in the cen- stimulus occurs, and this is known as autonomic
tral gray matter. The expansion and increase in dysreflexia. It may be precipitated by bowel or
number of hemorrhagic areas cause even more bladder distention or by stimulation of the skin or
pain receptors. Symptoms may include severe
compression, edema, and finally, necrosis of the
cord. The cervical area is the most vulnerable part blood pressure increases, pounding headache, pro-
of the spine because of the mobility of the head fuse sweating above the lesion, blurred vision,
goosebumps, and bradycardia. Treatment is aimed
and poor support by the muscles, but cervical
at removing the stimulus that causes the problem,
fractures do not necessarily cause neurological
and treating the hypertensive episode.
problems.
Spinal shock occurs when there is an abrupt loss
The level of the injury relates to how much func-
of continuity between the spinal cord and the
tional ability is retained. At the C1 to C8 levels,
higher nerve centers, with a complete loss of all
the patient is a quadriplegic with variances in
reflexes and a flaccid paralysis below the level of
muscle function from complete paralysis of respi-
injury. Normally, this spinal shock lasts 7-10 days
ratory function to limited use of the fingers. At TI
and when it begins resolution, the flaccidity
to L1 levels, paraplegia is noted with intact arm
changes to a spastic type of paralysis.
movement. At L1 and below, there may be mixed
dysfunction with bowel and bladder dysfunction.
1 c;n CRITICAL CARE NURSING CARE PLANS
MEDICAL CARE INTERVENTIONS RATIONALES
Arterial blood gases: used to identify hypoxemia Monitor EKG for changes in Sympathetic blockade may cause
rhythm and conduction, and conduction problems such as
and acid-base imbalances treat according to hospital escape rhythms, and vasovagal
protocol. reflexes may provoke cardiac
Radiography: chest x-rays used to identify
arrest.
diaphragmatic changes or respiratory
Monitor hemodynamic parame- Fluid shifts, hypotension, and
complications; spinal x-rays used to identify frac-
ters if feasible. hemorrhage may be reflected in
ture or dislocation and identifies level of injury lowered pressures and lower car-
diac output/index.
CT scans: used to identify structural aberrancies
and localize injury site Administer oxygen as warranted, Assists in preventing hypoxia
ensuring pre-oxygenation prior which can result in vasovagal
Magnetic resonance imaging: used to identify to suctioning or prolonged reflex and cardiac arrest.
cord lesions, compression, or edema coughing exercises.
Administer vasopressors as May be indicated if fluid resusci-

Surgery: may be required to align or stabilize frac- warranted. tation is not successful in
ture, or repair other traumatic injuries that may be maintaining systolic blood pres-
concurrent sure above 90 mmHg.
Traction: may be required to align and stabilize Information, Instruction,

fracture or dislocation of the vertebral column Demonstration
NURSING CARE PLANS
Instruct patient in avoidance of May lower blood pressure and
Risk j i b decreased cardiac output valsalva-type maneuvers. facilitare vasovagal response.
Related to: neurogenic shock, sympathetic block-

ade, spinal shock Discharge or Maintenance Evaluation
Defining characteristics: hypotension, bradycar- Patient will exhibit no episodes of cardiac
dia, vasovagal reflex, hypoxia, decreased venous rhythm disturbances.
return, decreased hemodynamic pressures
Patient will have normotensive blood pressure
with stable hemodynamic pressures.
Outcome Criteria
Patient will have optimal cardiac output and
Patient will be able to maintain systolic blood index.
pressure above 90 mmHg and have stable vital
signs and heart rhythm. Patient will exhibit no hypoxic episodes and
~~
avoid desaturation with procedures.

Monitor vital signs, especially Transection of the spinal cord
Inneflective breathing pattern
blood pressure and heart rate. above the T5 levels may result in
Related to: trauma, spinal cord lesions at high
vasodilation, decreased venous
return, and hypotension. levels, paralysis of respiratory musculature, ineffec-
Sympathetic blockade may cause tive coughing, pneumonia, pulmonary edema,
bradycardia. pulmonary embolism
NEUROLOGICAL SYSTEM lG1
Defining characteristics: dyspnea, use of accessory Information, Instruction,

muscles, diaphragmatic breathing, decreased tidal Demonstration
volumes, sputum, abdominal distention, abnormal
arterial blood gases, apnea, oxygen desaturation INTERVENTIONS RATIONALES
Prepare patientlfamily for place- Hypoxemia that cannot be cor-
Outcome Criteria ment on mechanical ventilation rected with addition of
as warranted. supplemental oxygen may
Patient will maintain adequate oxygenation and require intubation and ventila-
tion to maintain airway and
ventilation without evidence of respiratory com- oxygenation.
plications.
Prepare patient for bronchoscopy May be required to remove
INTERVENTIONS RATIONALES as warranted. obstructive secretions.
Assess respiratory status for ade- Spinal cord lesions below C4 Monitor for signslsymptoms of Edema may result from fluid
quacy of airway and ventilation, level induces diaphragmatic pulmonary embolism, pneumo- resuscitation efforts, and pneu-
rate, character, depth, increased breathing and hypoventilation. nia, or pulmonary edema. monia may develop from
work of breathing, or use of immobility and ineffective cough
accessory muscles. ability. Pulmonary emboli may
result from venous thrombosis as
Auscultate lung fields for pres- May reflect the presence of infil- a complication of immobility or
ence of adventitious sounds and trates, pneumonia, atelectasis, or hemorrhagic causes.
other changes. fluid overload.
Instruct family member in tech- Provides information that will be
Assist withlmeasure pulmonary Measurement of pulmonary niques to assist patient with used when patient is discharged
parameters, such as spontaneous parameters may facilitate prompt coughing, repositioning and facilitates feelings of control
tidal volume, vital capacity, and identification of deterioration in frequently, and suctioning tech- over situation and self-esteem.
negative inspiratory force. respiratory status. ABGs are niques as warranted.
Obtain arterial blood gases as drawn to identify acidlbase dis-
warranted. turbances and hypoxemia that
may result from restriction of
lung expansion and ineffective
cough mechanisms. Patient will maintain adequate airway and venti-
lation.
Evaluate patient’s ability to Paralysis of respiratory muscula-
cough and assist with abdominal ture may prevent sufficient Patient will exhibit no signs/symptoms of respi-
thrusting technique, or quad pleural pressure to be produced
ratory complications.
coughing, as warranted. to maintain effective cough.
External technique can assist Patiendfamily will be able to verbalize
patient to cough effectively.
understanding of instructions and give adequate
Monitor oxygen saturation con- Oximetry assists in identification return demonstration.
tinually and notify physician if of deterioration in ventilatory
levels stay below 90%. status, allowing for prompt inter- Alteration in temperature regulation
vention.
Related to: poikilothermism, injury to hypothala-
Suction patient only when Suctioning may precipitate vaso-
required. Provide humidification vagal reflexes, bradycardia, and mic center or sensory pathways
of oxygen and utilize pulmonary cardiac arrest. Liquification of
toilette as warranted. environmental air and secretions Defining characteristics: elevated body tempera-
may prevent mucous plugs and ture, decreased body temperature, change of
thick mucoid secretions. temperature based on environmental temperature
Outcome Criteria Outcome Criteria

Patient will achieve and maintain body tempera- Patient will be able to achieve maximum mobility
ture above 95 degrees. within limitations of paralysis and will avoid skin
breakdown and contractures.
Monitor temperature every 2 Interruption of the sympathetic
hours until stabilized, then every nervous system pathways to the Assess motor strength and func- Identifies level of sensory-motor
4 hours and prn. temperature control center in the tion at least every 4-8 hours, and impairment and evahares resolu-
hypothalamus causes body tem- prn. Identify level of tactile sen- tion of spinal shock. Specific
perature swings in an effort to sation, ability to move parts of injury level may have partially
match environmental tempera- body, spasticity, etc. mixed or occult sensorimotor
tures. impairment.
Maintain a slightly cool environ- Hyperthermia may occur during Observe for muscle atrophy and May be noted during flaccid
mental temperature. If patient is periods of spinal shock because wasting. paralysis stage of spinal shock.
hypothermic, apply warm the sympathetic activity is
blanket. Encourage independent activity C1-4 lesions result in quadriple-
blocked and the patient does not
perspire on paralyzed areas of as able. gia with complete loss of
body. respiratory function; C4-5
lesions result in quadriplegia
with potential for phrenic nerve
Information, Instruction, involvement that may result In
Demonstration loss of respiratory function; C5-6
lesions result in quadriplegia
INTERVENTIONS RATIONALES with some gross arm movement
ability and some sparing of
Instruct patienrlfamily regarding Provides knowledge and facili- diaphragmatic muscle involve-
variable body temperatures and tates compliance. ment; C6-7 lesions result In
methods to maintain comfort. quadriplegia with intact biceps;
C7-8 lesions result in quadriple-
Discharge or Maintenance Evaluation gia with intact biceps and triceps
but no intrinsic hand muscula-
Patient will exhibit normal temperature and be ture intact; T1-L2 lesions result
in paraplegia with variable
able to maintain core body temperature using
amounts of involvement to inter-
methods discussed. costal and abdominal muscle
groups; below L2 lesions result in
Impaired physical mobility mixed motor-sensory loss with
bowel and bladder impairment.
Related to: spinal cord lesion, trauma, paralysis,
spasticity, physical restraint, traction Assist withlprovide range of Improves muscle tone and joint
motion exercises to all joints. mobility, decreases risk for con-
Defining characteristics: contractures, inability to tractures, and prevents muscle
move as desired, spastic movements, muscle atro- atrophy.
phy, muscle wasting, skin breakdown, redness, Reposition every 2 hours and Decreases pressure on bony
pressure areas prn. Utilize kinetic bed therapy prominences and improves
as warranted. peripheral circulation. Kinetic
beds can immobilize the unstable
vertebral column and decrease
potential for complications from
immobility.

Ensure proper alignment with Correct anatomic alignment pre- Patient will maintain appropriate body
each position. vents contractures and
deformities. alignment and maximal function within limit of
injury.
Utilize footboards or high-top Prevents footdrop.
tennis shoes. Patient will avoid complications of immobility.
Observe for changes in skin Loss of sensation, paralysis, and
status and provide frequent skin decreased venous return predis-
care. pose the patient for pressure and demonstrate effective therapeutic
wounds. modalities.
Assist with/consult physical ther- Exercises help stimulation circu- Patient will exhibit suppleness of joints and
apists or occupational therapists lation and preserves joint
mobility.
muscles.
to develop plan of care for
patient.
Alteration in comfort
Maintain cervical traction appa- Cervical traction provides for [See Guillain-Barrt]
ratus as warranted. stabilization of vertebral column,
reduction, and immobilization to Related to: trauma, surgery, cervical traction
maintain proper alignment. Halo
bracddevices provide immobi- Defining characteristics: burning pain below
lization but can facilitate with lesion, muscle spasms, phantom pain, hyperesthe-
active participation with rehabili-
sia above lesion level, headaches, communication
tation processes.
of pain, facial grimacing, irritability, restlessness
Observe for redness and swelling Thrombus formation may occur
to calf muscles. Measure circum- as a result of immobilization and Risk for impaired skin intepity
ference daily if problem is noted. flaccid paralysis. [See Fractures]
Information, Instruction, Related to: immobility, surgery, traction appara-

Demonstration tus, changes in metabolism, decreased circulation,
impaired sensation
Defining characteristics: wounds, drainage, red-
Instruct family in rehabilitative Facilitates adaptation to patient’s ness, pressure sores, abrasions, lacerations
therapy, exercises, and reposition- health status and allows for
ing, and involve them with family members to contribute to Sensory-perceptual alteration
patient’s care. patient’s welfare.
[See CVA]
Avoid improper placement of May create pressure resulting in
footrests, headrests, or padding pressure sores or necrotic injury. Related to: traumatic injury, sensory receptor and
when repositioning patient. tract impairment, damaged sensory transmission
Instruct in methods for shifting Improves circulation by reducing Defining characteristics: decreases sensory acuity,
weight. pressure to body surfaces.
impairment of position relation, proprioception,
Administer muscle relaxants as May be required to reduce pain motor incoordination, mood swings, disorienta-
warranted. and spasriciry.
tion, agitation, anxiety, abnormal emotional
responses, changes in stimulation response
164 CRITICAL, CARE NURSING CARE PLANS
Bowel incontinence Information, Instruction,

Demonstration
Related to: trauma, impairment of bowel innerva-
tion, impairment of perception, modifications of INTERVENTIONS RATIONALES
dietary intake, immobility
Instruct patientlfamily regarding Promotes independence and
Defining characteristics: inability to evacuate method for daily bowel program. self-esteem.
bowel voluntarily, ileus, gastric distention, hypoac-
tive bowel sounds, absent bowel sounds, nausea, Discharge or Maintenance Evaluation
vomiting, abdominal pain, constipation
Patient will establish and maintain daily bowel
pattern.
Outcome Criteria
Patient will be able to establish and maintain and demonstrate appropriate methods to
bowel elimination patterns. accomplish bowel care.
INTERVENTIONS RATIONALES Patient will be able to avoid complications that
Observe for presence of abdomi- Innervation may be impaired as a
may be caused by gastric distention or ileus.
nal distention. result of the injury with resultant
decrease or loss of peristalsis, and
Urinary retention
potential for development of
Related to: traumatic loss of bladder innervation,
ileus. Bowel distention may pre-
cipitate autonomic dysreflexia bladder atony
after spinal shock recedes.
Defining characteristics: urinary retention, incon-
Auscultate for presence of bowel High-pitched tinkling bowel tinence, bladder distention, urinary tract
sounds, noting changes in sounds may be heard when
patient has an ileus, and bowel
infections, kidney dysfunction, stone formation,
character.
sounds may be absent during overflow syndrome
spinal shock phase.
Evaluate bowel habits, such as Establishes pattern and facilitates Outcome Criteria
frequencp character, and amount treatment options.
of stools. Patient will be able to achieve and maintain bal-
Establish bowel pattern by use of Effectively evacuates bowel. anced intake and output with no signs/symptoms
stool softeners, suppositories, or of complications.
digital stimulation.
Increase dietary bulk and fiber. Promotes peristaltic movement
through bowel and improves Monitor intake and output every May identify urinary retention
consistency of stool. shift, noting significant differ- from an areflexic bladder.
ences in amounts.
Provide frequent skin care. Incontinence of stool increases
potential for skin breakdown. Observe for ability to void and Spinal shock is exhibited in the
palpate for bladder distention. bladder when there is a loss of
Insert Foley catheter as sensory perception and the
warranted. bladder is unable CO contract and
empty itself. Bladder distention
may precipitate autonomic
dysreflexia.
INTERVENTIONS RATIONALES level of the lesion, bradycardia, piloerection, pupil

______~ ~~~
dilation, nasal congestion, nausea

Monitor urinary output for Cloudiness, blood, concentra-
changes in color or character. tion, or foul smell may indicate
urinary tract infection. Outcome Criteria
Administer urinary antiseptic Vitamin C and mandelamine
agentdacidifiers as ordered. may be given to acid$ the urine Patient/nurse will be able to recognize signs/symp-
to hinder bacterial growth and toms and take appropriate action to prevent
prevent stone formation.
complications.
Demonstration
Observe for hypertension, tachy- Identification of potential Iife-
Instruct patiendfamily in meth- Catheterization may be required cardia, bradycardia, sweating threatening complication
ods for intermittent catheter- for long-term due to injury and above level of lesion, pallor facilitates prompt and timely
ization when warranted. dysfunction to bladder. below level of injury, headache, intervention.
Intermittent catheterization is piloerection, nasal congestion,
preferred and is performed at metallic tare, blurred vision,
specific intervals to approximate chest pain, or nausea.
physiological function and may Assess for bowel or bladder dis- May be indicative of precipitat-
decrease complications from tention, bladder spasms, or ing factor for autonomic
indwelling catheter. changes in temperature. dysreflexia.
Increase fluid intake, when war- Decreases formation of kidney or Monitor vital signs frequently, Hypotensive crisis may occur
ranted, up to 3-4 Llday, bladder stones, helps prevent especially blood pressure every 5 once stimulus is removed, but
including acidic juices, such as infection, and ensures hydration. minutes during acute phase. dysreflexia may recur and should
cranberry juice. be monitored.
Ensure sterile technique for Decreases potential for urinary Palpate abdomen VERY gently Palpation should be done gently,
catheter insertions. tract infection. for bladder distention, and irri- if at all, so as to not increase
gate catheter VERY slowly with stimulating factor and worsen
tepid solution. condition. Irrigation may iden-
Discharge or Maintenance Evaluation tify and correct catheter
obstruction which may have
Patient will have balanced intake and output been predisposing factor.
without signs of urinary tract infection.
Check for rectal impaction May increase rectal stimulation
VERY gently, and only after and worsen dysreflexia.
Patient/family will be able to verbalize
anesthetic-rype rectal ointment
understanding of need for catheterization, and has been applied.
will be able to give return demonstration of pro-
Position in high-Fowler's position Promotes decrease in blood pres-
cedure. in bed. sure to avert intracranial
hemorrhage or seizure activity.
Risk f i r dysreflexiu
Administer medications as Atropine may be required to
Related to: spinal cord injury at TG level and ordered. increase heart rate if bradycardia
above, excessive autonomic reaction to stimulation is present; apresoline, hyperstar,
or procardia may be required ro
Defining characteristics: hypertension, blurred decrease blood pressure.
vision, throbbing headache, diaphoresis above the
Demonstration
Instruct patient/farnily on Problem may be lifelong but can

signslsymptoms of syndrome, be prevented by avoiding pres-
and methods for preventing sure-causing sensation.
occurrence.
Administer antihypertensive May be required for long-term

drugs as ordered. use to alleviate chronic
autonomic dysreflexia by relax-
ation of the bladder neck.
Prepare patient for nerve block as May be required if dysreflexia is

warranted. unresponsive to other treatment
modalities.

Patiendfamily will be able to verbalize
understanding of condition and methods to
reduce occurrence.
Patient will exhibit no signs/symptoms of auto-
nomic dysreflexia, and have no complications.
SPINAL CORD INJURIES
Disease processes Trauma

(Loss of function without trauma) (Flexion, hypertension, rotation)
c c
Contusion Compression Transection of cord
c c c
Edema to cord Tumor or hernorrhage Incomplete Complete
c c c c
Increased intradural Muscle weakness Partial dysfunction Total loss of
pressure of spinal cord tracts sensory and
motor function
c c I I
I
Neurodysfunction
4
Paralysis of muscles
1
Loss of autoregulation
I
Sympathetic Release of
blockade vaso-active
substances
c c 4 J,
Hypoventilation Poikilothermism Bradycardia Vasodilation

c c JI
Decreased VC, TV Decreased spinal cord Decreased venous
ineffective cough blood flow return
Decreased oxygenation
c
Hypoxia
c
Spinal shock/vasovagal reflex
c
Arrest
4
DEATH
6uillain-Barre Syndrome MEDICAL CARE

Lumbar puncture: used in the diagnostic process;
Guillain-Barrt syndrome, also known as infectious
initially protein levels are normal for the first 48
polyneuritis, polyradiculoneuritis, and Landry-
hours but then increase as the disease progresses;
Guillain-Barrt-Strohl syndrome, is an acute
cell count is usually normal; ICP may be elevated
neuropathy in which inflammation and swelling
of spinal nerve roots create demyelination and Electromyography: helps to differentiate Guillain-
degeneration to the nerves beginning distally and BarrC from myasthenia gravis; in Guillain-Barrt,
ascending symmetrically. nerve impulse conduction speed is decreased
Demyelination causes nerve impulse conduction Nerve conduction studies: nerve conduction
to be delayed. Both dorsal and ventral nerve roots velocity is slowed
are involved, so both sensory and motor impair-
Plasmapheresis: may be used on an experimental
ment is noted. The disease progress may cease at
basis to remove circulating antibodies that com-
any point or continue to complete quadriplegia
promise nerve receptors
with cranial motor nerve involvement.
Symmetrical muscle weakness occurs and moves Laboratory: white blood cell count is elevated;
upward, with associated paresthesias and pain. sedimentation rate is elevated; electrolytes are
Dysphagia, facial weakness, and extraocular done to identifjr hyponatremia that may occur due
muscle paralysis occur. Blood pressure and heart to problems with volume receptors
rate can be affected with marked fluctuations in
response to a dysfunctional autonomic nervous NURSING CARE PUNS
system. After demyelination stops, remyelination
begins and frequently complete function is Risk f i r inefective breathing pattern
restored in approximately 70% of patients. The [See Head Injuries]
recovery phase may last from 4 months to 2 years. Related to: muscle weakness, paralysis, inability to
The exact cause of the syndrome is not known but swallow
several factors have been known to be associated Defining characteristics: dyspnea, bradypnea,
with Guillain-Barrt, such as, viral infections apnea, hypoxia, hypoxemia, abnormal arterial
occurring 2-3 weeks prior, vaccinations, surgery, blood gases, inability to handle secretions
pre-existing systemic disease, and autoimmune
d'iseases. Impaired physical mobility
[See Head Injuries]
Guillain-Barrt syndrome may cause complications
of hypertension, bradycardia, respiratory failure, Related to: neuromuscular impairment, paralysis
and cardiovascular collapse. When sacral nerve Defining characteristics: inability to move at will,
roots are affected, incontinence becomes a prob- inability to turn, transfer, or ambulate, decreased
lem. range of motion, muscle weakness, muscle incoor-
dination, decreased reflexes
Risk for alteration in nutrition: less than INTERVENTIONS RATIONALES

body requirements Monitor for complaints of Patient may be unable to verbal-
[See Mechanical Ventilation] painldiscornfort and for non- ize complaints.
verbal indications that patient
Related to: neuromuscular impairment, intuba- m q be in discomfort.
tion
Administer medication as Reduces or alleviates pain.
Defining characteristics: weight loss, muscle wast- ordered. Narcotics may cause respirarory
depression.
ing, catabolism, inability to take in sufficient
nutrients, impaired cough/gag/swallow reflexes Apply hot or cold packs as Helps to alleviate discomfort and
warranted. improves muscle and joinr stiff-
Impaired verba2 commun ication ness.
[See CVA] Use therapeutic touch, massage, Helps to refocus attention away
imagery, visualization, or relax- from pain and provides for active
Related to: neuromuscular impairment, loss of ation therapies as warranted. participation in relieving pain.
muscle control, weakness
Defining characteristics: inability to speak, inabil- Discharge or Maintenance Evaluation
ity to write
Patient will have no complaints of pain or
Sensory-perceptual alterations: visualj
paresthesias.
kinesthetic, gustatory, tactile
[See CVA] Patient will be able to communication pain and
requests for analgesics.
Related to: neuromuscular deficits, altered recep-
tion of stimuli, altered sensation, inability to Patient will have pain controlled effectively to
communicate, hypoxia his satisfaction.
Defining characteristics: paresthesias, hypersensi- Risk for alteration in tissue per-sion: car-
tivity to stimuli, muscle incoordination, inability diopulmonary, peripheral, renal
to communicate, anxiety, restlessness
Related to: autonomic nervous system
Alteration in comfort impairment, hypovolemia, electrolyte imbalance,
hypoxemia, thrombosis
Related to: neuromuscular impairment
Defining characteristics: hypotension, hyperten-
Defining characteristics: communication of pain
sion, blood pressure lability, bradycardia,
or discomfort with minimal stimuli, muscle aches,
tachycardia, dysrhythmias, altered temperature
tenderness, joint pain, flaccidity, spasticity
regulation, decreased urine output, anuria, skin
breakdown
Outcome Criteria
Patient will have no complaints of pain, or pain Outcome Criteria
will be controlled to patient's satisfaction.
Patient will achieve and maintain normal perfu-
sion of all body systems.

Monitor vital signs at rest and Severe changes with blood pres- hours, or if significant imbalance shifting, and decreases in vascular
with turning. Notify M D of sure may occur as a result of in I&O occurs. tone.
significant changes. autonomic dysfunction because
of the loss of sympathetic out- Administer IV fluids as ordered. Fluids help to prevent or correct
flow to maintain peripheral hypovolemia but impaired vascu-
vascular tone. Postural hypoten- lar tone may result in severe
sion may occur as a result of hemodynamic lability based on
small increases in circulating
impaired reflexes which normally
readjust pressure during changes volumes.
in position. Administer heparin SQlIV as May be given prophylactically
ordered, if no contraindications. due to immobilization.
Monitor EKG for changes, and Rate changes may occur as a
treat dysrhythmias per protocol. result of vagal stimulation and
impairment of the sympathetic
innervation of the heart.
Hypoxemia or electrolyte imbal-
ances may alter vascular tone and Patient will be able to maintain adequate perfu-
impair venous return. sion.
Monitor temperature of skin and Vasomotor tone changes can Patient will have stable vital signs and hemody-
core body. Observe for inability impair the ability to perspire and
to perspire. cause temperature regulation
namic parameters.
problems. The patient’s impaired
sensation may further promote
Patient will have regular cardiac rhythm with no
difficulty with warming and dysrhythmias.
cooling the body.
Risk for urinary retention
Measure hemodynamics if pul- Impairment in vascular tone and
monary artery catheter in place, venous return can decrease car- Related to: neuromuscular impairment, immobil-
and notify MD for significant diac output.
ity
changes.
Decreases in sensation as well as
Defining characteristics:inability to void, inabil-
Observe skin surfaces for redness
or breakdown. Place patient on circulatory changes may result in ity to completely empty bladder
kinetic bed, egg crate mattress, impaired perfusion and facilitate
alternating pressure mattress, skin breakdown or ischemia.
etc., if warranted Special bedslmattresses help to Outcome Criteria
reduce hazards of immobility.
Patient will be able to empty bladder with no
Observe calves for redness, Venous stasis may increase
potential for deep vein thrombo-
signs/symptoms of infection or retention.
edema, or positive Homan’s or
Pratt’s signs. sis formation, and patient may
be unaware of discomfort due to
paresthesias. Monitor for ability to void. Provides information regarding
Measure output carefully. neuromuscular progression.
Provide anti-embolic hose or Helps to decrease venous stasis
Progression of disease may
sequential compression devices to and promotes venous return.
predispose patient to retention
both leg and remove at least
which may lead to urinary
once every 8 hours.
tract infection or other
Monitor hourly intake and Circulating volume may be complications.
output. Notify MD if urine decreased by patient’s inability to
output is less than 30 cdhr for 2 take in adequate hydration, fluid
~~~

Observe and palpate for bladder Bladder may become distended Patient will be able to eliminate soft formed stool
distention. as sphincter reflex is involved in on a normal basis.
neuromuscular progression.
Insert indwelling catheter as May be required to facilitate ~~~~~ ~~
warranted. urinary emptying until disease

process has resolved and bladder
control has been achieved.
Evaluate elimination pattern, Provides baseline information to
Observe for concentrated urine, May indicate presence of urinary
normal habits, ability to sense facilitate appropriate intervention
presence of blood or pus, infection.
urge to defecate, presence of for the patient’s plan of care.
changes in clarity or odor.
nausedvomiting, presence of
painful hemorrhoids, and history
Information, Instruction, of constipation problems.
Demonstration Observe for abdominal disten- May indicate present or impend-
tion, tenderness, or guarding, ing ileus or impaction.
INTERVENTIONS RATIONALB nausea, vomiting, and absence of
stool.
Instruct on need and procedure Promotes understanding and
for catheter placement. facilitates patient compliance. Palpate rectum for presence of Manual removal of stool may be
stoollimpaction. required, and should be
performed gently to avoid vagal
stimulation. Other interventions
may be necessary to allow for
Patient will be able to void suficient amounts bowel elimination.
without presence of retention or infection.
Auscultate bowel sounds for Diminished or absent bowel
Patient will be able to accurately recall informa- presence, pitch, and changes. sounds, or presence of high-
pitched tinkling sounds may
tion regarding need and procedure for catheter
indicate that an ileus has devel-
placement. oped.
Patient will be able to achieve bladder control Administer stool softeners, laxa- May be required to stimulate
once disease process has resolved. tives, suppositories, or enemas as bowel evacuation and to establish
warrantedlordered. a bowel regime until patient is
Risk for constipation able to regain normal muscula-
ture control.
Related to: neuromuscular impairment, bedrest, Insert nasogastric tube as Decompresses abdominal disten-
immobility, changes in dietary habits, changes in ordered. Connect with intermit- tion that occurs with ileus
environment, analgesics tent suction per hospital policy. formation, and helps prevent
nausea and vomiting.
Defining characteristics: inability to expel all or
Increase fiber in dietltube feed- Helps to promote elimination by
part of stool, passage of hard stool, frequency less ings as warranted. adding bulk and helps to regulate
than normal pattern, rectal fullness, abdominal fecal consistency.
paidpressure, decreased bowel sounds, decreased
peristalsis, weakness, fatigue, appetite impairment

Demonstration ~ _ _ _
Evaluate anxiety level frequently. Determination of severity of

INTERVENTIONS RATIONALES Stay with patient during acute patient's anxiety/fear can help to
episodes. determine appropriate interven-
Instruct on increases in fluid Promotes knowledge and can
tion. Nurse's presence during
intake, dietary requirements, use help facilitate improvement in acute anxiety may foster feelings
of fruits and juices to improve bowel regime.
of reassurance and concern for
bowel elimination.
the patient's well-being.
Instruct o n needlprocedure for Helps to promote understanding Maintain consistency with nurse Helps to decrease anxiety and
nasogastric tube insertion. of complications that may occur assignmenes. builds trust in relationships.
with the loss of peristalsis due to
the disease process. Patient should be placed near Reassures patient that assistance
nurse's station and within visual will be nearby should he be
Discharge or Maintenance Evaluation con tact. unable to use call bell.
Patient will achieve normal bowel elimination. Provide method for patient to Reduces anxiety and fear of
summon assistance. abandonment.
Patient will require no bowel aids to facilitate
Involve patienc and family in Helps to foster understanding
his normal routine. plan of care. Allow patient to and facilitates feelings of control
make as many decisions as and improved self-esteem.
Patient will regain muscle control and be able to warranted. Improves cooperation with pro-
evacuate stool. cedures and care.
Patient will be able to utilize dietary modifica- Provide time for patientlfamily Discussion of fears provides
to discuss fears and concerns. opportunity for clarification of
tion to maintain bowel regime.
Offer realistic options and d o not misperceptions and for realistic
give false reassurance. methods of dealing with prob-
Patient will be able to recall information
lems.
correctly.
Administer anti-anxiety medica- Patient$ anxiety may result in
Anxz'ev, fear tions or sedation as alterations in hemodynamic sta-
warran ted/ordered. bility and may require
Related to: disease process, change in health medication to initially deal with
status, paralysis, respiratory failure, change in situational crises. Patient may
require medication to facilitare
environment, threat of death
improved ventilation should
mechanical ventilation be
Defining characteristics: restlessness,
war ranted.
apprehension, tension, fearfulness, sympathetic
stimulation, changes in vital signs, inability to
concentrate or focus, poor attention span, uncer- Discharge or Maintenance Evaluation
tainty of treatment and outcome, insomnia
Patient will be able to deal with changes in
health status effectively.
Outcome Criteria
Patient will be able to control anxiety and
Patient will be able to reduce and/or relieve anxi- reduce fear to a manageable level.
ety with appropriate methods.
Patient will have decreased anxiety and fear.
GUILLAIN-B-’ SYNDROME
TRIGGERING EVENT
s
Immunologic demyelination of perepheral nervous system
s
Lymphocytes infiltrate into nerve roots, nerves, and CNS
J,
Schwann cells deposit myelin around axons

with interruption at intervals by the nodes of ranvier
J,
Nerve conduction slows as impulses are conducred from node to node

instead of along zonal pathway
J,
Anterior horn cells in spinal cord degenerate

J,
Loss of reflexes
(usually symmetrical and ascending)
J,
Paralysis of muscles Decreaselloss of autonomic reflexes Peripheral volume

4 J, Receptors impaired
Vital capacity decreased BP fluctuations SIADH

NIF decreased
J, J,
Loss of respiratory muscles Hyponatremia

J, J,
Apnea Hypovolemia
J, 4
Hypoxia Dysrythmias
Remyelination begins
s
Return of nerve impulse transmission
J,
Function restored proximally

and proceeds in reverse from
last area involved upward
I
Complete recovery
I
Varying degrees of function restored
Status Epilepticus rhabdomyolysis and renal failure. Other complica-

tions may occur as a result of the significantly
Seizures occur when uncontrolled electrical elevated metabolic state.
impulses from the nerve cells in the cerebral cortex
discharge and result in autonomic, sensory, and MEDICAL CARE
motor dysfunction. Status epilepticus is a series of Laboratory: glucose levels decreased; electrolytes
repeated seizures, a prolonged seizure, or sequen- to identie imbalances that may be precipitating
tial seizures longer than 30 minutes in which the factor or result from prolonged seizure activity;
patient does not regain consciousness. This seizure enzymes, especially creatine phosphokinase
activity has a high mortality rate of up to 30% as elevated after seizure activity; drug screen done to
a result of neurological and brain damage. identify potential factor for drug withdrawal;
There are three types of status epilepticus: convul- CBC used to identify hemorrhage or infection
sive, nonconvulsive, and partial status epilepticus. with shift to the left on differential; drug levels for
In the convulsive type, seizure activity may have a medications being given for seizures to evaluate
focal onset, but has tonic-clonic, grand mal type therapeutic response and discern toxicity; renal
seizures without experiencing alertness between profiles to evaluate renal function; urinalysis to
motor attacks. Nonconvulsive seizures are noted identify hematuria or myoglobinuria
with a prolonged twilight state and are usually not CT scans: may be done to identify lesions or pre-
motor activity. Partial status epilepticus occurs cipitating factors
when continuous or repetitive focal seizures occur
but consciousness is not altered. Electroencephalogram: used to identify presence
of seizure activity
Status epilepticus usually occurs in patients with
pre-existing seizure disorders who have a precipi- Arterial blood gases: used to identify hypoxia and
tating factor occurance. These factors can include acid-base imbalances; usually acidosis seen
withdrawal from anticonvulsant medication, alco-
hol withdrawal, sedative or antidepressant NURSING CARE PLANS
withdrawal, sleep deprivation, meningitis,
Risk for impaired gas exchange
encephalitis, brain abscesses or tumors, pregnancy,
hypoglycemia, uremia, cerebrovascular disease,
cerebral edema, or cerebral trauma. Relat'ed to: altered oxygen.supply from repetitive
seizures, cognitive impairment, neuromuscular
The initial stage causes sympathetic activity
impairment
increases with a decrease in the cerebral vascular
resistance. After 30 minutes, hypotension occurs Defining characteristics: restlessness, cyanosis,
with a decrease in cerebral blood flow because of inability to move secretions, tachycardia,
loss of autoregulation. The continuing massive dysrhythmias, abnormal ABGs, decreased oxygen
autonomic discharges can cause bronchial secre- saturation
tions and restriction, with increased capillary
Risk for inefective airway clearance
permeability and pulmonary edema.
[See :Mechanical Ventilation]
Dysrhythmias can occur and patients may develop
Related to: neuromuscular impairment, cognitive INTERVENTIONS RATIONALES

impairment, tracheobronchial obstruction
Maintain patent airway and ade- Intubation and placement on
Defining characteristics: adventitious breath quate ventilation. mechanical Ventilation may be
sounds, dyspnea, tachypnea, shallow respirations, required if seizures cannot be
controlled.
cough with or without productivity, cyanosis, anx-
iety, restlessness Monitor oxygen saturation by Decreases in saturation that
oximeter. cannot be improved with supple-
Hyperthemia mental oxygen may require
[See Pheochromocytoma] mechanical ventilation. Seizure
activity increases oxygen con-
Related to: continued seizure activity, increased sumption and demand.
metabolic state Provide supplemental oxygen as May be required to maintain
warranted. desired levels of oxygen.
Defining characteristics: fever, persistent tonic-
clonic seizure activity, persistent focal seizures, Monitor ABGs for imbalances Metabolic increases may lead to
and treat per protocol. lactate formation and acidosis.
persistent generalized seizures, tachycardia
Administer medications as Valium may be given IV at 5
Risk for fluid volume deficit ordered. mg/min rate to control seizure
[See ARDS] activity by enhancing neurotrans-
mitter GABA. Ativan 2-4 mg IV
Related to: excessive loss of fluid, decreased intake may be given and repeated every
15 minutes as needed for seizure
Defining characteristics: hypo tension, tachycar- control. Caution should be exer-
dia, fever, weight loss, oliguria, abnormal cised because respiratory and
cardiovascular depression can
electrolytes, low filling pressures, decreased mental
occur. Phenobarbital IV at 60
status, decreased specific gravity, increased serum mg/min may be given to depress
osmolality excitation, decrease calcium
uptake by nerves, and to
Risk fir injury strengthen repression of synapses.
Dilantin IV at 50 mglmin rate
Related to: seizure activity, increased metabolic may be given to decrease cellular
demands influx of sodium and calcium
and blocking neurotransmission
Defining characteristics: respiratory acidosis, release.
metabolic acidosis, hypoxemia, hyperthermia, Maintain patient in seizure-free Once seizures have stopped, anti-
hypoglycemia, electrolyte imbalances, renal failure, status. conwlsant drugs must be given
rhabdomyolysis, exhaustion, death to prevent recurrence of seizure
activity.
Monitor EKG for dysrhythmias Electrolyte imbalances, too-rapid

Outcome Criteria and treat per hospital protocol. administration of medications,
and hypoxia may contribute to
Patient will achieve and maintain seizure-free appearance of cardiac dysrhyth-
status with optimal oxygenation and ventilation mias that may require
without complications. interventional care.
Monitor intake and output every Identifies imbalances with fluid

2 hours and prn. status and fluid shifting.

Monitor labwork for changes Electrolytes may fluctuate Patiedfamily will be able to verbalize
and trends. because of cellular movement of
ions. Myoglobin may be present
understanding of all instructions and comply
in urine as a result of prolonged with medical regimen.
seizure activity and can lead to
renal failure. Drug levels may rise Patient will remain free of seizures and injury.
to toxic levels and should be
evaluated for therapeutic effec- Patient' will be able to effectively access commu-
tiveness. nity resources for help and support.
Identify and treat underlying Identification may lead to timely Patient will exhibit no signs of complications.
cause of seizures. intervention and treatment.
Disturbance in self-esteem
Related to: perception of loss of control, ashamed
Demonstration
of medical condition
INTERVENTIONS RATIONALES Defining characteristics: fear of rejection,
Instruct patient/family in disease Promotes knowledge and facili- concerns about changes in lifestyle, negative feel-
process and methods for reduc- tates compliance. ings about self, change in perception of role,
tion of seizures.
changes in responsibilities, lack of participation in
Instruct in drug regimen, effects, Promotes knowledge and helps therapy or care, passiveness, inability to accept
side effects, contraindications, prevent lack of cooperation with
positive reinforcement, little eye contact, brief
and precautions. medication regime with resultant
seizure breakthrough activity. responses to questions
Presence of side effects may indi-
cate the need for changes in
doses or medication type.
Outcome Criteria
Interactions with other drugs
may produce adverse reactions, Patient will be able to participate in own care and
such as potentiated anticoagula- have positive perceptions of self.
tion effect when dilantin and
coumadin are concurrently
taken,
Instruct in oral care. Prevents gingival hypertrophy
that may occur while taking Encourage patient to initiate Participation in care facilitates
dilantin. self-care or request assistance. feelings of normalcy.
Instruct on use of medical alert May hasten emergency treatment Discuss patient's perceptions of Provides opportunities to estab-
bracelet. in critical situations. illness and potential reactions of lish patient's knowledge base,
others to his disease. clear up any misconceptions, and
Instruct on methods to promote May facilitate prevention of opportunity to problem-solve
safety with activities, such as, injury to self or other if seizures responses to future seizures.
driving, using mechanical equip- occur without warning.
ment, swimming, or hobbies. Discuss previous success episodes Concentrating on the positive
and patient's strengths. experiences may help to reduce
Instruct on contact people, com- May provide opportunities for self-consciousness and allow
munity resource groups, long-term support and sharing patient to begin to accept condi-
counselors, as warranted. ideas with others who have simi- tion.
lar problems.
~~ ~~
Discuss concerns with family Negative feelings from patient’s

members, allowing ample time family may afFect his sense of
for members to discuss problems self-esteem.
and attitudes.
Consult with counselors, minis- Provides opportunity for parient

terial support, or resource to deal with stigma of disease
groups. and overcome feelings of inferi-
ority.

Patient will be able to identify ways to cope
with negative feelings.
. Patiendfamily will be able to discuss concerns
and effect realistic problem-solving plans.
Patient will become more accepting of self, with
increased self-esteem.
Patient will be able to effectively access commu-
nity resources to gain help and support.
Grieving
[See Amputation]
Related to: traumatic injury, loss of physical well-
being
Defining characteristics: communications of dis-
tress, denial, guilt, fear, sadness, changes in affect,
changes in ability and desire for communication,
crying, insomnia, lethargy
STATUS EPILEPTICUS
Pre-existing seizure disorder

(tumors, trauma, encephalopathy)
c
Seizure activity
Rapid succession of action-potentials in cells
c
Increased sympathetic activity
c
Increased metabolic demand
Increased temperature, pulse, and blood pressure
c
Decreased ATP
Sodium-potassium ATP pump failure
e
Decreased cerebral vascular resistance
Increased cerebral vascular dilation
c
Increased cerebral metabolic rate
c
Prolonged seizure state (>30 minutes)
c
Blood flow becomes pressure dependent
Cerebrovascular autoregulation mechanisms fail
4
Increased uptake of metabolic by-products
(lactate, ammonia, amino acids)
JI
Cellular edema
4
Decreased cerebral blood flow
Decreased blood pressure
4
Metabolic acidosis
c
Bronchial constriction Increased oxygen consumption
Decreased PaO2 -A
Increased PaCO2
Increased pulmonary
pressures
a- Dysrhythmias
gitis, LDH elevated with bacterial meningitis,

ESR elevated
Meningitis is an acute infection of the pia and Radiography: skull and spine x-rays used to iden-
arachnoid membrane that surrounds the brain and tify sinus infections, fractures, or osteomyelitis;
the spinal cord caused by any type of microorgan- chest x-rays may be used to identify respiratory
ism. Bacterial meningitis is frequently caused by infections, abscesses, lesions, or granulomas
Streptococcuspneumoniae, Huemophilus injuenzae,
or Neisseriu meningitidis. Lumbar puncture: treatment of choice to identify
presence of meningitis, help identify type of
Organisms are able to thrive because of opportune meningitis, and identify causative organism
access during surgery, with invasive monitoring
and lines, penetrating injuries, skull fractures, dura Electroencephalogram: may be performed to
tears, otitis media, or with septic emboli. Once the show slow wave activity
organism begins multiplying, neutrophils infiltrate
into the subarachnoid space and forms an exudate. NURSING CARE PLANS
The body’s defenses attempts to control the invad- Alteration in tissue perfusion: cerebral
ing pathogens by walling off the exudate and [See Ventriculostomy]
effectively creating two layers. If appropriate med-
ical treatment is begun early, the outer and inner Related to: increased intracranial pressure
layers will disappear, but if the infection persists Defining characteristics: increased ICE changes in
for several weeks, the inner layer forms a perma- vital signs, changes in level of consciousness,
nent fibrin structure over the meninges. This memory deficit, restlessness, lethargy, coma,
meningeal covering causes adhesions between the stupor, pupillary changes, headache, pain in neck
pia and the arachnoid membranes and results in or back, nauseahomiting, purposeless movements,
congestion and increased ICP papilledema
One of the major complications of meningitis is Risk Jor injury
residual cranial nerve dysfunction, such as
deafness, blindness, tinnitus, or vertigo. Related to: infection, shock, seizures
Sometimes these symptoms resolve, but cerebral Defining characteristics: presence of infection,
edema may occur and cause seizures, nerve palsy, elevated white blood cell count, differential shift
bradycardia, hypertension, coma, and even death. to the left, positive cultures, hypotension, tachy-
The main goal of treatment is to eliminate the cardia, tremors, fasiculations, seizures, hypoxemia,
causative organism and prevent complications. acid-base disturbances
MEDICAL CARE Outcome Criteria

Laboratory: white blood cell count elevation to Patient will be free of infection with stable vital
identify infection; cultures to identify the signs.
causative organism, CSF analysis to identify infec-
tion; urinalysis may show albumin and red and
white blood cells; glucose levels elevated in menin-
Defining characteristics: headache, muscle

spasms, backache, photophobia, crying, moaning,
restlessness, communication of pain, muscle ten-
Assist with lumbar puncture. Identifies prezence of infection sion, facial grimacing, pallor, changes in vital signs
and can differentiate between
types of meningitis. CSF with Hyperthemia
low white cell counts, less pro-
[See Pheochromocytoma]
tein elevation, and "glucose levels
approximately half that of the Related to: infection process
blood glucose level may be
indicative of viral meningitis. Defining characteristics: fever, tachycardia,
CSF that has an elevated initial
pressure, high protein, low glu-
tachypnea, warm, flushed skin, seizures
cose, cloudy color, and high
white cell count indicates baccer-
id meningitis.
Administer antimicrobials as Aqueous penicillin G is usually

ordered, as soon as possible. the drug of choice, but culture
results may indicate a different
agent needed to eradicate the
organism. Antibiotics are usually
given in larger doses at closer
intervals in order to facilitate
penetration across the blood-
brain barrier.
Observe appropriate isolation Prevents spread of infection.

techniques up to 48 hours after After antimicrobial therapy has
antibiotic regimen has begun. been instituted for 2 days, the
patient is not considered infec-
tious.
Administer anticonvulsants as May be required for control of

ordered. new seizure activity due to
rneningeal irritation.

Patient will be free of infection with no compli-
cations from antimicrobial agents.
Patient will be free of seizure activity.
Patient will comply with isolation restrictions.
[See Guillain-Bard]
Related to: infectious organisms, circulating
toxins, invasive lines, bedrest
MENINGITIS
Infectious organisms gain access to meninges and subarachnoid spaces

(viral, bacterial, yeast)
Exudate forms
e
-
Meningeal irritation/inflammation
c
Cortical irritation
4
Cerebral edema
c
Increased ICP
c
Vasculitis Increased infection Petechial hernorrhages Neuritis Hydrocephalus

c c 4 c c
Cortical Brain abscess Septic emboli Cranial nerve Increased
necrosis Septicemias involvement ICP
c 4 J,
DIC
Adrenal Seizures Compression
hemorrhage I of brain structures
1 -
hemorrhage Hypoxia
I -
Inadequate perfusion
Shock
-
c
DEATH
UentriculostomyhCP until a vicious cycle is established. When ischemia

increases to a certain level, the medulla causes
Monitoring blood pressure to rise in an effort to compensate
for the increasing ICE but eventually the ICP will
The brain is housed in a nondistensible cavity that equal the MAP and precipitate curtailing of cere-
is filled to capacity with CSF, interstitial fluid, and bral blood flow, resulting in vascular collapse and
intravascular blood, all of which possess very mini- brain death.
mal ability for adjustment for increasing ICP is increased when brain volume is enlarged by
intracranial pressure. If the volume of any one of mass lesions, tumors, abscesses, hematomas or
these constituents increases, there is a reciprocal cerebral edema. Vasodilation and venous outflow
decrease in the volume of one or more of the obstructions cause changes in cerebrovascular
others, or else intracranial pressure becomes ele- status due to hypoventilation, hypercapnia,
vated. Intracranial pressure is normally beween improper position of the head, or maneuvers that
2-15 mmHg or 50-200 cm H,O, and fluctuates increase intrathoracic pressure. CSF volumes may
depending on positioning, vital signs changes, increase from decreased reabsorption from an
increased intra-abdominal pressure, and stimuli. obstruction, such as with hydrocephalus.
There are compensatory mechanisms that assist in Monitoring of ICP can be done from several sites.
decreasing intracranial hypertension. The most The lumbar or cervical subarachnoid area is
easily changed element is intravascular volume simple to access, but potential for herniation
which results from compression of the venous exists. The lateral cerebral ventricles [per ventricu-
system and decreases fluid level. The CSF is lostomy] is highly accurate and allows for
another element that can be used to compensate withdrawal of CSF and measurement of compli-
for increasing pressures. CSF can be displaced ance, but infection to this area is catastrophic.
from the cranial vault to the spinal canal, which Subdural sites are most easily inserted but carry
increases absorption of CSF by the arachnoid villi, serious infection risks, and an epidural site has less
slows production of CSF by the choroid plexus, potential for infection, but lacks accuracy.
and decreases ICl? Other compensatory
mechanisms may be seen, such as skull expansion The three types of ICP monitoring are epidural
in infants whose sutures have not closed, as well as sensor monitoring through a burr hole, subarach-
reduction of cerebral blood flow to a small extent, noid screw or bolt monitoring through a twist
but these are not desirable. drill burr hole, and ventricular catheter monitor-
ing. Insertion of these may be performed in
Although auto-regulatory mechanisms can control surgery or in the intensive care setting, but
small increases in ICE rapid or sustained increases requires sterile field maintenance.
suppress these compensatory efforts, and decom-
pensation occurs. As the ICP increases, the ICP monitoring may be performed on patients
cerebral blood flow decreases because of pressure with head trauma, ruptured aneurysms, Reye’s
exerted on vessels. This causes brain ischemia and syndrome, intracranial bleeds, hydrocephalus, or
accumulation of lactic acid and carbon dioxide, tumors. A ventriculostomy is a cannula placed in
resulting in hypoxemia and hypercapnia. Cerebral the lateral ventricle and connected with a
vasodilation ensues which increases blood volume transducer for measurement of pressures of CSF
and cerebral edema, which further increases ICE directly, for periodic drainage of CSF, and for
withdrawal of fluid for analysis.
Cerebral perfusion pressure (CPP) is the difference Laboratory: electrolytes drawn to evaluate imbal-
between the mean arterial pressure (MAP) and the ances that may contribute to ICP increases;
mean ICE and indicates the pressure in the cere- toxicology screens to identify other drugs that may
bral vascular system and approximates the cerebral be responsible for changes in mentation and level
blood flow. A CPP of 60 m m H g is the minimum of consciousness; serum levels of drugs to assess
value for perfusion to occur, with normal ranges therapeutic response versus toxicity
from 80-100 mmHg.
Increases in ICP can be manifested by signs such
NURSING CARE PLANS
as systolic blood pressure elevations, widening Alteration in tissue per-sion: cerebral
pulse pressure, bradycardia, headache, nausea with
Related to: cerebral edema, space-occupying
projectile vomiting, papilledema, changes in level
lesions, hemorrhage, substance overdose, hypoxia,
of consciousness, pupillary changes, respiratory
hypovolemia, trauma
changes, and cerebral posturing.
Defining characteristics: increased ICE changes in
MEDICAL CIIRE vital signs, changes in level of consciousness,
memory deficit, restlessness, lethargy, coma,
Surgery: may be required for traumatic injuries
stupor, pupillary changes, headache, nausea/vomit-
and/or placement of ICP monitoring device
ing, purposeless movements, papilledema
Arterial blood gases: may be used to identify acid-
base imbalances, hypoxemia, and hypercapnia; Outcome Criteria
frequently patients are hyperventilated to keep
PaC02 between 25-28 Patient will have stable vital signs and mentation
with no signs or symptoms of increased ICP
Osmotics: mannitol used to create osmotic diure-
sis in an attempt to decrease ICP INTERVENTIONS RATIONALES
Barbiturate therapy: pentothal or nembutal used Monitor for changes in level of Alterations in levels of conscious-
to place patient in coma to produce burst-suppres- consciousness or mentation, ness are among the earliest signs
sion on the EEG and to reduce metabolic activity speech, or response to of increasing ICP and can facili-
commandslquestions. tate prompt intervention.
Paralyzing drug therapy: pancuronium may be Progressive deterioration may
used to decrease metabolic requirements but must require emergent care.
be used in conjunction with sedatives since drug Monitor vital signs at least every As ICP increases, blood pressure
only paralyzes muscles and does not change level hour, and prn. elevates, pulse pressure widens,
bradycardia may occur changing
of awareness to tachycardia as ICP progres-
sively worsens. Tachypnea is seen
Adrenocorticosteroids: decadron has less sodium-
as an early sign but slows with
retaining properties and is used to assist with increasingly longer periods of
decreasing edema apnea. Fever may indicate hypo-
thalarnic damage or infection
CT scans: used to identify lesions, hemorrhage, which can increase metabolic
ventricular size, structural shifting, ischemic event demands and further increase
ICE
(may be several days prior to visibility on scan)
Perform pupillary checks, noting Increased ICP or expansion of a Elevate head of bed 30-45 Decreases cerebral edema and
equality, position, response to clot can cause shifting of the degrees as warranted. congesrion, thereby decreasing
light, and nystagmus every 1-2 brain against rhe oculomotor or ICI?
hours and prn. optic nerve which causes pupil-
Maintain head placement in Moving head from side to side
lary changes. Early increased I C P
may be signified by impairment neutral, or midline, position compresses jugular veins and
using rolled towels or sandbags as increases ICE!
of abduction of the eyes as a
result of injury to the fifth cra- warranted.
nial nerve. Absence of the doll’s Avoid excess stimuli in room; All stimulation increases ICP and
eyes reflex may indicate brain allow visitation when warranted. should be limited to necessary
stem dysfunction and poor prog- tasks only in the presence of
nosis. Uncal herniation produces intracranial hypertension. Family
ipsilateral pupillary changes. members may have calming
effect o n patient and may facili-
Monitor neurological status uti- GCS facilitates identification of
tate decreased ICl?
lizing the Glasgow Coma Scale arousabilig and level and appro-
(GCS). priateness of responses. Motor Avoid suctioning unless manda- Minimizes hypoxia and acid-base
response to simple commands or tory, and when necessary, limit disturbances. Hyperoxygenation
purposeful movement with srim- active suctioning to 15 seconds prior to, during, and after proce-
uli assist with identification of or less. dure may also minimize
problem. Abnormal posturing, complications.
decerebrare and decorticate, may
indicate diffuse cortical damage. Provide continuous monitoring Provides for prompt recognition
Inability ro move one side of the of oximetry. of deterioration in patient‘s abil-
body may indicate damage to the ity to maintain saturation which
opposite side’s cerebra hemi- allows for prompt intervention.
sphere.
Apply oxygen at ordered concen- Supplemental oxygen decreases
Monitor EKG for changes in Brain srem pressure or injury trations; prepare for mechanical hypoxemia which results in
hearr rate and rhythm, and treat may result in rate changes, nor- ventilation as warranted. increased ICI? Mechanical venri-
as per hospital protocol. mally bradycardia, or cardiac larion may be required if
dysrhythmias. space-occupying lesions shift and
destroy respirarory cenrer enerva-
Observe for presence of blink, Reflex changes may be indicative tion.
gag, cough, and Babinski of injury at the mid brain or
reflexes. brain stem level. Lack of blink Administer medications as Diuretics andlor mannirol may
reflex indicates damage to the ordered. be used to draw water from cere-
pons and medulla. Cough and bral cells ro decrease edema and
gag reflexes that are absent may ICP. Steroids may be used to
indicate damage at medulla and decrease rissue edema and
presence of Babinski reflex indi- inflammation. Anticonvulsanrs
cates pyramidal pathway injury. may be used prophylactically and
for the rreatment of seizures.
Observe for nuchal rigidity, May indicate meningeal irrita- Sedatives or analgesics may be
tremors, fasiculations, twitching, tion from a break in the dura or used ro control restlessness or
seizures, irritabiliv, or restless- the development of an infection. agitation.
ness. Seizures may occur from
increased ICP, hypoxia, or cere-
bral irritation.

Demonstration
If ICP is increasing, ensure that Hyperventilation results in respi-
airway is patent, and prepare for ratory alkalosis that causes
placement on mechanical ventila- cerebral vasoconstriction,
Observe continuous intracranial Increases above 25 mmHg that tion. decreases cerebral blood volume,
pressure monitoring for fluctua- are sustained for at least 5 min- and can decrease ICP Levels of
tions that are sustained, and for utes may indicate severe PaCO, are usually kept from 25-
the presence of A, B, and C intracranial hypertension. A 35 to decrease ICE but if
waves. waves, or plateau waves, have allowed to go below 25, may
elevations from 60-100 mmHg adversely affect ICP.
and then drop sharply, and often
Prepare patientlfamily for use of Used as a last ditch effort, pento-
coincide with headaches or dete-
barbiturate therapy to produce barbiral or other drugs are given
rioration. Cellular hypoxia is
coma. to produce complete unrespon-
most likely to occur during A
siveness, to reduce metabolic
waves, and sustained A waves
activity, and decrease ICP
indicate irreversible brain
damage. B waves have elevations
up to 50 mmHg and occur every
1.5-2 minutes in a sawtooth-type Discharge or Maintenance Evaluation
pattern. B waves can precede A
waves andlor appear in runs, and Patient will exhibit no complications due to
occur with decreases in compen- ICP monitoring.
sation. C waves are rapid,
rhythmic, and may fluctuate Patient will have ICP stabilized and controlled.
with changes in respiration or
blood pressure, and are not of Patient will have appropriate actions taken to
clinical significance. control increasing ICP
Measurelobtain the mean ICP Provides direct measurement of
every hour and prn; set alarms changes in ICP and cerebral per- Risk f i r infiction
for sustained elevations above fusion status. [See Head Injuries]
ordered limits.
Related to: invasive monitoring, lack of skin
Calculate CPP and do not allow CPP = MAP - MiCP; normal
integrity, increased metabolic state, intubation,
CPP to fall below 50 mmHg. CPP is 80-100 mmHg, and
levels below 50 mmHg decrease compromised defense mechanisms
cerebral blood flow and perfu-
sion, which frequently Defining characteristics: increased temperature,
precipitates death. chills, elevated white blood cell count, differential
Recalibrate ICP monitoring Ensures accuracy of readings.
shift to the left, drainage, presence of wounds,
device to level of foramen of positive cultures
Munro (eye canthus level
approximately) every 4 hours and
prn suspicious readings or posi-
tion changes.
Assist with removal of specified May be required to decrease

amounts of CSF through ven- severe ICP and prevent hernia-
triculostomy utilizing sterile tion from structural shifting.
technique.
Defining characteristics: changes in vital signs,

mental status changes, restlessness, anxiety, sensory
deficits, confusion, decreased level of conscious-
Carotid endarterectomy is the removal of a throm-
bus or plaque from the carotid artery to reduce ness
the risk of stroke in patients who have had a tran- R i d f o r decreased cardiac output
sient ischemic attack (TIA).Circulation is [See Spinal Cord Injuries]
augmented by increasing blood flow from the
internal carotid artery. T h e surgery is not without Related to: vasospasm, surgery, stroke
risk of its own due to the potential for shearing off Defining characteristics: hypotension, hyperten-
pieces of plaque or material resulting in a stroke. sion, heart rate changes, decreased cardiac
outputhndex, changes in systemic and peripheral
Initially, the major postoperative problem may be
vascular resistance, mental status changes, hypoxia
controlling labile blood pressures that occur
because of impairment in carotid sinus reflexes. Risk f o r injury
These blood pressure variances also predispose the
patient to a stroke. Related to: surgery, predisposing health factors,
injury to cranial nerves
Respiratory insufficiency may occur if the trachea
is compressed or shifted by a growing hematoma Defining characteristics: muscle weakness, nerve
at the wound site, or by lack of responses to injury, airway obstruction, hypoxia, dysphagia,
hypoxia with impairment of carotid body facial weakness, asymmetry of face, facial droop-
function. ing, vocal cord paralysis
Outcome Criteria
Surgery: performed as described above Patient will exhibit no complications from surgery
and will have all cranial nerve function
Vasoactive drugs: may be required to control
maintained.
blood pressures
Laboratory: CBC used to identify potential bleed-
ing problems, occult bleeding into neck; INTERVlENTIONS RATIONALES
electrolytes used to identify imbalances Observe for deviation of tongue May indicate hypoglossal nerve
toward side of operation, or damage.
Arterial blood gases: used to identify hypoxemia weakness of tongue muscles.
and acid-base imbalances
Observe for dysphagia, dyspha- May indicate bilateral hypoglos
sia, or impairment of upper sal palsy.
NURSING CARE PLANS airway.
Alteration in tissue perfision: cerebral Observe for facial asymmetry, May indicate facial nerve
drooping at corner of mouth, damage.
[See CVA] and inability to manage salivary
secretions.
Related to: occlusion, hemorrhage, vasospasms,
cerebral edema, interruption of blood flow, Monitor for changes in voice May indicate vocal cord paraly-
quality and sound. sis, injury to the vagus nerve, or
surgery
recurrent laryngeal nerve.

Patient will have facial symmetry and normal
voice modulation.
Patient will exhibit no signs/symptoms of cra-
nial nerve injury.
Patient will be free of any airway compromise
and have stable vital signs.
Alteration in skin integrity
[See Cardiac Surgery]
Related to: surgical wounds, invasive lines, immo-
bility
Defining characteristics: presence of wounds,
drainage, redness, swelling, abrasions, pressure,
lacerations, bruises, open skin
GASTROINTESTINAL/HEPATICSYSTEMS 191
Gastrointestinal Bleeding
Esophageal Varices
Hepatitis
Pancreatitis
Acute AbdomedAbdorninal Trauma
Liver Failure
Gastrointestinal Bleeding- The goal of treatment is initially prevention and

treatment of shock, with fluid volume
Gastrointestinal bleeding may be massive and replacement. Maintenance of circulating blood
acute or occult and chronic in nature. GI bleeding volume is imperative to prevent myocardial infarc-
results when irritation of the mucosal lining tion, sepsis, and death. Endoscopic examination is
results in erosion through to the submucosal layer. the primary diagnostic procedure utilized. Once
Upper GI hemorrhage is considered to be a bleed the lesion has been identified, treatment with
from any site proximally to the cecum, and all Pitressin infusion may be used to control bleeding.
ulcerative bleeding is arterial with the exception of
a tear that cuts across all vessels, malignant MEDICAL CARE
tumors, and in patients with esophagitis. Laboratory: CBC to identify changes in blood
When erosion into an artery occurs, it usually pro- volume and concentration, but may be normal
duces two bleeding sites because of arterio-arterial during rapid loss because of the lapsed time
anastomoses. When the bleeding occurs at the required for equilibration of intravascular with
ulcer base artery, it may be a life-threatening emer- extravascular spaces; MCV is useful to identify
prolonged chronic loss with iron deficiency; B,,
gency.
and folic acid levels used to identify anemia type;
Bleeding may occur from the lower gastrointesti- reticulocyte count may identify new RBC forma-
nal tract as well. Causes of lower GI bleeding tion which occurs with an old bleed; platelet
include hemorrhoids, diverticulosis, inflammatory count, PT, PTT, and bleeding times to evaluate
bowel disease, rectal perforation, or intussuscep- clotting status and platelet dysfunction; BUN and
tion. creatinine to evaluate effect on renal status; elec-
Acute upper GI bleeding may result from many trolytes to evaluate imbalances and treatment;
causes, such as gastritis, peptic ulcer, stress, drugs, ammonia levels may be used to identify liver dys-
hormones, trauma, head injuries, burns, and function; gastric analysis to determine presence of
esophageal varices. blood and assess secretory activity of gastric
mucosa; amylase elevated if duodenal ulcer has
Differential diagnosis between gastric and duode- posterior penetration; pepsinogen level to help
nal ulcers must be obtained. Duodenal ulcers identify type of bleeding, with elevation seen in
usually account for approximately 80% of all duodenal ulcer, and decreased levels seen in gastri-
ulcers noted and rarely become cancerous. Gastric tis; stool specimens for guaiac
ulcers, on the other hand, may become cancerous
and are more likely to bleed. Arterid blood gases: may be used to show
acid-base imbalances, compensation for decreased
Initial presenting symptoms of a GI bleed are blood flow; initially respiratory alkalosis changing
either hematemesis, melena, or hematochezia. An to metabolic acidosis as metabolic wastes accumu-
acute bleed will have more than 60 cc/day of black late
tarry stool and usually greater than 500 cc,
whereas occult bleeding is normally 15-30 cc/day. Esophagogastroduodenoscopy(EGD): primary
Stools can be positive for occult blood up to 12 diagnostic tool utilized for upper GI bleeding to
days after an acute bleed. Of all GI hemorrhages, visually identify lesion; can be performed as soon
80% usually stop spontaneously. as lavage controls bleeding
194 CRITICAL CAFE NURSING CARE PLANS
Angiography: used when bleeding cannot be Sucralfate: used to help heal ulcer by forming
cleared for endoscopy; can identify bleeding site protective barrier at site
and allow for injection of vasopressin for active
Surgery: required in less than 10% of patients;
mucosal bleeding
may be necessary for control of hemorrhage
Radiography: chest x-rays may be done to evalu-
ate for free aidperforation; upper GI series may be NURSING CARE PLANS
done after endoscopy, but is never done before
since the contrast media will adhere to mucosa Fluid volume deficit
and prevent further examination; may be done to Related to: gastrointestinal bleeding
identify other diagnosis; barium enema may be
done once lower GI bleeding is stopped; radionu- Defining characteristics: hypotension, tachycar-
clide scanning, such as Red Cell Tags, identify dia, decreased skin turgor, weakness, decreased
source of bleeding, but may take an extended time urinary output, pallor, diaphoresis, decreased cap-
for results to show illary refill, mental changes, restlessness, decreased
filling pressures
Electrocardiogram: used to identi+ changes in
heart rate and rhythm and identify conduction
Outcome Criteria
problems or dysrhythmias that may occur with
fluid shifting or electrolyte imbalances Patient will have no further bleeding and vital
Blood products: blood, plasma, and platelets may signs will be stable.
be required for replacement based on severity of
bleed
Nasogastric tubes: large bore NG tube or Ewald
tube is usually inserted to allow for iced/saline Monitor vital signs, including Patients with major GI blood
lavage, confirmation of bleeding, and for decom- orthostatic changes when feasi- losses will present with supine
pression of stomach ble. hypotension and resting tachy-
cardia greater than 1lolmin,
Levophed: may be used in solution with saline for orthostatic DBP decreases of at
least 10 mmHg, and orthostatic
lavage when plain saline is not effective in
pulse increases of at least 1Yrnin.
stopping bleeding due to its vasoconstrictor effects Changes in vital signs may help
approximate amount of blood
Vasopressin: may be used for direct infusion into loss and reflect decreasing circu-
the gastric artery to control bleeding, or via intra- lating blood volume.
venous route for specified length of time Monitor hemodynamic parame- Facilitates early identification of
ters when possible. fluid shifts. CVP values between
Antacids: used to alter pH so that platelets can
4-18 cm H,O are considered
aggregate and stop bleeding, and to prevent diges- adequate circulating volume.
tion of raw mucosal surfaces
Insert nasogastric tube for acute Facilitates removal of gastric con-
Histamine antagonists: used to inhibit gastric bleeding episodes, and monitor tents, blood, and clots, relieves
drainage for changes in bleeding gastric distention, decreases
acid secretion; commonly used are cimetidine, character. nausea and vomiting, and pro-
ranitidine, pepcid, and a i d vides for lavaging of stomach.
Blood that is left in stomach can
be metabolized into ammonia
and can result in neurologic
encephalopathy.
INTERVENTIONS RATIONALES INTERYENTIONS RATIONALES

Actively lavage stomach via NG Saline solution is utilized to fused, a 3 point increase in the
tube per hospital protocol with reduce wash-out of electrolytes hematocrit may be noted. If this
cold or room temperature saline that may occur with use of water. elevation is not noted, continued
until return is light pink or clear. Flushing facilitates removal of bleeding should be suspected.
clots to assist with visualization
Administer albumin as ordered. May be used for volume expan-
of bleeding site, and may assist
sion until blood products are
with control of bleeding through
available.
vasoconstrictive effect. The cur-
rent consensus of opinion is that Administer vasopressin as Intra-arterial infusion may be
differences between using cold ordered. required for severe active bleed-
versus room temperature solu- ing and patient must be
tions is negligible, and in fact, monitored closely for develop-
iced solution may actually inhibit ment of complications from the
platelet function by lowering infusion. Rates are usually 0.1-
core body temperature. 0.5 Unitslmin into the artery
supplying blood or peripherally
Notify physician if bleeding May indicate further bleeding or
at 0.3-1.5 Unidmin.
clears and then becomes bright renewed bleeding.
red again. Administer histamine blockers Histamine blockers decrease acid
andlor omeprazole as ordered. production, increase pH, and
Monitor intake and output, Helps facilitate estimation of decrease gastric mucosal irrita-
including amounts of lavage fluid replacement required. tion. Omeprazole can completely
solution, bloody aspirate, blood Lavage amounts facilitate inhibit acid secretion.
products, and vomitus. estimation of the magnitude of
bleeding based on the volume of Administer sucralfate as ordered. Decreases gastric acid secretion
solution needed to clear the gas- and provides a protective layer
tric return, and how long lavage over the ulcer site. May decrease
is required before the aspirate or inhibit absorption of other
clears. medications.
Administer IV fluids through Facilitates rapid replacement of Administer antacids as ordered. Facilitates maintenance of pH
large bore catheters as ordered. circulating volume prior to level to decrease chance of
Many facilities recommend at availability of blood products. rebleeding.
least two lines for active bleed- Solutions of choice are normal
ing. saline or Lactated Ringer’s, and Monitor labwork for changes Hemoglobin and hematocrit
should be run wide open until andlor trends. help to identify blood replace-
blood pressure is stabilized, and ment needs, but may nor initially
titrated to match volume require- change as a result of loss of
ments after that. plasma and RBCs. BUN levels
greater than 40 in the presence
Administer blood transfusions, Fresh whole blood may be of normal creatinine may signify
fresh frozen plasma, platelets, or ordered when bleeding is acute major bleeding, and BUN
whole blood as ordered. and patient is in shock so as to should normalize within 12
ensure that clotting factors are hours after bleeding has ceased.
not deficient. Packed red blood
cells are utilized most often for
replacement, especially when
fluid shifting may create over-
load. Frequently, fresh frozen
plasma (FFP) will be concur-
rently administered to replace
clotting factors and facilitate
cessation of an acute bleed. For
each unit of blood that is trans-
Information, Instruction, Alteration in comfort

Demonstration [See MI]
INTERVENTIONS RATIONALES Related to: muscle spasms, ulceration, gastric

mucosal irritation, presence of invasive lines
Administer antibiotics when May be indicated when infection
is thought to be the cause of the
Defining characteristics: verbalization of pain,
ordered.
gastritis or ulcer. facial grimacing, changes in vital signs, abdominal
guarding
Assist with and prepare patient EGD provides direct visualiza-
for EGDlsclerotherapy. tion of an upper GI bleeding Anxiety
site, and a sclerosing substance
may be injected at site to stop [See MI]
bleeding or prevent a recurrence.
Related to: change in environment, change in
Prepare patient for surgery. May be required to control gas- health status, fear of the unknown, life-threatening
tric hemorrhage. Vagotorny,
crisis
pyloroplasty, oversewing of the
ulcer, and total or subtotal gas- Defining characteristics: tension, irritability, rest-
trectomy may be procedure of
choice based on severity of lessness, anxiousness, fearfulness, tremors,
bleeding. tachycardia, tachypnea, diaphoresis
Risk for altered tissue perfksion: gastroin-
Discharge or Maintenance Evaluation testinal, cerebral, cardiopulmonary, renal,
peripheral
Patient will have stable fluid balance with
Related to: hypovolemia, hypoxia, vasoconstrictive
normal vital signs and hemodynamic
therapy
parameters.
Patient will have adequate urine output.
tachycardia, decreased peripheral pulses, decreased
Patient will have no complications from fluid or hemodynamic pressures, abnormal ABGs, abdorn-
blood replacement therapy. inal pain, decreased urine output, confusion,
mental status changes, dyspnea, headache
Patient will have labwork within normal limits.
Patient will have no active bleeding or occult Outcome Criteria

blood in stools.
Altered nutrition: less tban body body systems.
requirements
[See DKA]
~~ ~ ~~
Related to: nausea, vomiting, nasogastric tube INTERVENTIONS RATIONALES

~~ ~______ ~~~
Defining characteristics: inability to ingest Perform neurological checks Decreases in blood pressure may
adequate amounts of food, weakness, fatigue, every 4 hours and prn. Notify result in decreased cerebral perfu-
physician of changes in menta- sion that may cause confusion.
weight loss tion or level of consciousness. Increases in ammonia levels from
GASTROINTESTINAL/HEPIC SYSTEMS 197
Knowledge deficit
~~ ~~
[See MI]
residual blood may result in cere-
bral encephalopathy.
Related to: lack of information, lack of
understanding of medical condition, lack of recall
Monitor for complaints of May indicate ischemia and
increasing severity of abdominal necrosis from vasoconstrictive Defining characteristics: verbalized questions
pain, as well as pain radiating to medication which may result regarding disease, care or instructions, inadequate
shoulders. when catheter is displaced, or
may indicate peritonitis or fur- follow-up on instructions given, misconceptions,
ther bleeding. development of preventable complications
Monitor EKG for changes and Decreased blood pressure, elec-
treat according to hospital proto- trolyte imbalances, hypoxemia,
cols. or response to cold injectate
solution may cause cardiac dys-
rhythmias or changes with
perfusion loss.
Palpate peripheral pulses for Decreased circulating blood

presence and character of pulses. volume may result in peripheral
Monitor for changes in color and vasoconstriction and shunting to
temperature of extremities. core.
Monitor urine output for Renal perfusion may be affected

decreases or changes in color or by hypovolemia.
specific gravity. Notify physician
for abnormalities.
Monitor for complaints of chest Myocardial ischemia and infarc-

pain. tion may result if hypovolemic
state decreases perfusion to crisis
state.
Provide continuous pulse oxirne- Facilitates early identification of

try and notify physician for level hypoxia and allows for timely
below 90%. intervention.

namic parameters.
Patient will have adequate and stable intake and
output.
Patient will have ABGs within normal limits,
with no respiratory insufficiency or distress
noted.
Patient will have equally palpable pulses with
equal color and temperature bilaterally to
..
extremities.
GASTROINTESTINAL BLEEDING
ACUTE BLOOD LOSS

(variceal bleeding, coagulation abnormality, cancer, ulcer, gastritis, Mdlory-Weiss tears)
Decreased circulating blood volume Acid-peptide activity

4 J
Hypovolemia Increased pepsin action
J J
Attempts of body for autoregulation Digestion of mucosal surfaces
Increased pulse and BP Mucosal injury
-
J
Decreased platelet aggregation
4
Absorbtion of nitrogen products
from gastrointestinal tract
4
Sodium and potassium reabsorbed
Hypernatremia and hyperkalemia
d Cardiac dysrythmias Overload of renal

and hepatic systems
I
Renal insufficiency Portal hypertension
4 4
Renal Failure Shunting of
metabolites from the liver
4
Serum ammonia
increases
4
Hepatic encephalopathy
Tissue hypoxia 4 I
J
Cardiovascular compromise
J
DEATH
GASTROINTESTINAUHEPATIC SYSTEMS 199
be elevated, stools for guaiac, bilirubin may be ele-

vated if cirrhosis is a factor
Esophageal varices are twisting, dilated veins that Esophlagogastroduodenoscopy (EGD): used to
are found in the gastrointestinal tract, but most identify and sometimes treat variceal bleeding
frequently develop in the submucosal areas of the with sclerotherapy
lower esophagus. Most esophageal varices occur as Radiography: arteriogram used to identify tortu-
a result from liver disease and portal hypertension ous portovenous vessels; chest x-ray used to
and the development of collateral esophageal
identify other complicating problems with respira-
veins. When these veins become eroded, the ensu-
tory system
ing rupture causes extensive vigorous bleeding that
is difficult to control. Arterial blood gases: may be used to identify acid-
base imbalances; may show metabolic acidosis
Normally, the patient does not exhibit symptoms
with bleeding
until coughing, vomiting, alcohol, c:' gastritis
causes the varices to bleed. Mortality rates are high Nasogastric tube: used to keep stomach clear of
(above 60%) due to other complications of liver blood and for lavage, but must be inserted
dysfunction, sepsis, or renal failure. Blood loss cautiously so as to refrain from increasing bleeding
may be sudden, massive, and life-threatening, with
Balloon tamponade: Sengstaken-Blakemore (SB)
shock and hypovolemia occurring.
or Minnesota tube is a multi-lumen tube that
Nearly all patients with esophageal varices have at exerts pressure on part of the stomach and against
least one of the precipitating factors of cirrhosis, bleeding varices to help control bleeding, and
portal vein thrombosis, hepatic fibrosis, schistoso- allows for removal of stomach contents; caution
miasis, hepatic venous outflow obstruction, or must be exercised since placement of this tube can
splenic vein or superior vena caval abnormalities. create complications such as airway occlusion or
esophageal rupture
The initial goal of treatment is to replace blood
loss and prevent shock from hypovolemia. Balloon Visopressin: may be used as infusion through
tamponade, utilizing the Sengstaken-Blakemore or superior mesenteric artery or a peripheral vein to
Minnesota tube, may be required to produce decrease splanchnic blood flow and promote
hemostasis. hemostasis; may induce water intoxication or
accentuate cardiac disease by increasing systemic
Complications that occur in conjunction with vascular resistance
bleeding may become irreversible and lethal, such
as hepatic coma, renal failure, myocardial infarc- Nitroglycerin: may be used in conjunction with
tion, or congestive heart failure. vasopressin to balance systemic vasoconstriction
Vitamin K: may be used to counteract increased
MEDICAL CARE prothrom bin time
Laboratory: hemoglo bin and hematocrit Cathartics: magnesium citrate or sorbitol may be
decreased, BUN increased, liver function tests may used to decrease risk of ammonia-induced
be abnormal due to liver involvement and disease, neuroencephalo pathy
sodium may be elevated, clotting studies may be
abnormal due to liver involvement, ammonia may
Surgery: may require distal splenorenal shunt, Risk for injury

mesocaval and portocaval anastomoses, or devas-
Related to: utilization of balloon tamponade to
cularization of the varices all in the effort to lower
control esophageal bleeding
pressure in the portal system
Defining characteristics: increased bleeding,
NURSING CARE PLANS exsanguination, tube migration, air leakage,
esophageal necrosis, encephalopathy, airway
[Care plans in GI bleeding section also apply to occlusion, asphyxia
this diagnosis]
Risk for alteration in tissue p e r - i o n : cere- Outcome Criteria
bral, cardiopulmona? gastrointestinal,
Patient will be free of complications and injury to
renal, and periphera
self.
[See Infective Endocarditis]
Related to: variceal bleeding ~
Defining characteristics: decreased peripheral
pulses, hypotension, tachycardia initially, brady- Examine Sengstaken-Blakemore Facilitates easier detection of
cardia, cold and clammy skin, diaphoresis, mental (or other type tube) balloons by leaks by escaping air bubbling,
status changes, lethargy, pallor, abnormal ABGs, testing inflation of balloons with and ensures balloons are patent
air while tube is underwater. prior to insertion of tube into
decreased oxygen saturation, decreased urine patient.
output
Refrigerate tube prior to inser- Chilling firms the tube to facili-
Risk for decreased cardiac output tion, and assist physician with tate easier placement.
[See Cardiogenic Shock] insertion of tube into patient’s

noselmouth by encouraging
Related to: variceal bleeding, hemorrhage, exsan- swallowing small sips of water.
guination Ensure that tube is patent in Proper positioning is crucial to
stomach by auscultating stomach ensure that the gastric tube is not
Defining characteristics: decreased peripheral for injected air bolus. inflated in the esophagus.
pulses, hypotension, tachycardia, cold and clammy
Obtain KUB x-ray after place- Verifies correct anatomical place-
skin, decreased urinary output, mental status ment and securing of tube. ment.
changes, pallor
When placement is verified, Applies pressure against the
Risk for inflective individual coping inflate the gastric balloon with cardia to attempt to control
air and gently pull the tube back bleeding. Marking the tube facil-
[See Mechanical Ventilation] against the gastroesophageal itates prompt detection of
junction. Secure tube, marking accidental migration.
Related to: bleeding disorder, alcohol abuse,
location at the nares, and clamp
hepatic disease the gastric balloon.
Defining characteristics: history of excessive alco- Balloon tubes should be Facilitates stable position of tube
hol usage, anxiety, fear, hostility, manipulative adequately secured with some and prevents migration due to
device [frequently used is a foot- peristalsis or coughing, while
behavior, guilt, rationalization, blaming behavior ball helmet with face guard] with exerting appropriate pull/pressure
slight traction to the balloon on anatomical sites.
tube.
GASTROINTESTINAL/HEPATICSYSTEMS 20 1

Attach a y-connector to the Maintains sufficient pressure to
Demonstration
esophageal balloon opening, with tamponade bleeding with pres-
a syringe on one side, and a sure lower than level that may INTERVENTIONS RATIONALE5
manometer to the other. Fill result in esophageal ischemia and
balloon with air until manometer necrosis. Instruct patientlfamily regarding Promotes knowledge and facili-
need for balloon tamponade, tates compliance. Decreases fear
reading is between 25-35 mmHg
and clamp balloon. procedure of insertion, what to of the unknown.
expect, etc.
Connect gastric port to intermit- Facilitates removal of old blood
tent suction and irrigate every from stomach, allows observation Observation of patient should be Deterioration in patientk status
hour. of changes in bleeding, and constant. can occur rapidly and continuous
relieves gastric distention. observation facilitates prompt
intervention to prevent injury.
Insert nasogastric tube above the Facilitates removal of salivary
level of the esophageal balloon secretions and monitors for
and connect to intermittent suc- bleeding above the esophageal Discharge or Maintenance Evaluation
tion. If tamponade tube has an balloon, and reduces aspiration
esophageal suction port, attach it risk. Patient will have bleeding from varices
to intermittent suction. controlled with no injury or complication from
Clearly identify and label each Proper identification may pre- treatment modalities.
port, checking connections vent accidental deflation or
frequently, and have scissors and improper irrigation. If the Patient will be able to comply with treatment.
resuscitative equipment at esophageal balloon migrates to
bedside. the hypopharynx, the esophageal Patitent will have stable vital signs and
balloon must be cut immediately oxygenation.
and removed to prevent airway
obstruction.
Monitor for complaints of chest May indicate complication or

pain. esophageal rupture.
Monitor respiratory status for May result from tube migration

any changes, decrease in oxygen and asphyxia.
saturations, or changes in mental
status.
Keep head of bed elevated at Prevents regurgitation and

least 30 degrees at all times. decreases nausea.
Compare character and amounts Facilitates identification of cessa-

of drainage coming from each tion of bleeding, as well as
lumen. potentially identifying level of
bleeding site.
Deflate esophageal balloon for Decreases risk for esophageal

30 minutes every 12 hours, or as mucosal ischemia and
indicated per hospital protocol. damage.
ESOPHAGEAL VARICES
Obstruction in portal system

9
Increased pressure in portal vein
9
Normal circulation disrupted
9
Collateral channels form
Blood bypasses liver
9
Portal hypertension increases
9
Esophageal veins become varicosed and torturous
9
Portal hypertension increases
Contributing factors cause inflammatiodirritation
9
Esophageal varicosities rupture
9
Massive hemorrhage
9
Hypovolemic shock
9
DEATH
immunity and offers protection to people who are

at high risk.
Acute hepatitis is an infection of the liver that

usually is viral in origin but may be induced by
drugs or toxins. There are currently five types of
hepatitis, denoted HAV, HBV, NANB or hepatitis Laboratory: CBC shows decreased RBCs as a
C, HDV, and HEV, with HAV being the most result of decreased lifespan from enzyme
common type. Hepatitis B, or HBV, is more alterations or from hemorrhage; white blood cell
severe and because it can be acquired from expo- count usually shows leukocytosis, atypical
sure to individuals who are asymptomatic, the lymphocytes, and plasma cells; liver function stud-
potential for transmission is increased many-fold. ies are abnormal, up to 10 times normal values in
some cases, albumin decreased, blood glucose may
Hepatitis A, or HAV, is transmitted via fecal-oral be decreased or elevated transiently due to liver
route, with poor sanitation practices, with conta- dysfunction; Anti-HAV IgM presence shows either
mination of food, water, milk, and shellfish, or currenc infection or after 6 weeks may indicate
oral-anal sexual practices. HAV patients may immunity; hepatitis B surface antigen and hepati-
exhibit no acute symptoms or have symptoms that tis Be antigen show presence of HBV; Anti-HBc
are related to other causes. in serum indicates carrier status; Anti-HBsAg
Hepatitis B, or HBV, is transmitted via blood and indicates HBV immunity; antidelta antibodies
present without HBsAg indicates HDV; urine
blood products, breaks in the skin or mucous
bilirubin elevated; prothrombin time may be ele-
membranes, or from an asymptomatic carrier with
vated with liver dysfunction
Hepatitis B surface antigen (HBsAg).
Liver biopsy: may be used to delineate type of
Hepatitis C, or Non-A, Non-B hepatitis, is trans-
hepatitis and degree of liver necrosis
mitted via intravenous drug use, sexual contact,
blood or blood products, and from asymptomatic Liver scans: may be performed to identify level of
carriers. parenchyma1 damage
Hepatitis D, or HDV, is transmitted through the
same routes as HBV but must have hepatitis B NURSING CARE PLANS
surface antigen to replicate.
Activity intolerance
Hepatitis E, or HEV, is seen in developing coun-
tries and not encountered in the United States. It Related to: infective process, decreased endurance
is transmitted through food or water contamina- Defining characteristics: easy fatiguability,
tion. lethargy, malaise, decreased muscle strength, reluc-
Once the disease has been contracted, treatment is tance to perform activity
symptomatic. Prophylactic therapy may assist in Outcome Criteria
prevention of hepatitis from developing after
being exposed to the virus. Immune globulin (IG) Patient will achieve and maintain ability to
is generally given to provide temporary passive perform normal activities without intolerance and
immunity. Hepatitis B vaccine provides active fatigue.
INTERVENTIONS RATIONALES Related to: changes in health status, changes in

physical status, imposed physical isolation, inade-
Maintain bed rest and quiet Decreases energy expenditure quate support system
environment, allowing rest peri- that is needed for healing.
ods in between activities. Activity can decrease hepatic Defining characteristics: feelings of loneliness,
blood flow and prevent circula- feelings of rejection, absence of family
tion and healing to liver cells.
memberslfriends, sad, dull affect, inappropriate
Reposition every 2 hours and Decreases potential for skin behaviors
provide good skin care. breakdown.
Alteration in nutrition: less than body
Increase activities as patient is Assists with return to optimal requirements
able to tolerate. activity levels while enabling
patient to have some measure of
[See Liver Failure]
control over the situation.
Related to: metabolism changes, anorexia
Monitor labwork for liver hnc- May assist with identification of
tion studies. appropriate levels of activity. Defining characteristics: nausea, vomiting,
Administer medications as war- Sedatives and antianxiety drugs anorexia, abdominal pressure, malabsorption of
ranted. may be required to effect needed fats, altered metabolism of protein, carbohydrates,
rest. Caution should be taken to and fat, weight loss, fatigue, edema
ensure drugs used are not
hepatotoxic.
Risk for infiction
[See Transplants]
Demonstration Related to: leukopenia, immunosuppression, mal-
nutrition, exposure to causative organisms
Defining characteristics: increased white blood
Administer antidotesltherapeutic Removal of substance may cells, differential with a shift to the left, fever,
treatment modalities to remove restrict amounts of tissue
chills, hypotension, tachycardia, positive cultures
causative agent with toxic damage.
hepatitis.
Risk for impaired skin intepity
Instruct patient/fmily on disease Promotes knowledge and facili- [See Liver Failure]
process and need for extended tates compliance with treatment.
rest. Related to: bile salt accumulations on skin
Discharge or Maintenance Evaluation Defining characteristics: jaundice, pruritus, itch-

ing, scratching
of disease process and treatment program.
Patient will be able to perform usual activities
without fatigue.
Patient will be able to gradually increase level of
activities performed.
Social isolation
[See Transplants]
Knowledge &fieit INTERVENTIONS RATIONALES

Related to: lack of information, lack of recall, Instruct on avoidance of recre- May jeopardize recovery from
unfamiliarity of resources, misinterpretation of ational drugs or alcohol. infection and increases liver dys-
function.
information received
Consult with counselors, minis- May be required for assistance
Defining characteristics: questions, requests for ters, drug or alcohol treatment with substance withdrawal and
information, statements of misperceptions, devel- facilities as warranted. for long-term support once dis-
opment of preventable complications charged.
Outcome Criteria Discharge or Maintenance Evaluation

disease, treatment, and causative behaviors. Patient will be able to accurately verbalize
understanding of all instructions given.
Patiedfamily will be able to modify environ-
INTERVENTIONS RATIONALES ment to control spread of disease.
Discuss patient’s perceptions of Identifies knowledge base and Patient will be able to effectively access commu-
disease process. misconceptions to facilitate nity resources for treatment programs and
appropriate teaching plan.
discharge follow-up care.
Instruct on disease process, pre- Types of isolation will vary
vention and transmission of according to type of hepatitis Patient will be able to effectively manage med-
disease, and isolation require- and personal situation. Family ical regimen with follow-up from physician.
ments. members may require treatment
depending on type of hepatitis.
Instruct in appropriate home Dirty environment and poor

sanitation. sanitation methods may be
responsible for transmission of
the disease.
Instruct on activity limitations. Complete resumption of normal

activity may not take place until
liver returns to its normal size
and patient begins to feel better
and this may take up to several
months.
Instruct on all medications, side Promotes knowledge and facili-

effects, effects, contraindications, tates compliance. Some
and dangers of administration of medications are hepatoroxic or
over-the-counter drugs without are metabolized by the liver,
physician approval. increasing its workload.
Instruct to refrain from blood Most states do not allow anyone

donation. who has a history of any type of
hepatitis to donate blood or
blood products to prevent possi-
ble spread of the infection.
HEPATITIS
(viruses; IV drug use; contaminated food, water, or blood; alcohol)

PRECIPITATING FACTORS
4
Inflammation to liver
4
Liver cell destruction
6
Liver enlargement
6
Necrosis of liver acini cells
4
Mononuclear infiltrates
I
I 1
Autolysis Decreased ability to remove
6 toxins from blood stream
J
Anorexia, nausea, vomiting, Increased bilirubin levels
urticaria, rashes, arthralgias 4
Darkened urine, jaundice
I I
I
Scarring of liver
I
I I
Regeneration of liver cells Continued hepatic failure
4 4
Return to normal health Encephalopathy
after period of recuperation J
Coma
4
DEATH
Pancreatitis weight loss, jaundice, diaphoresis, dehydration,

and poorly defined abdominal mass may also be
encountered.
Acute pancreatitis is a life-threatening inflamma-
tory response to an injury, in which pancreatic Pseudocysts and abscesses in and around the pan-
enzymes are abnormally activated and these creas may occur as a result of localized necrosis,
enzymes destroy tissues in and surrounding the and may exert pressure on the stomach or colon.
pancreas by autodigestion. Precipitating factors for They may develop slowly and may result in fistula
the abnormal activation may be caused by effects formation.
of ethanol and its metabolite, acetaldehyde, The goal of therapy is to maintain adequate circu-
diseases of the biliary tract, obstruction of the
latory fluid volume with electrolyte replacement,
common bile duct, bile reflux into the pancreatic
pain relief, treatment of infection and treatment of
duct, ischemia, trauma, infections, surgical or hyperglycemia.
invasive procedures, neoplasms, metabolic aberra-
tions, use of oral contraceptives, corticosteroids,
thiazide diuretics, or antihypertensives, or stimula- MEDICAL CARE
tion of vasoactive substances. Obstruction may
result in widespread edema to the pancreas, which Laboratory: serum amylase is elevated up to 40
increases pressure in the pancreatic system. This times the normal limit in the early stages and then
increase in pressure results in the rupture of the decreases over 2-3 days; urine amylase elevated
ducts which allows the enzymes to spill into the and lasts longer than serum amylase; elevated glu-
cells, and begin the autodigestion process. cose, bilirubin, alkaline phosphatase, lactic
dehydrogenase, aspartate transferase, potassium,
Trypsin activates the pancreatic enzymes, triglycerides, cholesterol, and lipase; decreased
phospholipase A, elastase, and kallikrein. Trypsin albumin, calcium, sodium, and magnesium; white
may cause edema, necrosis, and hemorrhage in the blood cell counts from 8,000-20,000 with
pancreas. Elastase may attack the walls of smaller increased polymorphonuclear cells; hematocrit
blood vessels and facilitate hemorrhage. may exceed 50%; prothrombin time may be
Phospholipase A allows damage to the acinar cell increased; fat content in the stool increased; amy-
membrane to occur, and may alter coagulation. lase-creatinine clearance ratio may indicate
Vasomotor changes and increases in vascular per- pancreatic disease; renal profiles used to evaluate
meability may be caused by kallikrein, and this renal function and hypovolemia
may also be the cause of the pain experienced with
pancreatitis. If the disease is allowed to progress, CT scans: used to identify size, shape, density,
the inflammation leads to massive hemorrhage, masses, or infiltrates in the pancreas
destruction of the pancreas, diabetes mellitus, aci- Ultrasonography: used to identify neoplasms,
dosis, shock, coma, and death. edema, inflammation, cysts, abscesses, or
One of the predominant symptoms of this disease infiltrates in the pancreas, but cannot confirm the
is the unrelenting abdominal pain located in the diagnosis of pancreatitis
epigastric and/or periumbilical areas that may Angiography: helps to visualize early pancreatic
radiate to the chest and back. Nausea, continuous tumors or problems with vasculature
vomiting, low-grade fever, anorexia, diarrhea,
Endoscopic retrograde cholangiopancreatography decreased bowel sounds, anorexia, increased

(ERCP): used to directly visualize the pancreatic metabolism, lack of adequate food ingested
duct system by use of endoscopy and radiography;
used to identify cysts, calculi, stenosis, pancreatic Fluid volume dtlficit
and biliary duct disease when other diagnostic [See DKA]
tools are not conclusive
Related to: nausea, vomiting, fever, diaphoresis,
Surgery may be necessary to drain abscesses or nasogastric drainage, fluid shifting, diarrhea
pseudocysts, or to anastomose the pseudocysts to
an adjacent structure to provide internal drainage; Defining characteristics: nausea, vomiting, ascites,
chronic pancreatitis may require a pancreaticoje- nasogastric suctioning, hypotension, tachycardia,
junostomy to relieve obstruction of the duct to decreased urinary output
relieve pain; experimental surgery for transplanta-
tion of the pancreas or islet cells may be performed
NURSING CARE PWNS Related to: complications from disease
Alteration in comfort Defining characteristics: altered arterial blood

[See MI] gases, dyspnea, use of accessory muscles, tachyp-
nea, bradypnea, cough, sputum
Related to: pancreatic obstruction, autodigestion
of pancreas, leakage of pancreatic enzymes, Potential for injury
inflammation
Related to: sepsis, pseudocysts, fistula formation,
Defining characteristics: unrelenting epigastric abscess formation, complications from disease
pain, patient curled up with both arms over
Defining characteristics: fever, abdominal pain,
abdomen, nausea, vomiting, tenderness, facial gri-
drainage, increased white blood cell count, shift to
macing, groaning
the left, systemic infection symptoms, DIC, elec-
INTERVENTIONS RATIONALES trolyte imbalances
Administer Demerol IV as Demerol is the drug of choice
warrantediordered. for pancreatitis. DO NOT Outcome Criteria
GIVE Morphine because most
opiate-type narcotics cause Patient will be afebrile and have no complications
spasms of the Sphincter of
Oddi, increasing patient's pain.
from disease.
Alteration in nutrition: less than body INTERVENTIONS RATIONALES

requirements Monitor vital signs at least every Allows for prompt identification
[See DKA] 2 hours, and note changes. of early signs of infection to
facilitate timely treatment. Third
Related to: nausea, vomiting, anorexia, digestive spacing, bleeding, and secretion
enzyme leakage, increased metabolic needs, sepsis of vasodilating substances may
result in hypotension.
Defining characteristics: increases in nausea and
vomiting, retching, absent bowel sounds,

Monitor hemodynamic pressures Allows for actual measurement of Prepare patientlfamily members Surgical drainage of abscesses or
if possible. cardiac output and other para- for surgical procedures as pseudocyscs may be required.
meters to identify fluid shifts and warranted.
Long-term replacement may be
hemodynamic alterations which
Instruct in usage of pancreatic required for exocrine deficiencies
may precede systemic complica-
enzyme supplements/bile salts. from permanent pancreatic
tions.
damage.
Monitor EKG for cardiac Hypovolemia and electrolyte
rhythm, rate, and changes, and imbalances may precipitate car-
treat dysrhythmias per hospital diac dysrhythmias. Discharge or Maintenance Evaluation
policy.
Auscultate heart sounds for JVD in conjunction with a new Patient will be free of complications from pan-
changes, gallops, or murmurs. S, gallop may indicate heart fail- creatitis, and will exhibit timely healing of all
ure or pulmonary edema. wounds.
Observe for changes in respira- Gram negative sepsis may be
tory status, especially when seen symptomatically with
Patient will be able to accurately verbalize all
occurring concurrently with fever cholestatic jaundice and decreases instructed information.
and jaundice. in pulmonary function.
Observe for increasing May indicate formation of

complaints of abdominal pain or abscess, especially if symptoms
tenderness, chills, fever, or occur while patient is receiving
hypotension. vigorous medical treatment.
Abdominal rigidity or rebound
tenderness may indicate peritoni-
tis.
Observe for presence of May indicate impending DIC as

petechiae, continued bleeding, or a result of circulating pancreatic
hematoma formation. enzymes.
Measure and monitor abdominal Identifies increases in fluid reten-

girth changes. tion and ascites.
Monitor intake and output every Oliguria may occur as a result of

2 hours, noting hematuria, or renal involvement due to
significant imbalance. increases in vascular resistance or
decreased renal blood flow.
Hematuria may occur as a result
from circulating pancreatic
enzymes.
Demonstration
Strict aseptic technique should Failure to maintain technique

be maintained when dealing with may result in sepsis, which is
invasive lines or dressings. responsible for over 80% of
deaths associated with
pancreatitis.
210 CRITICAL CARE NURSING CAFE PLANS
PANCREATITIS
Pancreatic duct obstruction or injury

4
Inflammation and edema
4
Increased pressure
Rupture of duct
4
Activation of pancreatic proteolytic enzymes
II
I I
Trypsi; leakage Lipase leakage
4 4
I 1 - -7
Elastase digestion Kallikrein Phosolipase A Fat Necrosis
of blood vessels 4
Vasodilation Necrosis of
4 acinar cells
Increased
permeability
4 4
Hemorrhage
s
Ed:ma 1
Thrombosis Combine with Ca++
4
4 1
systematically and locally I
Continued release of toxic substances Hypocalcemia
Acute Abdomen/ MEDICAL CARE

Abdominal Trauma Surgery: usually the treatment of choice due to
potential or presence of peritonitis from injury;
When someone is said to have an acute abdomen, procedure is dependent on source of bleeding or
it generally indicates that they have a sudden onset contamination
of severe abdominal pain that typically requires Laboratory: urinalysis to identify bleeding or uri-
surgery to prevent peritonitis from contaminated nary tract injuries; CBC to identify sepsis and
materials spilling into the peritoneal cavity. There changes in hematological status; WBC is normally
are numerous situations that could be responsible elevated in trauma; differential used to identify
for this diagnosis, such as perforation of the shifts to the left; amylase elevated with pancreatic
appendix, peptic ulcer, bowel, gallbladder, diverti- injury or gastrointestinal perforations; renal and
culi, or abdominal aortic aneurysm, ruptured liver profiles to discern damage to the particular
ectopic pregnancy, or an abdominal injury. system; clotting profiles to monitor for coagula-
Abdominal injuries may be caused from either tion status; myoglobin levels elevated with crush
blunt trauma or penetrating damage. Blunt injuries, peritoneal fluid analysis for bleeding or
trauma, with compression of abdominal structures infection
against the vertebral column, can result from Radiagaphy: chest and abdominal x-rays used to
sports injuries, accidents, or falls, and can be identify pneumothorax, free air below the
caused as a result of a direct impact, rotary or diaphragm, foreign body that may have caused
shearing forces, or rapid deceleration. Any of these injury, or other complications; loss of psoas
mechanisms can cause tearing of body structures muscle outline indicates retroperitoneal bleeding
that may involve substantial bleeding into the
peritoneal cavity. CT scans: may be used to identify abdominal and
retroyeritoneal injuries that may not be overt with
Penetrating injuries can cause perforation of the regular x-rays; can identify cysts or abscesses that
bowel or hemorrhage from lacerations to major may require surgical intervention
vessels. These types of trauma can either be low-
velocity, which damages tissues at the injury site, Intravenous pyelogram: used to detect hematuria
or high-velocity, in which tissues and organs sur- and trauma to renal structures
rounding the penetration path are damaged. Retrograde urethrography/cystography: used to
All of the types of injuries discussed have signifi- identify urethral or bladder injury
cant potential for critical emergencies, based on Ultrasound: use is limited; may be useful to dis-
the severity of the wound, and how much damage tinguish between splenic hematoma from
it has caused. Mortality is approximately 10% peritoneal blood or ascites
from abdominal trauma due in part to the pres-
ence of structures involving many body systems Paracentesis: may be used to identify presence of
being located in the abdomen. The goals of imme- pus, blood, or other substance, and may be used
diate treatment involve maintaining the for peritoneal lavage to identify effects of abdomi-
hemodynamic status, control of hemorrhage, and nal trauma and prevent unnecessary surgical
preparation for surgical procedures. intervention
NURSING CARE PLANS Information, Instruction,

Demonstration
Risk for infection
Related to: perforation of abdominal structures,
laceration of vasculature, open wounds, peritoneal Prepare for surgery as warranted. Surgical intervention may be the
cavity contamination treatment of choice to drain
abscesses or remove or repair
Defining characteristics: fever, trauma, elevated perforated structures.
white blood cell count, sepsis Assist with peritoneal aspiration May be performed to remove
as warranted. fluid and identify causative
organism.
Outcome Criteria
Change wound dressings as Dressings protect wound and
Patient will be free of infection, with stable vital ordered. prevent spread of infection.
signs and labwork within normal parameters. Monitor CBC, especially WBC Facilitates assessment of effective-
count. ness of antimicrobial therapy, as
well as identifies blood loss or
changes in infection.
Limit visitors as indicated, utiliz- Decreases potential for cross-
Monitor vital signs, especially May indicate presence of or ing appropriate isolation contamination.
temperature. impending infection and sepsis. precautions as warranted.
Decreasing pulse pressure,
hypotension and tachycardia may Discharge or Maintenance Evaluation
signifj impending septic shock
from endotoxic vasodilation. Patient will have stable vital signs and hemody-
Observe skin color, temperature, Patient may have warm, flushed, namic status.
and monitor for changes. dry skin in shock's warm phase,
Patient will have white blood cell count within
changing to cold and clammy
pale skin as shock progresses. normal limits.
Obtain blood, urine, sputum, Identifies causative organism and Patient will have negative cultures.
drainage, or other cultures as facilitates appropriate selection of
ordered. antimicrobial agents. Patient will not exhibit further signs/symptoms
Monitor intake and output every Sepsis may impair renal perfu- of infection.
2 hours. sion and result in oliguria or
anuria.
Patient will not develop secondary infection.
Administer antibiotics as Cephalosporins and aminoglyco- Family members will adhere to isolation regula-
ordered. sides are frequently used to fight tions.
these types of infections.
Ensure that universal precautions Assists in preventing spread of

Risk for injury
are utilized, and that sterile or infection by cross-contamination, Related to: trauma
aseptic technique is used when as well as preventing other bacte-
caring for wounds or inserting rial growth from invasion of Defining characteristics: hemorrhage, peritonitis,
invasive lines or catheters. skinlbody.
altered arterial blood gases, mental status changes,
Administer tetanus toxoid as Decreases risk of development of hypotension, tachycardia, bradycardia, arterial
ordered. tetanus.
injuries, fractures, electrolyte imbalances
GASTROINTESTINAL/HEPATICSYSTEMS . . . 213

abdomen or liver may indicate
Patient will be free of injury to self, and free of hepatic or splenic vein thrombo-
complications that may ensue from trauma. sis, and friction rubs heard over
the spleen may indicare infarc-
tion or inflammation of spleen.
INTERVENTIONS RATIONALES Percuss abdomen for changes, Dullness that is decreased over
dullness or tympany. liver may indicate presence of
free air below the diaphragm.
Monitor vital signs every 1-2 Decreases in blood pressure or
Upper abdominal distention and
hours, and prn. Check blood changes with orthostatic readings
increased tympany over the
pressure readings in both arms may indicate impending hypov-
stomach may indicate gastric
and legs. olemia. Pulse pressures may
dilation. Flank area dullness may
increase during the latent effects
indicate retroperitoneal hemor-
of shock or with head injuries,
rhage.
and may decrease in early stages
of shock. Differences benveen Cover protruding abdominal Protects viscera from drying, and
right and left sides greater than viscera with saline-soaked sterile positioning prevents additional
20 mmHg may indicate aortic gauze or sterile towels, and posi- protrusion/evisceration.
injury. tion patient with knees flexed.
Monitor respiratory status, Injury to lungs or diaphragm Palpate peripheral pulses for Changes in pulse characteristics
noting changes in breath sounds. may result in tachypnea and dys- presence, quality, and character. may indicate arterial or venous
pnea. Breath sounds that are Notify physician for significant impairment which may require
distant or absent may indicate changes. immediate treatment.
pneumothorax or hemothorax.
Observe for Grey Turner's and Grey Turner's sign is a bluish
Observe chest for symmetry, Splinting by patient or obvious Coopernail's signs. discoloration on flank that indi-
paradoxical movement, anatomi- deformity or swelling may be cates retroperitoneal bleeding
cal deformity, swelling, bruising, seen if ribs are fractured. accumulation in abdomen.
or crepitus. Paradoxical movement may indi- Coopernail's sign is ecchymoses
cate flail chest. Palpable crepitus on scrotum or labia and may
may be present if lung or medi- indicate pelvic fracture.
astinum has been punctured.
Monitor for complaints of pain May indicate rupture of spleen
Auscultate heart sounds for Extra heart sounds or murmurs at the tip of the left shoulder or or irritation of the diaphragm
changes or abnormalities. may indicate injury to valves or right shoulder. from blood or other substance
heart, and distant, muffled heart with left shoulder pain, and pos-
tones may signal cardiac tarnpon- sible liver laceration with right
ade. shoulder pain.
Observe abdomen for wounds, Bluish discolorations around the

masses, swelling, pulsations, umbilicus may indicate retroperi-
hemaromas, protrusion of organs toneal bleeding accumulating in Demonstration
or viscera, lacerations, and abra- abdomen. An odd number of ~ ~~ ~~ ~
sions; auscultate for bowel bullet holes may indicate the INTERVENTIONS RATIONALES
sounds. remaining presence of a foreign ~~~ ~~
objectlbullet in the body. Assist with peritoneal tap and Done to identify intraperitoneal
Decreased or absent bowel lavage. bleeding which is diagnosed
sounds may indicate ileus or when fluid is analyzed.
peritonitis. Abdominal bruits
may result when a vessel is par- Instruct on all procedures and Promotes knowledge and
tially occluded, venous hums testing; prepare for surgery as decreases anxiety which facilitates
auscultated over the upper warranted. compliance with medical regi-
men.
INTERVENTIONS RATIONALES weight loss, nitrogen and electrolyte imbalance,

decreased albumin and protein levels, vitamin
Instruct patientlfmily to notify Abdominal injury signs and deficiencies
physician for fever or abdominal symptoms may not appear for
pain. several hours to days.

Patient will have no evidence of abdominal
injury complication.
Patient will have no intraperitoneal bleeding or
structural damage to organs.
Patient will be compliant with regimen.
Patient will have successful surgical intervention
with no postoperative complications.
Risk fir fluiduolmve &ficz't
[See GI Bleeding]
Related to: fluid shifts, hemorrhage, nasogastric
suctioning
Defining Characteristics: hypotension, tachycar-
dia, decreased urinary output, decreased
hemoglobin and hematocrit, decreased filling pres-
sures, electrolyte imbalances, presence of
peritonitis
Alteration in comfirt
[See MI]
Related to: trauma, surgery, edema
Defining characteristics: grimacing, complaints of
pain, restlessness, splinting, shallow respirations,
abdominal rigidity
requirements
[See DKA]
Related to: trauma, surgery, nasogastric suctioning
Defining characteristics: abdominal pain, ordered
nutritional status of NPO, increased metabolism,
ACUTE ABDOMEN/ABDOMTNAL TRAUMA

(bowel obstruction, peritonitis, trauma, perforation)
TRAUMA PERFORATION OBSTRUCTION

J, 4 J,
Hemorrhage from major vessel Subcapsular hematoma Decreased blood flow to major vessels
4 4 J,
Hypovolemia Increased pressure Vasoconstriction

4 J,
Rupture of organ Vasospasm

4
Decreased oxygenation
J,
Accumulation of fluids
J,
,xra-abdominal pressure increases

J,
Perforation
J,
Peritonitis or systemic infection
w SHOCK f-
I
J,
DEATH
G A S T R O I N T E S T I N A L / H E P I C SYSTEMS 217
Fulminant hepatic failure may begin as stage I

hepatic encephalopathy, progressing to drowsiness
and asterixis, stupor and incoherent communica-
The liver plays a vital role by providing multiple tion, finally to stage IV with deep coma. The
functions, such as, metabolism of carbohydrates, stages may progress over at little as two months.
proteins, and fats, storing fat-soluble vitamins, vit- Distinguishing attributes between acute and
amin B,,, copper, and iron, synthesis of blood chronic failure are the presence of cerebral edema
clotting factors, amino acids, albumin, and globu- and intracranial pressure increases.
lins, detoxification of toxic substances,
phagocytosis of microorganisms, and plays a role The goal of treatment is to halt progression of the
in glycolysis and gluconeogenesis. Liver function- encephalopathy that occurs with increasing
ing can be preserved until up to 75% of the ammonia levels, and is accomplished with use of
hepatocytes become damaged or necrotic, at cathartics, decreasing dietary protein, and
which time the liver can no longer perform its electrolyte replacement. Even with treatment,
normal operation. mortality rates are as high as 90%, depending on
the age of the patient and severity of disease.
Early hepatic failure presents as a type of cirrhosis
of the liver. Liver cells become inflamed and MEDICAL CARE
obstructed, which results in damage to the cells
around the central portal vein. When the inflam- Laboratory. elevated ammonia levels, liver func-
mation decreases, the lobule regenerates, and this tion studies elevated, elevated BUN; electrolytes
cycle is repeated until the lobule is irreversibly tested to identify imbalances; serum bilirubin ele-
damaged and fibrotic tissue replaces liver tissue. vated; urine bilirubin may be present if direct,
serum bilirubin is elevated; albumin decreases and
Advanced hepatic failure develops when all com-
globulin increases in liver failure; cholesterol is ele-
pensatory mechanisms fail, causing the serum
vated; PT prolonged; toxicology screens for
ammonia level to rise. The already-damaged liver
ingestion of alcohol or other drugs that may have
is unable to synthesize normal products, so acido-
precipitated failure; magnesium level may be low
sis, hypoglycemia, or blood dyscrasias develop,
with alcoholic cirrhosis and toxic if magnesium
and the patient becomes comatose.
replacement is used
Acute liver failure, also known as fulminant
Medication: Neomycin or Kanamycin frequently
hepatic failure, may be precipitated by a stress
used to prevent intestinal bacteria from converting
factor that aggravates a preexisting chronic liver
proteidamino acids to ammonia; lactulose or sor-
disease. Some stress factors include alcohol intake,
bitol used to induce catharsis to empty intestines
ingestion of Amanita mushrooms, large amounts
to decrease conversion to ammonia; thiazide
of dietary protein, gastrointestinal bleeding, and
diuretics may be given to decrease fluid retention
portacaval shunt surgery. An acute type of liver
failure may occur as a result of viral or toxic Hyperalimentation: may be used as diet of choice
hepatitis, biliary obstruction, cancer, acute infec- due to ability to control concentration of
tive processes, drugs, such as acetaminophen, nutrients, electrolytes, and vitamins
isoniazid, and rifampin, severe dehydration, Reye’s
syndrome, or shock states.
Hemodialysis: may be used as a temporary mea- INTERWNTIONS RATIONALES

~~~ ~
sure for severe hepatic encephalopathy Observe for asterixis or other Rapid wrist flapping when arms
tremors. are raised in front of body with
Liver biopsy: may be done to establish diagnosis hands dorsiflexed may indicate
by study of biopsied tissue presence of encephalopathy.
Liver scans: may be used to detect degenerative Provide safe environment for Decreases risk of injury due to
patient. altered consciousness levels.
cirrhosis changes or identifj. focal liver disease
Provide low protein diet. Decreased dietary protein may
NURSING CARE PUNS lessen serum ammonia levels.
Avoid sedatives and narcotics if May worsen decreasing level of

Alteration in thought processes at all possible. consciousness and make identifi-
cation of cause of decreased
Related to: serum ammonia levels, sensorium more difficult.
encephalopathy
Defining characteristics: increased ammonia,
Demonstration
increased BUN, mental status changes, decreasing ~
level of consciousness, changes in personality, INTERVENTIONS RATIONALES

handwriting changes, tremors, coma Instruct patientlfamily in poten- Provides knowledge and facili-
tial for altered sensorium and tates family involvement with
Outcome Criteria encephalopathy signs. Reorient maintaining optimal orientation
Patient will be conscious and stable, with ammo- patient as needed. level. Provides support with real-
istic expectations of disease
nia levels within normal ranges. process since outcome is poor.
Instruct in side effects of drugs Diarrhea will occur, and lactulose
Monitor neurological status every Idenrifies onset of problem and used to facilitate decrease in should be titrated to where
1-2 hours, and prn. Notify potential trend. ammonia levels. patient has 3 stools per day.
physician for abnormalities.
If possible, have patient write As hepatic failure progresses, the

name each day and d o simple ability to write becomes more
mathematic calculation. difficulr, and writing becomes Patient will be awake, alert, and oriented.
illegible at pre-coma stage.
Inability to perform mental cal- Patient will have serum ammonia levels within
culations may indicate worsening acceptable ranges.
failure.
Lactulose minimizes formation

Patient andlor family will be able to verbalize
Administer cathartic agents as
ordered. of ammonia and other nitroge- understanding of instructions and be able to
nous by-products by altering communicate concerns.
intestinal pH. Neomycin or
Kanamycin help prevent conver- Alteration in nutrition: less than body
sion of amino acids into
ammonia. Sorbitol-type cathar-
requirements
tics cause an osmotic diarrhea to
empty the intestines to decrease
Related to: metabolism changes, increased ammo-
ammonia production. nia level
Defining characteristics: anorexia, nausea, vomit-

ing, malabsorption of fats, malabsorption of
vitamins, altered carbohydrate, fat, and protein Defining characteristics: presence of ascites, olig-
metabolism, malnutrition, weight loss, fatigue, uria, anuria, dry skin, decreased skin turgor,
edema, ascites hypotension
Outcome Criteria Impaired skin integrity

Relateld to: poor nutrition, renal involvement, bile
Patient will be able to achieve positive nitrogen
deposits on skin
balance and have stable weight.
Defining characteristics: edema, ascites, jaundice,
pruritus
Provide diet that has protein in Protein metabolism is altered

Outcome Criteria
ordered amounts, with supple- with liver disease and results in
mentation of vitamins and other increased ammonia levels. Patient will maintain skin integrity.
nurrients. Vitamin/nutrient supplementa-
tion may be required due to
malabsorption of element.
Ensure that patient is positioned Decreases abdominal tenderness Observe skin for changes, abra- Facilitates identification of
in sitting position for meals. and fullness, and prevents poten- sions, rashes, scaling, wounds, potential complications.
tial for aspiration. bleeding, redness, etc.
Avoid sodium intake of amounts Sodium should be restricted to Turn at least every two hours and Prevents pressure area compro-
greater than ordered. less than 500 mg per day to prn. mise of skin.
decrease edema and ascites.
Apply lotions frequently when Soap may dry skin furrher and
If patient is unable to ingest ade- Provides needed nutrients when providing skin care; do nor use result in breach of integrity.
quate dietary intake, administer patient is unable to eat. soap when bathing; apply corn- Lotions and other agents may
rube feedings or TPN as ordered. starch or baking soda pm. decrease itching.
Administer medications for pru- Decreases itching which may

Discharge or Maintenance Evaluation ritus as ordered. cause wounds. Bile salrs rhat are
deposited on the skin of parienrs
with hepatic or renal involve-
Patient will be able to ingest adequate amounts ment cause chronic and severe
of prescribed diet to maintain weighr and pruritus.
ammonia levels at acceptable levels.
6 Patient will comply with dietary regimen and Information, Instruction,
limitations. Demonstration
Patient will have no complications from enteral INTERVENTIONS RATIONALES
or parenteral therapies.
Instruct patient in merhods to Helps prevent patienr from
decrease itching: soothing mas- scratching during the night and
Fluid volume deficit sages, avoidance of extra covers, reduces tendency ro scrarch.
[See GI Bleeding] and use of clean white gloves at
night.
Related to: osmotic changes, hydrostatic pressure
Provide attention-diverting activ- May refocus concentration to
changes ity. decrease scratching.
Discharge or Maintenance Evaluation Risk f i r injury

Patient will exhibit no evidence of skin break- Related to: hemorrhage, altered clotting factors,
down. esophageal varices, portal hypertension
Patient will be able to use discussed methods to Defining characteristics: bleeding,

avoid scratching. exsanguination, decreased hemoglobin and hemat-
ocrit, decreased prothrombin, decreased
Patient will have no complications from lack of fibrinogen, decreased clotting factors VIII, IX, and
skin integrity. X, vitamin K malabsorption, thromboplastin
release
Inefective breathing pattern
Related to: increased pressure from ascites, Outcome Criteria
elevated ammonia levels, decrease lung expansion,
fatigue Patient will exhibit no evidence of bleeding.
Defining characteristics: presence of ascites, weak-

ness, tachypnea, dyspnea, decreased lung INTERVENTIONS RATIONALES
expansion, altered arterial blood gases
Monitor all bodily secretions for GI bleeding may occur due to
presence of blood; test stools and altered clotting factors and
Outcome Criteria nasogastric drainage for guaiac. changes that occur with cirrhosis
and liver disease.
Patient will maintain effective respiration with Observe for bleeding from punc- May indicate a form of dissemi-
normal ABGs and hemodynamics. ture sites, presence of hematomas nated intravascular coagulation
or petechiae, or bruising. as a result of altered clotting fac-
tors.
INTERVENTIONS RATIONALES Monitor vital signs and hemody- Changes in vital signs may indi-
Assist with paracentesis. May be required to remove namic parameters. Avoid rectal cate loss of circulating blood
ascitic fluid if respiratory insuffi- temperatures. volume. Vasculature in rectum
ciency cannot be corrected by may be susceptible to rupture.
other methods.
Insert nasogastric tube gently Esophageal vasculature may be
Prepare patient for placement of Surgical intervention may be and lavage as ordered. susceptible to rupture. Removal
peritoneovenous shunt. required to provide method to of blood from the stomach
return accumulations of fluid in decreases synthesis to ammonia.
abdominal cavity to the systemic Vitamin K facilitates synthesis of
Administer vitamins as ordered.
circulation and provides long- prothrombin and coagulation if
term ascites relief. liver is functional. Vitamin C
may reduce potential for GI
bleeding and facilitates healing
Discharge or Maintenance Evaluation process.
Administer stool softeners as Prevents straining to pass stool

Patient will be free of shortness of breath and
needed. which may result in rupture of
will have normal lung expansion with optimal vasculature or increase in intra-
arterial blood gases and oxygenation. abdominal pressures.
GASTROINTESTINAL/HEPATICSYSTEMS 22 1
Monitor labwork for CBC and Helps to identify blood loss or ones may enhance patient’s abil-
clotting factors. impending DIC. ity to accept changes.
Consult with social services, Additional professional and corn-

Discharge or Maintenance Evaluation counseling, psychiatric services, munity resources may be
minister, or other community required to deal with alcohol or
resources. drug rehabilitation, or with per-
Patient will have no active bleeding and labwork ceptions of body image.
will be within normal limits.
Patient will not exhibit any hemorrhagic com- Discharge or Maintenance Evaluation
plications from invasive lineltube placement.
Patient will be able to verbalize concerns over
Disturbance in body image his appearance.
Related to: changes in physical appearance, ascites Patient will be able to verbalize understanding
of disease process and changes that may occur.
Defining characteristics: presence of ascites, bio-
physical changes, negative feelings about body, Patient will be able to effectively utilize methods
fear of rejection, fear of reaction from others, fear for coping with changes.
of death, fear of the unknown Family will be supportive of patient‘s altered
appearance and self-esteem.
I Outcome Criteria
Patient will be able to verbalize concerns and nity resources for continuing needs.
accept bodylself perception within situational
limits.
Encourage patient to discuss Validates patient’s feelings and
concerns, fears, and questions concerns regarding changes in
regarding diagnosis being careful body.
to recognize and accept his fears
without minimizing them.
Discuss causes of alteration of Validates realistic changes and

appearance with patient and allows for reinstruction on areas
family members. that may not have been under-
stood. Jaundice, bruising, and
ascites may be considered unat-
tractive by patient andlor family,
and may precipitate feelings of
low self-esteem and body worth.
Encourage family to support Patient and family may experi-

patient without rejection or fear ence guilt, especially if the cause
of his appearance. is alcohol or drug-related.
Emotional support from loved
222 CRITICAT., CARE NURSING CARE PLANS
LIVER FAILURE
Liver cells inflamed or obstructed

I
Liver dysfunction due to damaged hepatoves
I
Hepatic lobule regenerates
I
Hepatic lobule irreversibly damaged
Hepatic tissue becomes necrotic
I
Fibrotic tissue replaces hepatic tissue
4
Extensive destruction of hepatocyces
Liver cannot perform function
I
Compensatory mechanisms fail
Hepatic failure
I - - - ~ I I I I
Ammonia remains Liver com resses Liver unable to Liver unable to Liver unable to
in circulation vesseP, synthesize clotting synthesize protein/ regulate glucose,
Obstructs flow factors amino acid store glycogen &
form glyconeogenesis
I I I I I
Ammonia binds with Portal Blood dyscrasias Decreased fat Hypoglycemia
carrier ion hypertension Decreased ability absorption
I for coagulation
I
I I 4 I c
Increased Acidosis Esophageal DIC Decreased protein
serum varices absorption
ammonia
I I
Increased hangui nat i on Hemorrhage Increased Decreased Fluid
BUN mercaptan secretion shifting
of bile to interstitial
tissues
I I I I I
Confusion I Renal impairment Fetor Increased Aldosterone
Decreased level secretion
of consciousness
J, I
Encephalopathy Bile salts Water & sodium
Coma deposited rerention
s I s J,
Cerebral edema Jaundice Edema
Increased ICP
s
Brainstem herniation
s
Respiratory arrest b DEATH
+ 4
Pruritis
s
Ascites
HEMATOLOGIC SYSTEM 223
Disseminated Intravascular Coagulation (DIC)

HELLP Syndrome
Anemia
underlying problem, correction of shock, acidosis,

and sepsis, supportive care to restore circulatory
lntravascular Coagulation volume and adequate oxygenation of tissues, and
to replace blood loss due to hemorrhage.
Disseminated intravascular coagulation, also

Laboratory: prothrombin time (PT) to measure
known as consumptive coagulopathy, defibrino-
activity level and patency of the extrinsic and final
genation syndrome, or DIC, is an acute disorder
pathways, increased in DIC; partial thromboplas-
that accelerates the activation of the intrinsic
tin time (PTT) to measure activity level and
and/or extrinsic cascade clotting mechanism and
patency of the intrinsic and final pathways,
depletes both clotting factors and platelets. DIC is
increased in DIC; thromboplastin time increased,
usually a complication of another disease process
platelet count decreased, fibrinogen usually
in which excessive thrombin is produced, convert-
decreased showing increased hypercoagability and
ing fibrinogen to fibrin, and the fibrin creates
decreased bleeding tendency, FSP elevated, usually
damaging thrombi in the microcirculation. Fibrin
> 10; clotting factor analysis used to identify fac-
blocks the capillary flow to the organs and results
tors being depleted; CBC used to evaluate anemia
in ischemic tissue damage, and as the clotting fac-
and RBC fragmentation; BUN and creatinine
tors, platelets, and fibrin split products (FSP) are
used to assess renal involvement from thrombosis;
consumed, hemorrhage and shock results. As the
guaiacs on all body fluids to identify occult bleed-
fibrin and FSP repolymerize, a secondary fibrin
ing; cultures of sputum, blood, urine, CSF and
mesh forms in the microcirculation and when
other drainage used to identify causative organism
blood travels through this, the red blood cells
of infection and to ascertain appropriate antimi-
become damaged and a hemolytic anemia
crobial for therapy
can occur.
Blood components: used as replacement therapy
Some of the precipitating factors include sepsis,
for significant blood loss; RBCs given to increase
neoplasm necrosis, eclampsia, abruptio placentae,
the oxygen-carrying capability; whole blood,
saline-induced abortions, retained dead fetus,
plasma, plasmanate and albumin used to expand
amniotic fluid embolus, hemolysis, giant heman-
volume; fresh frozen plasma (FFP) and albumin
giomas, systemic lupus erythematosus,
used to replace proteins; FFP, cryoprecipitate, and
transfusions, trauma, shock, burns, head injuries,
fresh whole blood used to replace coagulation fac-
transplant rejection, snake bite, fractures, anoxia,
tors; platelet concentrate used to replace platelets
heat stroke, surgery utilizing cardiopulmonary
bypass, and necrotizing enterocolitis. lV fluids: used to treat hypovolemia and shock
Bleeding in a patient with no other previous his- Antibiotics: used to treat infection that may cause
tory of bleeding or coagulopathy problems should DIC
raise questions as to the possibility of the presence
Heparin: use is controversial; heparin inhibits
of DIC. DIC may be acute or chronic (usually
micro thrombi formation by neutralizing free cir-
seen with neoplasms) and can vary in severity
culating thrombin; shouldn’t be used unless
from mild oozing to exsanguination from all ori-
bleeding is unmanageable by replacement therapy
fices. Treatment is aimed at correction of the
of FFP and platelets
Risk fir impaired gas exchange Identify and treat underlying Treatment of cause and correc-
disorder. tion of coagulation problem is
[See GI Bleeding] major goal of treatment. DIC is
most often seen as the complica-
Related to: bleeding, disease tion of an underlying infection,
malignant disease, trauma, or
Defining characteristics: decreased P a 0 2 below
shock state.
80 mmHg, dyspnea, tachypnea, increased work of
breathing, restlessness, irritability, mental status Administer IV fluids as ordered. Large volumes may be required
to mainrain circulating volume
changes, changes in blood pressure and pulse, due to bleeding, and to maintain
decreased hemoglobin and hematocrit hemodynamic status.
Risk fir fluid volume &fieit Administer blood and blood by- May be required to replace circu-
products, such as cryoprecipitate, lating blood volume and to help
[See GI Bleeding]
fresh frozen plasma, etc. as correct thrombocytopenia or
Related to: blood loss, altered coagulability ordered. hypofibrinogenemia.
Administer supplemental oxygen Decreased blood volume impairs

Defining characteristics: weight loss, oliguria, as warranted. oxygen carrying capability and
abnormal electrolytes, hypotension, tachycardia, supplemental oxygen may be
decreased central venous pressures, decreased fill- required ro maintain
oxygenation.
ing pressures, altered coagulation studies, lethargy,
mental status changes Observe patient for petechiae, May be present with impending
bruising, overt and occult DIC.
Riskfor injury bleeding.
Related to: hemorrhage, blood loss, altered Monitor for dyspnea, hemopty- Crackles may be present and
sis, and decreased saturation; patient may exhibit these signs if
coagulability
auscultate lung fields for adventi- microemboli in the pulmonary
tious breath sounds. circulation are present.
Defining characteristics: bleeding,
exsanguination, decreased hemoglobin and hemat- Monitor intake and output. Microemboli or deposits of fibrin
ocrit levels, increased fibrin split products, within the renal system may pre-
sent as renal insufficiency or
increased prothrombin time, decreased platelet failure.
count, increased partial thromboplastin time,
Administer heparin therapy as Controversial treatment may be
decreased fibrinogen
ordered. given to disperse clumped clot-
ting factors, but is rarely used
Outcome Criteria today.
Monitor labwork for coagulation Provides identification of effec-

Patient will be free of unexplained bleeding and studies and CBC. tiveness of therapy or worsening
will have stable vital signs and hemodynamic pres- of condition.
sures.

namic pressures.
Patient will exhibit no bleeding tendencies or
active hemorrhage.
Patient will exhibit no complications from other
disease processes.
Patient will achieve and maintain adequate
blood volume.
Patient will have underlying disease process
corrected.
DISSEMINATED INTUVASCULAR COAGULATION (DIC)
Triggering event
4
Activation of extrinsic and intrinsic coagulation cascade
4
Intravascular thrombin produced
4
Increased platelet Fibrinogen converted Inactivation of anti-thrombin
-
aggregation to fibrin by plasmins
4 4
Capillary clotting Thrombin inhibited
J,
Clots lysed
Depletion of clotting factors
P
Secondary activation of the fibrinolytic system
P
Fibrin split products increased
J,
Inability of blood to clot

4
Hemorrhage
4
Hypovolemia
L
Shock
J,
4
DEATH
fibrinogen levels is found only in severe forms.

H E 11P Syndrome Decompensated coagulation occurs with other
complications such as liver hematoma, abruptio
HELLP syndrome is an acute and severe compli-
placenrae, renal failure, and pulmonary edema.
cation that presents as a multi-organic disease
process occurring concurrently with pregnancy- There is usually a low recurrence rate (50/0or less),
induced hypertension (PIH). The initials are and the HELLP syndrome usually resolves with
compiled from the symptoms that comprise the delivery of the baby. Treatment involves prophy-
syndrome: hemolysis, elevated liver enzymes and laxis against postpartum worsening, curettage of
low platelets. These same findings may also be the uterus, and treatment with calcium antagonists
associated with DIC and frequently is diagnosed and decadron, as well as intense monitoring for a
as such. decline in liver function and for potential for
bleeding.
PIH usually occurs after the twentieth week of
gestation in approximately 5% of all pregnancies,
and most often in the primagravida patient. PIH MEDICAL CARE
results in increased edema, proteinuria, and hyper- Laboratory: hematocrit used to assess intravascular
tension. Although the cause is unknown, theories fluid status; protime and partial thromboplastin
often involve immunologic, endocrine, and chori- time used to evaluate clotting; magnesium levels
onic villi exposure. used to evaluate therapeutic levels for treatment;
HELLP may represent an acute autoimmune state urine collection for protein used to diagnose com-
in which the red blood cells lyse, liver enzymes are plications
elevated as a result of fibrin thrombi blocking Magnesium: used to prevent and treat convulsions
blood flow to the liver, and platelets decrease due by decreasing the neuromuscular irritability and
to vasospasm and platelet aggregation. Vasospasm depressing the central nervous system
results in increases in systemic and peripheral vas-
cular resistance, which increase blood pressure Antihypertensives: apresoline is the drug of
further. Sensitivity to angiotensin I1 is increased, choice; used to relax arterioles and stimulate car-
and vasoconstriction may result in increases in vas- diac output and is utilized with diastolic blood
cular permeability and hemoconcentration. pressures greater than 110 mmHg
The pathological changes in the liver may develop Beta-blockers: occasionally used to control acute
due to generalized activation of the intravascular hypertensive crises
coagulation process. Fibrin deposits and hemor- Vdium: used to control seizure activity
rhagic necrosis develops in periportal areas and
may lead to subcapsular hematomas or liver rup-
ture. A decrease in antithrombin I11 and an
NURSING CARE PLANS
increase in thrombin-antithrombin I11 complex
Risk for impairedgas excbaage
(TAT) and the appearance of fibrin monomers [See GI Bleeding]
and D-dimers is found in almost all cases of Related, to: bleeding, disease
HELLP, but decompensated intravascular coagula-
Defining characteristics: decreased P a 0 2 below
tion with increased P T and P T T and decreased
80 mmHg, dyspnea, tachypnea, increased work of
wn CRITICAL CARE NURSING CARE PLANS
~~
breathing, restlessness, irritability, mental status INTERVENTIONS RATIONALE

changes, changes in blood pressure and pulse,
decreased hemoglobin and hematocrit Monitor vital signs every 1-2 Depression of CNS can result in
hours, and prn, especially respi- respiratory insufficiency or paral-
Risk for fluid volume deficit ratory status. ysis. Hypothermia may occur
with toxicity of drug. MgS04
[See GI Bleeding] should he held for respirations
less than 16 per minute.
Related to: blood loss,altered coagulability
Monitor EKG for changes and Dysrhythmias may occur with
Defining characteristics: weight loss, oliguria, dysrhythmias, and treat per hos- administration of magnesium or
abnormal electrolytes, hypotension, tachycardia, pital protocol. with its antidote, calcium.
decreased central venous pressures, altered coagu- Monitor intake and output every Magnesium sulfate may cause
lation studies, lethargy, mental status changes 2 hours. toxicity with large doses and
result in renal insufficiency and
Risk for injury oliguria.
Related to: administration of magnesium Monitor fetal heart tones every Fetal heart rate may decrease
hour. with use of magnesium sulfate.
Defining characteristics: CNS depression, venous
Assess deep tendon reflexes. Absence of DTRs may indicate
irritation, dyspnea, shallow respirations, decreased hyperrnagnesemia and toxicity.
oxygen saturation, oliguria, absence of deep Decreased DTRs may occur with
tendon reflexes, changes in vital signs therapeutic ranges.
Have calcium gluconate at Calcium gluconate is the anti-

Outcome Criteria bedside and give as warranted/ dote for magnesium sulfate.
ordered.
Patient will receive medication without experienc- Monitor labwork for magnesium Normal levels are 4-7.5mEq/L,
ing side effects. levels. with toxic levels above that.
INTERVENTIONS RATIONALES Demonstration
Monitor for convulsions or Identifies precipitation of
tremors. problem.
Administer magnesium sulfate as Magnesium is used to prevent Instruct on signs and symptoms Facilitates prompt identification
ordered. and treat convulsions by decreas- to report to nurselphysician. of problem to allow for timely
ing the neuromuscular irritability intervention.
and depression of the central
Observe IM injection sites for May indicate presence of sterile
nervous system. Normally,
redness, firm areas, warmth, and abscess from injections which
MgSO, is given W,with a load-
pain. have a variable rate of absorption
ing dose of 3-4 Grams, followed
given in this manner.
by an infusion of 1-4 Gramslhr.
It may be given IM with dosage
of 5 Grams in each hip every 4
hours using the 2-tract method.
Some facilities add xylocaine to
the medication to decrease the
pain of IM injections.
HEMATOLOGIC SYSTEM 23 1

Patient will have stable vital signs.
Patient will be free of convulsions.
Fetal heart rates will remain unaffected and
activity will be within normal range.
Patient will exhibit no signs of magnesium toxi-
city or complications from therapy.
HELLP SYNDROME
Pregnancy-induced hypertension
+
DIC
J
Hem01ysis Fibrin thrombi mobilized Platelet adhesion
J, J, J,
Abnormal morphology Decreased blood flow to liver Clumping of platelets

4 J,
Liver congestion Decrease in circulating

J, platelets
Elevated liver enzymes
Increased sensitivity to angiotension 11

4
Vasospasm
J
Vasoconstriction
Increased vascular resistance
J,
Increased arterial blood pressure

J
Increased vascular permeability
J,
Edema
J
Pro teinuria
heart valves or extracorporeal circulation and the

destruction of red blood cells. Anemias can also be
Anemia is a condition in which the red blood cell precipitated by toxic substance exposure or
count, hemoglobin, and hematocrit are decreased. chronic disease processes, such as uremia or
This decrease results in a decrease in the oxygen- chronic liver disease.
carrying capability and causes tissue hypoxia. As
the body tries to compensate, blood is shifted MEDICAL CARE
from areas that have a plentiful amount in tissues Laboratory: CBC to help differentiate type of
that have low oxygen requirements to those areas anemia-RBCs reduced; hemoglobin decreased
that require higher oxygen concentrations, such as with mild considered 10-14 G/dl, moderate 6-10
the heart and brain. G/dl, and severe below 6 G/dl; hematocrit
There are several types of anemias; those that are decreased; M C H , MCHC variable dependent on
due to decreased red blood cell production, those type of anemia; M C V 80-100 fl with normocytic,
that are due to blood loss, and the hemolytic ane- greater than 100 fl with macrocytic, and less than
mias caused from G6PD deficiency, 80 fl with microcytic; platelet count usually
autoimmunity, or physical causes. Microcytic, or decreased, but may be elevated after hemorrhage;
iron deficiency anemia, develops when the trans- RDW increased in iron depletion anemia; B,,
portation of iron by transferrin is insufficient to level decreased, folate decreased; serum iron and
meet requirements of the erythropoietic cells. TIBC may be decreased; stool guaiac may be posi-
Macrocytic, or megaloblastic anemia, occurs tive if blood loss is from GI tract
because of a deficiency in vitamin B,, or folic Radiography: chest x-ray to discern pulmonary or
acid. Pernicious anemia is a type of megaloblastic cardiac complications; upper and lower gastroin-
anemia in which the absence of vitamin B,, as testinal series may be done to identify active or
well as lack of the intrinsic factor is noted. current bleeding
Normocytic, or aplastic anemia, is caused from the
failure of the bone marrow or destruction of bone Bone marrow aspiration: may be performed to
marrow by either chemical or physical means. determine type of anemia
Autoimmune anemia is an acquired condition that Bone marrow transplants: may be required for
involves premature erythrocyte destruction from severe aplastic anemia
the person's own immune system. Hemolytic
anemia results when erythrocyte destruction is Blood transfusions: may be required to replace
increased and cells have a shortened life span. blood volume with hemorrhage
Sickle cell anemia is an inherited condition in
which hemoglobin S is present in the blood result- NURSINC CARE PLANS
ing in sickling and abnormal hemolyzation that
Alteration in tissue perfksion:
obstructs capillary flow. Thalassemia is a group of
inherited anemias that result from faulty produc-
cardiopulmonary, renal, cerebral, gastroin-
testinah peripheral
tion of alpha or beta hemoglobin polypeptides.
Related to: altered oxygen-carrying capability,
Anemia can occur as the direct result of prosthetic
blood loss
~~
Defining characteristics: decreased hematocrit and INTERVENTIONS RATIONALES

hemoglobin, chest pain, palpitations, pallor, dry
mucous membranes, cold intolerance, oliguria, Monitor for complaints of chest May indicate decreased cardiac
nausea, vomiting, abdominal pain, abdominal dis- pain, pressure, palpitations, or perfusion from hypoxia or
dyspnea. ischemia.
tention, increased capillary refill time, confusion,
lethargy, changes in pulse rate and blood pressure Administer blood andlor blood Blood replacement may facilitate
products as warranted. improved oxygen-carrying ability
due to increased number of red
Outcome Criteria blood cells and correct volume
deficiency.
Patient will have adequate perfusion to all body Monitor labwork for changes. May facilitate identification of
systems with stable vital signs and hernodynamics deficiencies and allow for assess-
ment of effectiveness of
treatment.
~~ ~~~ ~~
Monitor vital signs every 1-2 Facilitates identification of Demonstration
hours and prn. changes that may require
intervention. INTERVENTIONS RATIONALES
~~~ ~
Monitor neurological status for May be indicative of impaired

Maintain environment tempera- Reduction of peripheral perfu-
mental confusion or level of con- cerebral perfusion.
ture within normal ranges. sion may result in cold
sciousness changes.
intolerance to vasoconstriction.
Auscultate lung fields for adven- Crackles andlor new presence of Excessive heat may cause vasodi-
titious breath sounds. Auscultate cardiac gallops may indicate lation and further reduce organ
for abnormal heart tones. impending or present congestive perfusion.
failure that may have resulted
Prepare patientlfamily for surgi- May require transplantation of
from the body’s compensatory
cal procedures as warranted. bone marrow, or surgical repair
mechanism of increasing cardiac
for site of bleeding.
ourput. Mild anemia can cause
exertional dyspnea and palpita-
tions; moderate anemia can cause Discharge or Maintenance Evaluation
increased palpitations and dysp-
nea at rest; severe anemia causes Patient will achieve and maintain adequate per-
tachycardia, increased pulse pres- fusion to all body systems.
sure, systolic murmurs,
intermittent claudication, angina, Patient will have stable vital signs and hemody-
congestive heart failure, orthop- namic pressures.
nea, and tachypnea.
Administer supplemental oxygen Decreases in red blood cells Patient will exhibit no evidence of GI bleeding.
as warranted. decreases oxygen carrying capa-
bility since oxygen is bound to
Patient will exhibit no signs of complications of
the hemoglobin for transport, disease or therapy.
and may require supplementa-
tion to maintain oxygenarion. Risk for fluid volume deficit
[See GI Bleeding]
Monitor EKG for changes in Changes may occur with imbal-
cardiac rhythm or conduction. ances of electrolytes, with fluid Related to: bleeding
shifts, or with hypoxia.
Defining characteristics: hypotension, tachycar-
dia, decreased skin turgor, weakness, decreased uri- INTERVENTIONS RATIONALES

nary output, pallor, diaphoresis, decreased
capillary refill, mental changes, restlessness, Instruct on particular rype of Provides knowledge and facili-
anemia that patient has tates compliance.
decreased filling pressures developed.
Activity intolerance Instruct on labwork and other Decreases anxiety and fear of the
[See COPD] procedures. unknown.
Instruct on dietary requirements. Increasing iron sources from red

Related to: decreased oxygen-carrying capability
meat, egg yolks, dried fruits and
Defining characteristics: weakness, lethargy, green leafy vegetables may facili-
tate correction of anemia. Folic
fatigue, dyspnea, activity intolerance, chest pain, acid and vitamin C which aug-
palpitations, tachycardia, decreased oxygen satura- ments iron absorption may be
tion, increased respiratory rate with exertion, found in green vegetables, whole
grains, citrus fruits, and liver.
hypertension
Instruct on signs and symptoms Decreased leukocyte count may
Alteration in nutrition: less than body of which to notify physician. potentiate the risk of infection
requirements and patient should seek
[See DKA] medical assistance for timely
intervention.
Related to: inability to absorb required nutrients Iron or vitamin B,, replacement
Instruct on medications, effects,
for red blood cell production side effects, contraindications, may be necessary for life, and
and avoidance of over-the- knowledge regarding therapeutic
Defining characteristics: weight loss, activity counter medications without management will increase com-
intolerance, dyspnea, fatigue, weakness, loss of physician approval. pliance with treatment and allow
muscle tone, anorexia for prompt identification of
complications that may require
Knowledge deficit changes in dosages, types of'
medication, or schedule of
Related to: lack of information, unfamiliarity with administration.
information, lack of recall, misinterpretation of
information Discharge or Maintenance Evaluation
Defining characteristics: questions, communica- Patient will be able to verbalize and demonstrate
tion of misconceptions, development of understanding of all instructed information.
preventable complications, incorrect follow-up
with instructions
Outcome Criteria
disease process, treatment regimen, and
procedures, and comply with therapy.
ANEMIA
Sickle cell anemia Blood loss, hemolytic destruction/production anemia

s (decreased RBC production, lack of intrinsic factor, etc.)
Presence of HgB S
J
HgB S sensitive to 0 2
Saturation decreases
4
Sickling of cells
4
Capillary blood flow
obstructed
1
I
Decrease of normal hemoglobin concentration
4
Decreased oxygen carrying capability
J
Cellular hypoxia
J
Oxyhemoglobin dissociation curve shifts to the right
4
Increased oxygen removal by tissues
Increased oxygen demand and consumption
Redistribution of blood to areas with higher oxygen demands
J
Hypoxemia
4
Organ dysfunction
4
Organ failure
J
DEATH
RENAL/ENDOCRINE SYSTEMS 237
Acute Renal Failure (ARF)

Diabetic Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK)
Syndrome of Inappropriate A D H Secretion (SIADH)
Diabetes Insipidus (DI)
Pheochromocytoma
Thyrotoxicosis (Thyroid Storm)
Acute Renal Failure (ARF) obstruction anpvhere in the system from the
kidney to the urethra. Some clinical conditions in
Acute renal failure (ARF) is noted when there is a which this type of failure is seen includes urethral
sudden deterioration in function of the renal obstruction, prostatic hypertrophy, bladder carci-
system that may be caused by renal circulation noma, bladder infection, neurogenic bladder, renal
failure or glomerular or tubular dysfunction. The calculi, and abdominal tumors.
build-up of waste materials that accumulates There are three phases in ARF-an oliguric phase,
affects multiple organ systems. a diuretic phase, and a recovery phase. Oliguria
ARF can be subclassified according to the etiology occurs when the tubule obstruction and damage
of condition, such as prerenal, intrarenal, and makes absorption unstable, and BUN, creatinine,
and potassium levels increase. During the diuretic
postrenal. Prerenal conditions occur when blood
phase, tubular function begins to return but the
perfusion is inadequate, such as with hypotension,
hemorrhage, myocardial infarction, congestive patient must be monitored for excessive diuresis
heart failure, pulmonary embolism, burns, third with loss of electrolytes. When diuresis is no
spacing, septic shock, diuretic abuse, or volume longer excessive, the recovery phase begins with
gradual improvement in kidney function for up to
depletion. This dysfunction causes glomerular fil-
one year. There may be a permanent decrease in
tration rates to decrease, and decreased
renal function that, depending on severity, may
reabsorption of sodium in the tubules.
require dialysis.
Intrarenal renal failure occurs either from damage
to the tubular epithelium, known as acute tubular MEDICAL CARE
necrosis (ATN), or from damage to glomeruli and
the small vessels. This condition causes renal capil- Laboratory: CBC- hemoglobin decreased with
lary swelling that decreases the glomerular anemia, RBCs decreased due to fragility, white
filtration rate (GFR), or decreased GFR is blood cell count elevated if sepsis or trauma is pre-
secondary to the obstruction of the glomeruli by cipitating event; BUN and creatinine elevated
edema and cellular debris. ATN is the most with ratio of 10:1; serum osmolality increased
common type of ARF and is the result of nephro- above 285 mOsm/kg; electrolytes used to show
toxins or ischemia. Intrarenal failure may take imbalances, with elevated potassium due to reten-
many weeks to repair damage and is usually seen tion, hemolysis, or acidosis; sodium usually
with trauma, sepsis, DIC, transfusion reactions, increased, but may be normal; bicarbonate, pH,
renal vasculature blockages, heavy metal poison- and calcium decreased; magnesium, phosphorus,
ing, and with use of aminoglycosides, penicillins, and chloride increased; complement studies may
tetracylines, dilantin, and amphotericin. be used to identify lupus nephritis; serum
Glomeruli damage is seen with acute electrophoresis may be used to identify abnormal
glomerulonephritis, polyarteritis nodosa, lupus proteins that may damage kidneys permanently;
erythematosus, Goodpasture’s syndrome, A S 0 titer may be used to diagnose recent strepto-
endocarditis, abruptio placentae, abortion, serum coccal infection that could cause poststreptococcal
sickness, malignant hypertension, or hemolytic glomerulonephritis; UA: Urine color is dirty, tea-
uremic syndromes. colored brown, volume is less than 400 cc/day,
specific gravity less than 1.020 indicates renal dis-
Postrenal failure may occur as a result of an ease and fixed at 1.O 10 indicates severe renal
damage; p H greater than 7.0 seen with UTI,

ATN, and chronic renal failure; osmolality less NURSING CARE PUINS
than 350 mOsmlkg indicates tubular damage; cre- Fluid volume excess
atinine clearance decreased; sodium decreased but
Related to: impairment of renal system regulation,
may be greater than 40 mEq/L if kidney does not
reabsorb sodium; RBCs may be present if infec- retention of water
tion, renal stones, trauma, or tumor is cause; Defining characteristics: oliguria, anuria, changes
protein of 3 or 4+ indicates glomerular damage, in urine specific gravity, intake greater than
1+ or 2+ may indicate infection or interstitial output, weight gain, elevated blood pressure,
nephritis; casts indicate renal disease or infection, edema, ascites, increased central venous pressure,
brownish casts and numerous epithelia1 cells indi- neck vein distention, dyspnea, orthopnea, crackles,
cate ATN, and red casts indicate acute glomerular muffled heart tones, decreased hemoglobin and
nephritis hematocrit, altered electrolytes, increased filling
Electrocardiogram: used to identify dysrhythmias pressures, restlessness, anxiety, water intoxication
and cardiac changes that may occur with acid-base
imbalances or electrolyte imbalance Outcome Criteria
Radiography: KUB to identify size of structures, Patient will have balanced intake and output,
cysts, tumors, stones, or abnormal kidney stable weight, stable vital signs and hemodynamic
location; chest x-ray to identify fluid overload that parameters, and have effective dialysis when
may occur with fluid shifts required.
Radionuclide imaging: may be used to identify
hydronephrosis, calicectasis, or delayed filling or
emptying, or other causes of AW INTERVENTIONS RATIONALES
Retrograde pyelogram: may be used to identify Monitor vital signs and hemody- Hypertension with increases in
abnormalities of ureters or renal pelvis namic parameters every 1-2 heart rate may occur when kid-
hours. neys fail to excrete urine,
Renal arteriogram: may be used to identify changes occur within the renin-
angiotensin cascade, or with fluid
extravascular irregularities or masses, and provides resuscitation. Hemodynamic
visualization of renal circulation pressures can facilitate
identification of changes with
Magnetic resonance imaging: may be used to intravascular volume.
evaluate soft tissue
Monitor intake and output every Facilitates identification of fluid
CT scans: may be used to detect presence of renal 2 hours and prn, noting balance requirements based on renal
or imbalance per 24 hour period. function. Insensible losses can
d’isease Estimate insensible losses add up to 800- 1000 cc/day and
through lungs, skin, and bowel. metabolism of carbohydrates can
Dialysis: emergency and chronic dialysis may be liberate up to 350 cdday of fluid
required for ARF; ultrafiltration and CAVH may from ingested foods.
also be utilized
Weigh daily. Changes in body weight help to
Surgery: may be required for renal calculi identify fluid status. Gains over 1
poundlday indicate fluid reten-
removal, resection of the prostate, or placement of
fistula for long-term dialysis
RENWENDOCRINE SYSTEMS 24 1
tion. Fluid amounts of 500 cc Hyperkalemia may occur as body

are equivalent to 1 pound. attempts to correct acidosis,
hypernatremia may indicate total
Auscultate lungs for adventitious Adventitious breath sounds, such body water deficit, and hypona-
breath sounds. as crackles, will be heard with
tremia may result from fluid
development of pulmonary overloading or inability to con-
edema or congestive heart failure. serve sodium. BUN/crearinine
Measure urine specific gravity, Specific gravig is less than 1.010 ratio, which is normally 10: 1 is
and note changes in character of in intrarenal failure and signifies greater than 20:l with prerenal
urine output. inability to appropriately concen- failure.
trate the urine. Monitor urine specimen labwork Urine sodium less than 20
Administer fluids as warranted Prerenal failure is treated with for changes. mEq/L, osmolality above 450
with restrictions per physician fluid replacement, occasionally mOsm/kg, and urine creatinine
orders. with use of vasopcessors. above 40 indicates prerenal fail-
Management of fluids is based ure. Urine sodium above 40
on replacement of output from mEqlL, osmolality below 350
all sources. mOsm/kg, and urine creatinine
below 20 indicates ATN.
Administer diuretics as ordered. May be given to convert oliguric
phase to nonoliguric phase, to
flush debris from tubules, Information, Instruction,
decreased hyperkalemia, or foster Demonstration
improved urine output. ~_______
'Ihsert Foky catheter as Catheterization eliminates poten- INTERVENTIONS RATIONALES

warranted. tial lower GU tract obstruction
and provides for accuracy of Identify and correct any Improvement of perfusion,
measurement of urine output, reversible reason for ARE enhancing cardiac output and
but may not be treatment of hemodynamics, or removal of
choice due to potential for infec- obstruction may facilitate recov-
tion. ery from ARF and limit residud
effects.
Observe for presence and charac- Dependent edema may be pre-
ter of edema. sent, but pitting edema may not Obtain chest x-rays and compare May be used to identify increas-
be discernable until the patient with previous films. ing cardiac silhouette, effusions,
has more than 10 pounds of infiltrates, pulmonary edema, or
fluid in body. Periorbital edema other complications that may
may be the first clinical evidence occur with fluid overload.
of edema and indication of fluid
shifting. Administer antihypertensives as May be required to treat hyper-
warrantedlordered. tension that occurs from
Monitor for mental status May indicate impending hypoxic decreased renal perfusion or fluid
changes. state, electrolyte imbalances, overload.
acidosis, or sepsis.
Instruct patient/family on neces- Promotes understanding and
Monitor arterial blood gases. May indicate presence of acidosis sity for fluid restriction. facilitates compliance.
and facilitate intervention for
hypoxemia. Prepare patientlfamily for dialysis Dialysis may be required to
treatment as warranted. remove toxic wastes and to cor-
Monitor labwork for alterations. Electrolyte imbalances may occur rect electrolyte, acid-base, and
from impaired sodium reabsorp- fluid imbalances.
tion, fluid overload, or lack of
excretion of potassium.
. Patient will achieve and maintain urinary losses without adequate replace-
ment may lead to hypovolemia
output within normal limits for character and and shock.
amount.
Measure intake and output every Facilitates identification of fluid
Patient will have stable weight, vital signs, and 1-2 hours, or prn, including loss and replacement require-
insensible fluid losses. Compare ments.
hemodynamic parameters.
for balance at least every 24
Patient will exhibit no respiratory dysfunction hours.
and have normal arterial blood gases. Supply allowed amounts of fluid Lack of fluid intake maintenance
throughout the day ensuring that may predispose nocturnal dehy-
Patient/family will be able to verbalize all fluids are counted. dration.
understanding of instructions and comply with Administer IV fluids as ordered. May requite intermittent
treatment. fluid boluses to challenge fluid
shifting.
Patient will have no signs of edema.
* Patient will tolerate dialysis procedure without Discharge or Maintenance Evaluation
complications.
Patient will have stable weight.
Risk f i r fluid volume deficit Patient will have equivalent intake and output.
Related to: fluid loss, diuretic phase
Defining characteristics: weight loss, output namic parameters.
greater than intake, hypotension, tachycardia,
Patient will have urine output within normal
decreased central venous pressure, decreased
limits.
hemodynamic pressures, increased temperature,
dilute urine with low specific gravity, oliguria with * Patient will have normal neurological status.
high specific gravity, weakness, stupor, lethargy
Alteration in tissue perfision: renal,
cardio ulmonary, cerebral, gastrointestinal,
Outcome Criteria R
perip eral
Patient will exhibit equivalent intake and output, Related to: fluid shifts, renal obstruction, impair-
have stable vital signs and weight, and will have ment of renal function, septic shock, trauma,
urine output within acceptable levels. burns, uremia
Defining characteristics: oliguria, anuria, dehydra-
tion, hypotension, abnormal vital signs, abnormal
blood gases, abnormal electrolytes, mental status
Monitor vital signs and hemody- Hypovolemia may result in
namic pressures. hypotension and tachycardia.
changes, lethargy, nausea, vomiting, skin changes
Observe for complaints of thirst, May indicate presence of dehy-

dry mucous membranes, poor dration. When extracellular fluid Outcome Criteria
skin turgor, or lethargy. or sodium is depleted, the thirst
center is activated. Continued Patient will have adequate perfusion to all body
systems.
RENAL/ENDOCRINE SYSTEMS ~ , 243
INTERVENTIONS RATIONALES INTERWNTIONS RATIONALES

Monitor vital signs and hemody- Hypertension and fluid volume Monitor intake and output every Oliguria, with output less than
narnic parameters. increases may increase cardiac 1-2 hours and prn. Measure spe- 400 cclday, and anuria, or no
workload, increase myocardial cific gravity and note changes in output, may be seen with fluid
oxygen demand, and possibly character of urine. volume excess or decreased per-
lead to cardiac failure. Blood fusion states. Decreases in
pressure below 70 mmHg inter- urinary output that do not
feres with autoregulatory respond to fluid challenges cause
mechanisms. renal vasoconstriction and
decryased perfusion from
Monitor EKG for dysrhythmias Renal failure and electrolyte increased renin secretion.
or changes in cardiac rhythm, imbalances may predispose
and treat appropriately. patient to dysrhythmias and con- Monitor labwork for electrolyte May have hyperkalemia in olig-
duction problems. Hypokalemia changes. uric phase changing to
may be reflected with flat T hypokalemia with diuretic phase.
wave, peaked P wave, and some- Potassium levels above 6.5
times the presence of a U wave. rnEqlL should be treated as a
Hyperkalemia may be reflected medical emergency.
with peaked T wave, widened Hypocalcemia produces adverse
QRS complex, increased PR cardiac effects and potentiates
interval, and flattened P wave. potassium. Hypermagnesemia
Hypocalcemia may be may occur with use of antacids
manifested with QT prolonga- and cause neuromuscular dys-
tion. Treatment of function, or cardiac or
potentially-lethal cardiac dys- respiratory arrest.
rhythmias may prevent death
from complication of renal fail- Maintain oximetry of at least Facilitates oxygenation of tissues
ure. 90% by using supplemental in the presence of decreased per-
oxygen. fusion and increased workload.
Monitor neurological status for Decreased perfusion may result
changes in mentation or level of in cerebral perfusion decreases Monitor arterial blood gases. Facilitates measurement of actual
consciousness. resulting in lethargy, weakness, oxygen levels and identifies acid-
and stupor or from uremic syn- base disturbances that may
require further intervention.
drome.
Administer inotropic agents as May be required to improve car-
Monitor for peripheral pulse Pallor may be present with vaso-
constriction or anemia, and skin ordered. diac output, increase myocardial
presence and character, skin
may be cyanotic or mottled with contractility, and improve perfu-
color, appearance of mucous
sion.
membranes, turgor, capillary pulmonary edema or cardiac
refill time. failure. Administer glucoselinsulin com- May be used as temporary emer-
Fluid overload and decreased bination as ordered. gent treatment to decrease serum
Auscultate for breath sounds and
potassium by shifting potassium
heart tones, and notify physician p e r h i o n may result in develop-
into the cells.
of abnormalities. ment of S, or S4 gallops, and
pericardial friction rub may indi- Administer polystyrene sulfonate May be used to lower serum
cate the presence of uremic as ordered. potassium by exchanging
pericarditis. sodium for potassium in the GI
tract. Solutions that also contain
Monitor for complaints of May indicate impairment of neu-
sorbitol may also decrease potas-
numbness, paresthesias, muscle romuscular activity,
sium levels by osmotic diarrhea.
cramps, tremors, twitching, or hypocalcemia, and potential for
hyperreflexia. decreased cardiac perfusion and Administer mannitol as ordered. May be used with muscle trauma
function. for osmotic diuresis, but should

not be given repeatedly if Patient will achieve normalized perfusion of all
response is not achieved due to
accumulations of hyperosmolar
body systems.
compounds that may result in
Patient will have no long-term effects from per-
further renal damage and
decreased perfusion. fusion impairment.
Patient will have normal urine output with no
Information, Instruction, symptoms or signs of ARF.
Demonstration
INTERVENTIONS RATIONALES namic pressures.
Prepare patiendfamily for dialysis
as warranted.
Dialysis may be required to
remove toxins and excess fluids
. Patient will have balanced intake and output
with stable weight.
from body and maintain life
until kidney function is restored. Patient will have precipitating illness
Instruct on specifics of peritoneal Peritonea1 dialysis, or PD, may stabilized/resolved.
dialysis. be intermittent, continuous
ambulatory peritonea dialysis Alteration in nutrition: less than body
(CAPD), or continuous cycling requirements
peritoneal dialysis for use
overnight. With PD, the peri- Related to: dietary restrictions, hypercatabolic
toneum becomes the dialyzing state
membrane with dialysate solu-
tion infused into the peritonea Defining characteristics: elevated BUN and crea-
cavity, allowed to remain there
for 30 minutes and then
tinine levels, anorexia, nausea, vomiting, distorted
siphoned out through a closed taste perception, fatigue, weakness, loss of weight
system. The duration of this dial- (dietary restriction), weight gain (non-compliance
ysis depends on the severity of with fluid restriction), pain, depression, lethargy,
the renal condition and propor-
tions of the patient. Peritonitis oral mucosal lesions
may occur and antibiotics may
be added to the dialysate
prophylactically.
Outcome Criteria
Instruct on specifics of Hemodialysis, or HD, may be Patient will achieve and maintain nutritional
hemodialysis. used for chronic renal failure
requirements and stable weight.
patients as well as acute renal
failure patients who require
short-term dialysis. Blood passes
through a semipermeable mem- INTERVENTIONS RATIONALES
brane or kidney, to the dialysate
fluid where toxic substances Determine patient’s dietary Identifies nutritional deficiencies,
move from the blood to the habits and intake. Perform calo- non-compliance with
dialysate solution and are then rie count. restrictions, and metabolic
discarded. Requires circulatory requirements.
access, ind takes 3-4 hours 3
Provide several small meals rather Decreases nausea that may occur
times per week. Complications
than 3 large ones. because of diminished peristalsis.
may include infection, bleeding,
or obstruction of vascular access.

Smaller meals may not be as Patient will achieve and maintain desired
overwhelming and may facilitate
weight.
compliance with restrictions.
Give patient high caloric, low Protein requirements for renal Patient will be able to tolerate diet without
protein, low potassium, low failure patients are much less nausea/vomiting.
sodium diet as ordered. than normal to compensate for
their impaired renal function. Patient will exhibit no evidence of mucosal
Increased carbohydrates satisfy lesions in mouth.
energy requirements while
restricting catabolism and pre- Patient will adhere to dietary restrictions.
venting acid formation from
protein and fat metabolism. Patient will comply with medical regimen and
Restriction of potassium, supplementation.
sodium, and phosphorus may be
required to prevent further renal Risk f i r infiction
damage.
Assist withlencourage frequent Reduces distaste and freshens

Related to: renal failure, uremia, debilitation,
oral care. oral mucosa that may be septic shock, invasive procedures and lines, malnu-
inflamed. trition, impaired immune system
Weigh daily. Patient may lose up to 1 pound Defining characteristics: increased white blood
per day during NPO status.
cell count, shift to the left, BUN greater than 100
Administer vitaminslminerals as Patient may have iron deficiency mg/dl, history of repeated infections, fever, chills,
ordered. secondary to protein restriction,
anemia, or impaired GI function
cough with or without sputum production,
and need supplemental iron. wound drainage, hypotension, tachycardia,
Calcium may be given to replace impaired skin integrity, wounds, positive blood,
levels and facilitate coagulation urine, or sputum cultures, cloudy concentrated
and metabolism of bone.
Vitamin B complexes are urine
required to maintain cell growth.
Outcome Criteria
Demonstration Patient will exhibit no signs or symptoms of
infection.
Instruct patientlfamily member Protein and electrolytes are
on renal diet. adjusted to prevent uremia and INTERVENTIONS RATIONALES
electrolyte imbalances.
Instruction provides knowledge
and may facilitate compliance. Monitor vital signs and hernody- Systemic vascular resistance
namic pressures. decreases, cardiac output inirially
Consult dietician andor other May be helphl to discuss choices increases, blood pressure
dietary resources. for meals, replacements for foods decreases, and patient has tachy-
previously enjoyed but now cardia, tachypnea, and
restricted, and to allow patient hypertherrnia with warm flushed
some measure of control over his skin in early stages of septic
situation. shock.
Obtain urine culture. Urinary tract infections may be differential. potential for infection. C B C
asymptomatic initially. will identify presence of infec-
tion, and will be helpful to
Avoid insertion of invasive lines, Decreases potential of bacteria monitor therapeutic response to
catheters, and procedures when- gaining entrance to body and antimicrobials.
ever possible. Use aseptidsterile prevents risk of cross-contamina-
technique for changing IV sites, tion.
dressing changes, or caring for
catheters.
Patient will be free of infection.
Observe wounds for drainage, Allows for identification of detri-
noting changes in amount, color, mental changes in wound status Patient will be able to verbalize understanding
and character. Change IV sites and facilitates timely interven-
of instructions to prevent infection
per hospital protocol. tion. Early detection of infection
may preclude the development of complications.
septicemia.
Patient will not develop septic shock.
Observe P D return fluid for May indicate presence of peri-
cloudiness. tonitis from perforation or loss of Risk for impaired skin integrity
albumin.
Related to: uremia, malnutrition, immobility
Maintain adequate nutrition. Facilitates healing and body
metabolism. Defining characteristics: dry skin, edema,
Utilize appropriate isolation Prevents cross-contamination presence of wounds, presence of invasive
techniques when warranted. and minimizes patient’s risk of lines/grafts/fistulas, uremic frost, bruising,
secondary infection. erythema, pruritus, changes in skin texture and
Reposition patient every 2 hours, Decreases potential for atelectasis thickness
and encourage coughing and and facilitates mobilizing secre-
deep breathing. tions to avoid respiratory
infection. Outcome Criteria
Obtain cultures as ordered. Facilitates identification of Patient will maintain skin integrity or will have
causative organism and allows
for appropriate antimicrobial wound healing in a timely manner.
treatment.
Administer antimicrobials as May be required to combat

ordered. infection. INTERVENTIONS RATIONALES
Observe skin for wounds, pres- Prompt identification allows for
Information, Instruction, sure areas, abrasions, drainage, timely intervention.
Demonstration redness, rashes.
Bathe patient daily using oil in Removes waste products from

INTERVENTIONS RATIONALES bath, and scant soap. Provide skin while keeping skin supple
skin care with lotion or creams. and moist.
Instruct patient to avoid scratch- May precipitate infection and
ing and to maintain skin worsen renal dysfunction. Administer antipruritic drugs as Persistent itching may cause
integrity. ordered. patient to scratch body to the
point of bleeding and medication
Monitor labwork, especially BUN should be maintained
will help allay strong urge to
BUN and creatinine, CBC, and lower than 100 mgldl to decrease
scratch. Open areas of skin are Monitor for presence of acidosis. Acidosis may interfere with
more susceptible to infection. absorption of some drugs.
Reposition every 2 hours, Avoid Decreases potential for skin Ensure that nephrotoxic drugs Nephrotoxics will further impair
constricting garments. breakdown. are utilized only when absolutely renal failure.
necessary.
Discharge or Maintenance Evaluation Monitor patient for signs and Excretion of drugs may be hin-
symptoms of drug toxicity, and dered by renal failure and result
Patient will have clean, dry, intact skin. obtain serum drug levels for spe- in toxic levels with normally safe
cific drugs in use. dosages.
Patient will be free of itching.
Patient will have no signs/symptoms of Demonstration
infection.
Patient will have timely wound healing with no
complications. Instruct patient on all medica- Facilitates knowledge and
tions being taken, with increases compliance.
Risk for injury symptoms to be reported.
Give reduced drug dosages with Decreases potential for toxic

Related to: altered metabolism and excretion of longer time intervals between reaction to dosage with impaired
medications, kidney failure doses. excretion and metabolism.
Defining characteristics: decreased cardiac output

states, acidosis, decreased protein binding, Discharge or Maintenance Evaluation
presence of uremia, competition for binding sites,
decreased body stores of fat, decreased GI motility, Patient will comply and tolerate therapeutic reg-
changes in gastric pH, electrolyte imbalances, imen with no adverse drug effects noted.
decreased protein binding, present renal failure Patient will have serum drug levels within thera-
peutic ranges.
Outcome Criteria
Patient will exhibit no signs of toxicity to drugs.
Patient will be able to tolerate all pharmacological Patient will have stable renal function.
agents without adverse effects on renal or other
body systems. Patient will be able to verbalize understanding
of all instructions and be able to identify med-
ications being taken.
Altered oral mucous membrane
Determine methods of action Facilitates understanding of how
and excretion of all drugs being uremia may affect drug effects. Related to: uremia, restriction on fluids, lesions,
taken, as well as interactions Conditions that reduce renal thrush
among them. perfusion limits the amount of
drug that the kidney is exposed Defining characteristics: dry mouth, dry mucous
to and decreases the amount of membranes, taste distortion, presence of lesions,
metabolism or excretion of the inflammation, white patches on mucosa, coated
drug.
tongue, stomatitis, gingivitis
Outcome Criteria Defining characteristics: lack of energy, inability

to maintain normal activities, lethargy, disinterest
Patient will have moist mucous membranes and be
free of oral lesions and inflammation. Anxiety
[See MII
INTERVENTIONS RATIONALES threat to role functioning, threat to body image
Observe mouth and oral cavity a t Facilitates identification of prob- Defining characteristics: restlessness, insomnia,
least every shift, noting lesions, lem to permit prompt treatment anorexia, increased respirations, heart rate, and/or
redness, drainage, vesicles, lacera- and resolution.
tions, or ulcers.
blood pressure, dry mouth, poor eye contact,
decreased energy, irritability, crying, feelings of
Differentiate inflammation of the Thrush is initially identified as
helplessness
mucosa from thrush, and admin- white patches o n the tongue and
rsrer nystarin suspension as mucosa, and occurs frequently in
ordered. the presence of multiple antimi-
crobial agents as a fungal growth.
Nystatin is the drug of choice for
thrush.
Provide oral care at least every 2 Removes build-up of debris,

hours, with peroxide rinses or moistens mouth, and decreases
normal saline as ordered. bad taste.
Use ropical anesthetics as Viscous xylocaine or

ordered. Chloraseptic may be used to
anesthetize mucosal pain
receptors.

0 Patient will be free of oral mucosal lesions and
pain.
Patient will exhibit no evidence of inflammation
or infection to mouth.
Patient will be able to swallow without discom-
fort.
Patient will have no taste distortion and will be
able to ingest adequate nutrition.
Fatigue
[See DKA]
Related to: anemia, restriction on diet, increased
metabolic needs
ACUTE RENAL FAILURE (ARF)
Decreased renal perfusion Damage to nephrons Glomerular inflammation Obstruction
Decreased GFR
4
Decreased fluid Decreased secretion Increased pulmonary Production of uremic

excretion of erythropoietin capillary permeability toxins
4 4 4 4
Increased sodium Decreased RBCs via Left ventricular Urea decomposition

resorption dialysis or GI tract dysfunction via GI tract
4 4 4 4
Fluid overload Interference with folic Attempts to compensate Ammonia formed

acid utilization for acidosis
4 4 4 4
Increased BP Platelet dysfunction Increased respiratory Small ulcerations
Increased hydrostatic rate and depth formed
pressures
4 4 4
Decreased neutrophil Metabolic acidosis Calcium and
phagocytosis phosphorus deposited
on skin and increased
capillary fragility
4 4 4 4
Right
- ventricular Anemia and coagulopathy Hypoxemia Uremic encephalopathy
dysfunction
I I
I
Hypoxemia
4
Organ dysfunction
4
4
DEATH
RENAL,/ENDOCRINE SYSTEMS 25 1
Diabetic Ketoacidosis dehydration is severe and renal perfusion is

decreased; urinalysis will show positive for glucose
(D K I U and acetone, specific gravity and osmolality may
c
be elevated; hemoglobin A1 helps to differenti-
Diabetic ketoacidosis, or DKA, is a critical emer- ate whether episode is due to poor control of DM
gency state that is caused by a deficiency of insulin over previous few months or whether episode is
in patients with insulin-dependent diabetes melli- incident-related; hematocrit may be elevated with
tus. This deficiency can be caused by physiological dehydration; elevation of WBCs may occur in
causes, or by failure to take an adequate amount response to hemoconcentration or to stress; cul-
of insulin, and results in hyperglycemia, ketonuria, tures may be helpful to discern potential cause of
metabolic acidosis, and dehydration. Precipitating infection which may be precipitating factor
causes include failure to take an adequare amount Arterial blood gases: p H will be less than 7.3,
of insulin on a daily basis or failure to increase and bicarbonate levels will be decreased, usually less
compensate for acute infection processes, surgery, than 15 mEq/L
trauma, pregnancy, or other acute stress events.
Early symptoms include polyuria, polydipsia, Electrocardiogram: may show changes associated
fatigue, drowsiness, headache, muscle cramps and with electrolyte imbalances, especially
nausea/vomiting. Later symptoms, such as hyperkalemia, with peaked T waves
Kussmaul breathing, sweet, fruity breath odor,
hypotension, and weak and thready pulses will NURSING CARE PLANS
precede stupor and coma.
Fluid volume deficit
Treatment is aimed at correction of the acidotic
Related to: hyperglycemic-induced osmotic diure-
state, hyperglycemia, hyperosmolality,
sis, vomiting, inadequate oral intake
hypovolemia, and potassium deficits, in conjunc-
tion with treatment of the underlying cause of the Defining characteristics: dry mucous membranes,
problem. decreased skin turgor, thirst, hypotension, ortho-
static changes, tachycardia, weak and thready
MEDICAL CARE pulse, weight loss, intake less than output,
increased urinary output, dilute urine
Laboratory: serum glucose level is increased above
300 mg/dl and may be greater than 1000 mg/dl;
serum acetone positive; lipids and cholesterol
Outcome Criteria
levels elevated; osmolality increased but normally Patient will have stable vital signs, adequate skin
less than 330 mOsm/L; potassium initially normal turgor, intake and output equivalent, and
or elevated due to cellular shifting, then later electrolyte levels within acceptable ranges.
decreased; sodium may be decreased, normal, or
elevated; phosphorus is often decreased; amylase
can be elevated if pancreatitis is precipitating INTERVENTIONS RATIONALES
cause; serum insulin may be decreased in type I
Monitor vital signs, especially Tachycardia and hypotension are
DM or normal to high in type I1 suggesting that noting respiratory status changes classic symptoms of hypovolemia.
there is improper utilization of insulin or that or alterations in blood pressure. When systolic BP drops more than
insulin resistance may have developed secondary
to antibody formation; BUN may be elevated if

10 rnrnHg when position is vated initially in response to the
changed may indicate severity of acidosis, but with diuresis, a
hypovolemic state. Kussmauli hypokalemic state will ensue.
respirations may be present Sodium may be decreased with
depending on degree of hyper- shifting of fluids, and high
glycemia, and respiratory changes sodium levels may indicate either
may occur as the lungs attempt a severe fluid loss or sodium
to remove acids by creating a reabsorption in response to
compensatory respiratory alkalo- aldosterone secretion.
sis. Fever, in conjunction with
Administer electrolyte replace- Phosphate replacement may help
flushed, dry skin, may indicate
ments as per hospital policy/ with plasma buffering capacity,
dehydration.
doctor’s orders. but excessive replacement can
Monitor intake and output every Facilitates measurement and cause hypocalcemia. Potassium
2-4 hours. effectiveness of volume replace- supplementation is usually done
ment and adequate circulating as soon as urinary output is ade-
fluid volume. quate to prevent hypokalemic
states. As insulin replacement
Administer IV fluids per hospital Amounts and solution types may occurs and acidosis is corrected,
protocol, usually at least 2-3 vary based upon the degree of hypokalemia usually occurs.
L/day, and usually initially, 3+ L. dehydration and patient status.
Usual solutions of normal or Assess patient’s mental status and Mental status changes can occur
half-normal saline with or with- observe for significant changes in with exceedingly high or low
out dextrose are used, as well as status. glucose levels, electrolyte imbal-
occasional use of plasma ances, acidotic states, hypoxia, or
expanders depending on unsuc- with decreases in cerebral perfu-
cessful fluid rehydration. sion pressure.
Weigh every day. Assesses fluid status,

Observe for complaints of Gastric motility may be affected
nausedvomiting, abdominal by fluid deficits, and vomiting or Demonstration
bloating, or distention. other gastric losses may potenti- ~~
ate fluid and electrolyte INTERVENTIONS RATIONALES

imbalances.
Instruct patient/family members Provides information and pro-
Auscultate lungs for crackles, and Congestive heart failure or circu- regarding signs/symptoms of motes more timely identification
assess patient for presence of latory overload may occur with hyperglycemia. of complications.
edema, or bounding pulses. rapid rehydration.
Instruct in seeking medical atten- Infection may predispose the
Insert catheter per hospital Provides for more accurate assess- tion for infective processes or patient to fever and a hypermeta-
policy ment of output, especially if illness that may deplete circulat- bolic state which may increase
urinary retention or incontinence ing volume. volume depletion.
is present.
Monitor laboratory tests for Hematocrit may be elevated Discharge or Maintenance Evaluation
BUN and creatinine, serum because of hemoconcentration
osmolality, hematocrit, and following osmotic diuresis. Patient will have vital signs and hernodynamic
electrolytes. Dehydration may result in cellu- parameters within acceptable ranges.
lar destruction and may result in
renal insufficiency. Dehydration Patient will have normal skin turgor with ade-
will result in elevated osmolality.
Potassium levels are usually ele-
quate output.
RENAUENDOCRINE SYSTEMS 253-
9 Patient will have electrolytes and glucose levels INTERVENTIONS RATIONALES

within normal ranges.
may not show normal signs of
Alteration in nutrition: less than body hypoglycemia due in part to
their diminished response to IOW
requirements glucose levels.
Related to: insulin deficiency, excessive amounts Administer regular insulin, either Subcutaneous route may be an
of epinephrine, growth hormone, and cortisol, by continuous infusion after an option if the patient’s peripherd
IV bolus dose has been given, by perfusion is adequate but the
increased protein-fat metabolism, decreased oral
intramuscular injections every 1- response will not be as rapid as
intake, nausea, vomiting, altered mental status, 2 hours, or by subcutaneous with IV administration. Regular
infection injection. insulin is rapid acting and will
assist in movement of glucose
Defining characteristics: weakness, fatigue, into cells. The continuous IV
increased levels of glucose and ketones, weight loss method is normally preferred
because it oprimizes transition to
in spite of polyphagia, lack of adequate food
carbohydrate metabolism, and
intake, glycosuria helps to reduce hypoglycemia.
Normally, the infusion rate is
5-10 Unidhr until glucose
Outcome Criteria levels decrease within a stated
parameter. Another goal of IV
Patient will be able to have intake of appropriate administration of insulin is to
amounts and types of calories and nutrients, and decrease the acidosis.
have glucose levels within acceptable range for Monitor serum glucose every Blood glucose levels will decrease
patient. hour while on insulin IV with insulin therapy usually in
infusion, and notify MD per increments of 75 to 100
parameters of when blood glu- mg/dl/hr. Once the blood sugar
__ ~~~
cose has dropped to 250 mgldl. has dropped to 250 mg/dl, and
INTERVENTIONS RATIONALES depending upon the degree of
acidosis that is present, dextrose
Obtain weight every day. Facilitates assessment of nutri-
is added to the IV infusion, and
tional utilization and fluid shifts.
the insulin infusion should be
Provide high-nutrient liquids as Provides nutrition and helps stopped to prevent hypoglycemic
soon as patient is able to tolerate restore bowel function. episodes.
oral intake, with progression to Prevents recurrence of ketosis
Administer subcutaneous insulin
solid food as tolerated. and rebound hyperglycemia.
1-2 hours before stopping the
Auscultate bowel sounds every Elevated glucose levels can cause continuous insulin infusion.
4-8 hours, and observe for altered electrolyte levels and both
Administer IV solutions contain- Dextrose solutions are usually
abdominal distention or pain. may decrease gastric function.
ing dextrose as ordered. added after the blood glucose
DKA may also mimic an acute levels have decreased to 250
surgical abdomen.
mg/dl in order to avoid hypo-
Monitor for changes in level of When carbohydrate metabolism glycemia.
consciousness, cool or clammy begins and blood glucose level May be used to treat symptoms
Administer Reglan IV or PO as
skin, tachycardia, extreme decreases, hypoglycemia can related to neuropathies that
ordered by physician.
hunger, anxiety, headache, light- occur. Comatose patients may affect the GI tract, and facllitate
headedness, tremors, or not exhibit any noticeable oral intake and nutrient
irritability. change in mentation status and absorption.
should be monitored closely.
Long-standing diabetic patients
~
CRITICAL CARE NURSING CARE PLANS
Information, Instruction, Impaired gas exchange

Demonstration Related to: accumulation of ketones and acids sec-
INTERVENTIONS RATIONALES ondary to insulin deficiencies and excessive
production of stress hormones
Instruct patientlfamily member Complex carbohydrates decrease
in dietary management, with the amounts of insulin needs,
Defining characteristics: acid-base imbalances,
ideal amounts ofGO% carbohy- reduce serum cholesterol, and
drates, 20% fats, and 20% help to satiate patient. Food acetone breath, tachypnea, Kussmaul respirations,
proteins to be divided in desig- should be scheduled for peak serum and urine ketones present, decreased pH,
nated number of meals and effects with insulin as well as decreased bicarbonate levels, hyperkalernia,
snacks. patient preference. Snacks are
important to prevent Somogyi
decreased level of consciousness, confusion
responses and hypoglycemia
during sleep.
Outcome Criteria
Obtain consult with dietician. Assists in facilitating adjustments
to diet for patient's special needs, Patient will have normalized acid-base balance
and can facilitate development of with stable vital signs and mentation level.
workable meal plans.
Instrucr in correct procedure for Monitoring blood glucose levels

fingerstick glucose testing, with is more accurate than urine glu-
return demonstration as needed. cose testing, and can facilitate
identification of alterations in Monitor respiratory status for Acetone breath is due co break-
levels of glucose to promote changes in rate, rhythm and down of aceroacetic acids. The
tighter control of varying glucose depth, and for presence of ace- lungs remove carbonic acid
levelslinsulin usage. tone smell on breath. through respiration process, and
may produce a cornpensacory
Ensure that at least 50 cc of soh- Promotes saturation of binding respiratory alkalosis for ketoaa-
'tion is flushed through the sites on plastic tubing to decrease dosis. Increased work of
tubing prior to connection to incidence of insulin adhering to breathing may indicate that the
patient when intravenous insulin tubing rather than staying in patient is losing the ability to
drips are utilized. solution. compensate for the severe acido-
sis or respiratory fatigue.
Monitor for changes in neurolog- Acidosis, hypoxia, or decreased
Patient will have normalized blood glucose ical status. cerebral perfusion may cause
changes in mentation.
levels within their own special parameters. Impairment in consciousness
may predispose the patient to
Patient will be able to ingest oral food of suffi- aspiration and its complications.
cient amounts and nutrients to maintain and
Administer IV fluids and insulin Promote correction of acidosis
stabilize weight.
as ordered. with DKA.
Patient will be free of ketosis. Administer sodium bicarbonate, Current recommendations are
if ordered, for severe acidosis for use only where pH is 7.1 or
Patiendfamily member will be able to verbalize only. below because excessive use of
understanding of instructions and able to pro- sodium bicarbonate may induce
vide acceptable return demonstration of hypokalernia as well as alcer che
oxygen dissociation curve causing
procedure. prolongation of the comatose
state.
~
~~ ~~ _ _ _ ~

Monitor labwork for May occur as acidosis and bronchitis or pneumonia, either
hypokalemia. volume deficits are corrected. of which may be the precipitat-
ing cause of the DKA. Crackles
Administer supplemental oxygen Provides needed oxygen espe- may indicate fluid overload or
as necessary per hospital proto- cially in patients that may not be congestive failure as a result from
col. able to obtain adequate oxygena- rapid fluid replacement.
tion with room air, and helps to
improve acidosis. Provide perineal or catheter care Elderly female diabetics are
frequently. prone to the development of
Discharge or Maintenance Evaluation urinary tract and vaginal infec-
tions.
Patient will have pH, bicarbonate, potassium, Reposition patient and provide Facilitates lung expansion,
serum and urine ketones within normal limits. skin care every 2 hours. decreases risk of skin irritation
and breakdown, and improves
Patient will have stable vital signs with respira- peripheral circulation.
tory rate within normal limits. Obtain culture specimens as Assists with identification of
Patient will be free of acetone on breath. ordered or as per hospital policy. causative organism and appropri-
ate antimicrobial therapy.
Risk for infiction Administer antibiotics as Early intervention may reduce
ordered. the risk of sepsis or multi-system
Related to: elevated glucose levels, alterations in involvement.
circulation, pre-existing infection, especially URI
or UTI, decreased leukocyte function Information, Instruction,
Demonstration
Defining characteristics: increased serum and
urine glucose levels, temperature elevation, chills, INTERVENTIONS RATIONALES
fever, elevated white blood cell count, differential Ensure proper handwashing Prevenrs cross-contamination
with shift to the left techniques are used by staff and and decreases risk of spread of
patient. infection.
Maintain aseptic technique with Elevated glucose levels provide an

Outcome Criteria administration of IV medica- excellent culture medium for
tions, insertion of catheters and bacterial growth.
Patient will be free of infection and able to verbal- invasive lines, and maintenance
ize methods to prevent or reduce risk of infection. care. Restart IVs per hospital
protocol.
Instruct patients in perineal care, Promotes compliance, minimizes

INTERVENTIONS disposal of secretions and risk of spread of infection, and
RATIONALES infected materials. cross-contamination.
Monitor for fever, facial flushing, Patient may have been admitted Instruct in importance of oral Reduces risk of oral or gum
drainage from wounds, urine with undiagnosed infection or care. disease.
cloudiness, changes in sputum, have developed a nosocomial
tachycardia. infection.
Auscultate for changes in breath Accumulation of bronchial secre-
sounds. tions may be heard as rhonchi Patient will be able to identify actions to reduce
and may indicate the presence of or prevent infection and cross-contamination.
Patient will be free of infective process. Information, Instruction,

Demonstration
Patient will be able to adequately demonstrate
techniques to prevent or reduce infection risk. INTERVENTIONS RATIONALB
Potential for injury: bypoglycemia Instruct patientlfamily in signs of Promotes knowledge and facili-
hypoglycemia and treatment for tates compliance. Assists patient
Related to: insulin therapy, decreased insulin- this condition. and family to feel in control.
antagonist hormones circulating in body, rebound
action Discharge or Maintenance Evaluation
Defining characteristics: blood glucose levels
Patient will have stable blood glucose level
below 70 mg/dl, altered mental state, decreased
above 80 mg/dl.
level of consciousness, cool and clammy skin,
pallor, tremors, tachycardia, irritability, visual dis- Patient/family member will be able to identify
turbances, paresthesias, dizziness, hunger, nausea, signs and symptoms of hypoglycemia and inter-
fatigue, diaphoresis ventions for treatment.
Patient will have no hypoglycemic symptoms.
Outcome Criteria
Fatigue
Patient will have stable blood glucose levels and be
Related to: insufficient insulin, increased
able to identify methods of treatment and identifi-
metabolic demands, decreased metabolic energy
cation of hypoglycemic episodes.
production, infection
Defining characteristics: lack of energy, inability
INTERVENTIONS RATIONALES to perform normal routine, decreased
Monitor for signs/symptoms of Prompt identification of problem performance, accident prone, lethargy, tiredness,
hypoglycemia. will facilitate prompt treatment alterations in consciousness
and help prevent further compli-
cations.
Outcome Criteria
Change IV fluid to solution con- Prevents excessive drop in blood
taining glucose when blood glucose level and allows time for
Patient will have increased energy and be able to
glucose level reached 250 mgldl, blood chemistry to normalize.
a<well as change inhsion rate on participate adequately in normal activities.
insulin drip.
If hypoglycemia occurs, give the Glucagon, 10-50% solutions,

patient oral (if able to tolerate may be given IV, or 15 grams of INTERVENTIONS RATIONALES
fluids and awake) or parenteral a rapid-acting carbohydrate will
glucose solutions, as per policy. be effective in elevating the Observe patient for activity toler- Provides baseline information so
blood sugar level. Milk and ance. that identification of problem
crackers will assist in protecting and interventions may be
patient from recurrences of planned. Elevations in pulse,
hypoglycemic episode. blood pressure and respiratory
rate may indicate physiologic
intolerance of activity.
Provide period of rest or sleep Prevents excessive fatigue.


alternated with periods of activ- Instruct patiendfamily member Provides knowledge base on
ity as patient can tolerate. about disease process, normal which further instruction can be
ranges for blood glucose, glu- performed.
Increase activity and patient par- Provides time to build up toler- cometer use, relationship
ticipation gradually. ance, and increases self-esteem. between insulin and glucose
levels, type of diabetes the
patient has, etc.
Demonstration Instruct patient/family member Promotes tighter control of dia-
in glucometer use and urine test- betes with self-monitoring at
INTERVENTIONS RATIONALES ing, with return demonstration least four times per day, and may
by patient. help prevent or delay long-term
Discuss with patient/family Information may facilitate moti- complications.
member the importance of activ- vation to increase activity level
ity, planning schedules with knowing that decreased energy Instruct in dietary plan, Dietary control with assist with
alternating rest and activity, and will be expended and he will be allowances, caloric intake, meals maintenance of decreased blood
methods of conserving energy. able to accomplish more activity. outside the home, etc. glucose levels. Fiber may slow
glucose absorption and decrease
fluctuations in serum levels.
Instruct in medication regime, Promotes understanding of drug
0 Patient will be able to tolerate increased activity with actions, side effects, and use and facilitates compliance
contraindications noted. with regimen. Proper techniques
with stable vital signs. with administration of insulin
assist with understanding and
Patient/family will be able to verbalize and/or identification of potential prob-
demonstrate techniques to conserve energy lems so that interventions may
while performing activities. be found.
Knowledge &$kit Instruct in activity and other

factors that determine diabetic
Promotes control of diabetes and
may help reduce incidence of
Related to: lack of information, lack of recall, mis- control. ketoacidosis. Aerobic exercises
promote effective utilization of
interpreted information, unfamiliarity with insulin and strengthens the car-
resources diovascular system. Illness
management and management of
Defining characteristics: requests for information, other stress-type factors facilitates
questions, misrepresentation of facts, inaccurate equilibrium with disease process
follow-through of instructions, development of during these episodes.
preventable complications Instruct in avoidance of Nicotine causes constriction of

smoking. blood vessels which restricts
insulin absorption up to 30%.
Outcome Criteria
Instruct in examination and care Identifies potential complications
of feet. that may occur because of
Patient will be able to verbalize understanding of peripheral neuropathy or circula-
diabetes disease process, identify signs and symp- tory impairment, and allows for
toms of complications, correctly demonstrate all early intervention.
procedures, and access community resources Instruct in protocols for sick Provides plan for complications
adequately. days-to take medications, to that occur, and gives the patient
notify MD, to monitor blood the knowledge to enable him to
sugar every 2-4 hours, to check adequately care for himself
urine ketones if blood sugar is during times of illness.
>240 mg/dl, and to replace car-
bohydrates with liquids
Instruct in maintaining medical Vision changes may be gradual

maintenance, including vision and may be more pronounced in
checks, and follow-up care. poorly-controlled diabetics.
Visual acuity may deteriorate to
retinopathy and eventual blind-
ness. Follow-up care can assist in
preventing exacerbations of dia-
betic complications and delay
development of systemic prob-
lems.
Discuss sexual function and Impotence may occur as an ini-

questions patientlfamily member tial symptom of diabetes
may ask. mellirus. Penile prosthesis and/or
counseling may be of help.
Instruct in avoidance of use of May contain increased sugar

over-the-counter medications content and may interact with
without physician approval. other medications being taken.
Instruct in available community Provides continued support post

resources, support groups like the discharge, and assists to support
American Diabetic Association, lifestyle changes.
smoking and weight loss clinics,
etc.

Patient/family member will be able to accurately
verbalize knowledge base regarding diabetic dis-
ease process.
Patientlfamily member will be able to accurately
verbalize all information given.
Patient/family member will be able to accurately
return demonstration for all necessary
procedures.
.
~~ ~
DIABETIC KETOACIDOSIS (DKA)
Deficiency of insulin
II
s
Gluconeogenesis Fat metabolism
Hyperglycemia Free fatty acid

metabolism by liver
c
d m g ' d ' )
I1
Osmotic diuresis I Increased ketones
Ketonuria
c Acetone breath
c
Polyuria
Dehydration
c
Hypovolernia Plasma hyperosmolality Ketoacidosis
4 c
Hypotension Nauseahomiting
Tachycardia Acidosis
Flushed face High A-gap
Thirst Potassium shift
Dry mucus membranes from cells
Kussmaul resp.
I
Decreased CNS I
c
I W Brain ischernia
4
Coma
c
DEATH
RENAIJENDOCRINE SYSTEMS 26 1
Hyperglycemic HHNK has also been associated with usage of thi-

azide diuretics, glucocorticoids, phenytoin,
sympathomimetics, diazoxide, chlorpromazine,
sedatives, cimetidine, calcium channel blockers,
and immunosuppressive agents because of their
effects with glucogenesis and/or insulin.
(HHNK) Mortality is approximately 50% due in part to
common complications that occur, such as shock,
HHNK, or hyperglycemic hyperosmolar nonke-
coma, acute tubular necrosis, and vascular throm-
totic coma, may also be known as hyperglycemic
bosis. Correction of the problem is the main goal
nonacidotic diabetic coma, and presents a life-
of treatment, with fluid balance the initial
threatening emergency. Glucose transportation
concern. The lack of insulin may be corrected by
across the cell membrane is impaired by enough of
supplemental insulin administration and usually
an insulin deficiency that causes hyperglycemia
requires 100 Units or less in the first 24 hour
without inhibiting lipolysis or ketogenesis in the
period. Electrolyte imbalances are corrected and
liver. The hyperosmolality occurs from the hyper-
may require large amounts of potassium supple-
natremia and hyperglycemia, and may further
mentation.
impair the secretion of insulin and prevent fatty
acid release from adipose tissues. Extracellular
fluid volume deficits occur as a result of osmotic MEDICAL CARE
diuresis in the body's attempt to offset increasing Laboratory: blood sugar level elevated, frequently
' plasma osmolality. As fluid volume deficits over 1000 mg/dl; plasma osmolality elevated, fre-
increase, glomerular filtration rates decrease and quently as high as 450 mOsm/kg; hematocrit
reduces the ability of the kidneys to excrete the elevated due to hemoconcentration; urine and
glucose. serum acetone levels negative; BUN and creatinine
HHNK occurs when insulin action or secretion is elevated; marked leukocytosis; electrolytes to eval-
inadequate, and may occur in patients who have uate deficiency; hypernatremia usually present
no previous history of diabetes mellitus. The Arterial blood gases: used to identify acidosis; pH
elderly are especially prone to this because of the is usually greater than 7.30, bicarbonate is usually
lower body water content and dehydration, and greater than 15 mEq/L; acidosis is mainly due to
this may alter their buffering ability to respond to lactic acid or renal dysfunction
changes in osmolality. Illnesses, and other stress-
provoking episodes, may either cause or hasten the Electrocardiogram: used to identify dysrhythmias
development of HHNK by increasing glucose pro- that may result as a consequence of electrolyte and
duction in response to excessive stress hormone fluid disturbances
production.
HHNK has almost the same pathophysiologic
NURSING CARE PLANS
pattern as DKA, but the difference is that with Fluid volume deficit
HHNK, a sufficient amount of insulin is being [See DKA]
released to prevent the development of ketosis.
Alterution in nutrition: less thun body Information, Instruction,

requirements Demonstration
[See DKA]
Potentiulfor injury: hypoglycemiu
Instruct patiendfamily member Prevents circulatory impairment
[See DKA] to avoid constricting apparel, and risk of complications.
crossing legs or ankles, or any
Potentiulfor ulterution in tissue perjksion: other activity that impedes
per+herul circulation.
Related to: dehydration, increased platelet aggre- Notify physician for any Prompt identification can lead to
gation, increased viscosity of blood evidence of thrombus formation. timely intervention.
Defining characteristics: cool extremities,

decreased peripheral pulses, extremity pallor or
cyanosis, unequal extremity temperatures
Patient will have equal pulses, color, and tem-
Outcome Criteria perature to lower extremities bilaterally.
Patient will have bilaterally equal peripheral

. Patient will have no evidence of thrombus
formation.
pulses, color and temperature to extremities, with
no complications. Patient/family will be compliant with methods
to reduce risk of thrombus formation.
Monitor and assess lower extrem- Identifies the status of circulation
ities for color, temperature, in the extremities and assists
presence of pulses, and equality. with prompt identification of
complications.
Test for positive Homan’s sign, May indicate thrombus forma-

redness, warmth, tenderness, or tion, but is not always present
swelling to legs. with thrombus formation.
Remove TED hose at least every Provides opportunity for thor-

8 hours for 30 minutes to 1 ough assessment and
hour. identification of changes, as well
as for comfort of pztient.
Assist with passive range of Prevents venous stasis.

motion/encourage active range of
motion exercises.
RENAIJENDOCRINE SYSTEMS 263
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA (HHNK)
r
Relative lack of insulin but enough to prevent ketosis
Gluconeogenesis
1
Glycogenolysis
Hyperglycemia
(800-2600 mgldl)
Osmotic diuresis
lity
4
Profound dehydration
# 4
k-J'perosmc
Polydipsia
4 J,
Hypovolemia Increased BUN

Hyperthermia Increased sodium
Tachycardia Decreased potassium
Shock Depressed CNS
Gastric stasis 4
4
Cardiac dysrythmias
4
Renal impairment Cardiac dysfunction
4
Increased glucose 1
DEATH +
Syndrome of Nursing Care Plans

Inappropriate ADH Fluid volume excess
Secretion (SIADH) Related to: inability to excrete water, inappropri-

ate antidiuretic hormone secretion, failure of
negative feedback system
SIADH is another dysfunction of the antidiuretic
hormone in which there is increased secretion or Defining characteristics: hyponatremia, decreased
production of ADH. The increase is not related to plasma osmolality, increased urine osmolality,
osmolality, and therefore causes a slight increase in weight gain, neurologic disturbances, seizures
body water. Sodium concentration is decreased in
the extracellular fluid and plasma. SIADH is usu-
ally caused by bronchogenic or pancreatic cancer, INTERVENTIONS RATIONALES
but can occasionally result from pituitary tumors. Monitor for changes in level of May be early indication of
Other etiologies include central nervous system consciousness, fatigue, weakness, impending water intoxication.
injuries, infections and tumors, pulmonary headache or generalized pain.
diseases, Addison's disease, hypopituitarism,
aneurysms, AIDS, and use of tricyclic drugs, oral Monitor heart rhythm and Fluid shifts and electrolyte dis-
hemodynamics as ordered. turbances can precipitate cardiac
hypoglycemics, acetaminophen, chlorpropamide,
dysrhythmias and changes in
thiazide diuretics, cytotoxic agents, and excessive hemodynamic status.
vasopressin therapy.
Weigh patient every day, and Assists with identification of
Unlike diabetes insipidus, SIADH has a failure of maintain accurate I&O. fluid statudbalance.
the negative feedback system in which continued Administer IV and PO fluids as Restriction of fluid may be based
ADH secretion creates water intoxication because ordered, maintaining fluid partially on urine, nasogastric, or
restriction. other fluid losses.
of low plasma osmolality and expanded volume.
The primary initial goal is to restrict fluid intake Administer hypertonic saline IV These types of infusions are gen-
when ordered. erally reserved for severe
and correct electrolyte imbalances. With severe
hyponatremia or when accornpa-
cases, 3% hypertonic saline and IV lasix are used. nied by seizure activity. Fluid
overload may worsen and deteri-
MEDICAL CARE orate into heart failure. There are
controversial theories that
Laboratory: plasma sodium decreased, plasma sudden increases in serum
sodium can result in osmotic
osmolality decreased, urine sodium and osmolality demyelination syndrome which
increased, elevated plasma ADH levels; renal pro- may have adapted to the lower
files used to assess renal status changes from level of sodium.
imbalances and from nephrotoxic medications; Administer diuretics as ordered. Assists with decreasing the action
thyroid profiles to assess thyroid function; of ADH, but can also cause elec-
electrolytes to evaluate concurrent imbalances trolyte losses.
Administer other drugs that help Lithium and demeclocycline

Electrocardiogram: used to identify cardiac dys- inhibit ADH action, as ordered,' interfere with ADH ac the renal
rhythmias that may occur as a result of electrolyte tubular level, but can be nephro-
or fluid imbalances toxic. Phenytoin inhibits ADH
release.
INTERVENTIONS RATIONALES Constipation

Administer supplemental elec- Facilitates replacement of Related to: decreased gastric motility secondary to
trolyres as ordered. required electrolytes to maintain
hyponatremia, fluid restriction, decreased activity
function.
Defining characteristics: inability to pass stool,
hard stools, painful, small stools
Demonstration
Monitor lab studies, especially Some medications are nephro-
renal profiles for changes in renal toxic and can worsen renal Patient will be free of constipation.
perfusion. function.
Instruct patient/fmily regarding Promotes knowledge, and

fluid balance, seizure encourages compliance with INTERVENTIONS RATIONALES
precautions, drug therapy, proce- medical regimen. Facilitates
dures, lab studies, etc. patient taking active part in his Assess bowel habits of patient; Provides baseline from which to
care. normal routines, frequency of plan interventions.
stools, use of cathartics, etc.
Discharge or Maintenance Evaluation Administer laxatives or stool Caution must be used in selec-
softeners as ordered. Tap water tion of pharmacological agent so
Patient will be neurologically stable with enemas should be avoided. as to not further add to fluid
approximately equivalent intake and output, volume overload. Water in the
and vital signs will be stable. enemas can be absorbed and
increase overload.
Patient will have normalized weight and be able Discharge or Maintenance Evaluation
to maintain weight.
Patient will have laboratory values within Patient will have normal bowel function with
normal parameters. no complications to fluid status.
Patiendfamily will be able to accurately verbal-

ize understanding of all instructions.
Risk for injury
[See Status Epilepticus]
Related to: impairment of cognitive ability, physi-
cal inactivity, seizure activity
Defining characteristics: confusion, lethargy,
memory impairment, irritability, personality
changes, level of consciousness changes, restless-
ness, fatigue, weakness, seizures, imposed physical
inactivity
SYNDROME OF INAPPROPRIATE ADH SECRETION (SIADH)
Increased ADH (pitressin)

c
Antidiuretic effect
Distal tubules and collecting ducts
c
Free water retention
J,
Plasma dilution
I
I I
Decreased plasma osmolality Activation of
Increased urine osmolality volume receptors
Increased urine specific gravity
Increased urine sodium
Hyponatremia
I
Further decreased hyponatremia
e
Hypervolemia (sodium and water)
c
Excretion in proximal tubules
J,
Further decrease in plasma osmolality

Further increase in urine sodium
c
Weight gain
Weakness
Mental confusion
Convulsions
Coma
RENAL/ENDOCFUNE SYSTEMS 269
Diabetes Insipidus (DD greater than 295 mOsm/kg; urine osmolality

decreased, generally less than 500 mOsm/kg and
can be as low as 30 mOsm/kg; urine specific grav-
Diabetes insipidus, or DIYis a condition that
ity low, generally 1.001 to 1.005; plasma ADH
results when damage or destruction of the neurons
levels decreased in central diabetes insipidus;
of the hypothalamus causes decreased levels of
serum sodium elevated
antidiuretic hormone (ADH) and severe diuresis
and dehydration occur. The deficiency results in Water deprivation test: used to demonstrate that
the inability to conserve water, and if the patient's in the presence of simple dehydration, kidneys
thirst mechanism is not adequate, or if fluids are cannot concentrate urine; used to differentiate
not accessible, the fluid balance will be altered. psychogenic polydipsia from diabetes insipidus
The two main etiologies of DI are tumors of the Vasopressin test: used in conjunction with water
hypothalamus or pituitary and closed head injuries deprivation test to identify that the kidneys can
that may have damage to the supraoptic nuclei or concentrate urine with exogenous ADH and dif-
hypothalamus. Head injuries, neurosurgery, or ferentiates nephrogenic from central diabetes
hypophysectomy may lead to a loss of osmorecep- insipidus
tor function and/or damage to the areas that
produce antidiuretic hormone. Sometimes, a tran- NURSING CARE PLANS
sient type of DI occurs after surgical procedures,
histiocyctosis, sarcoidosis, aneurysms, meningitis, Fluid volume
encephalititis, or neoplastic conditions. All of the Related to: inability to conserve water, dehydra-
above respond to vasopressin. tion, decreased levels of A D H
DI that is nephrogenic is usually vasopressin- Defining characteristics: extreme thirst, decreased
insensitive, and is seen in polycystic kidney skin turgor, dry mucous membranes, hypotension,
disease, pyelonephritis, multiple myeloma, tachycardia, weight loss, dilute urine output,
sarcoidosis, sickle cell disease, or any disorder that increased urine output, hemoconcentration,
affects the kidneys. Usage of ethanol and pheny- hyperosmolality, increased serum sodium
toin inhibit ADH secretion, and drugs such as
lithium and demeclocycline inhibit ADH action
in the kidney.
Outcome Criteria
The main goal for treatment is to prevent dehy- Patient will have fluid volume balance restored
dration and electrolyte imbalances, while and be able to maintain adequate fluid volume.
determination and treatment of the underlying
cause is underway. Vasopressin administration will
control diabetes insipidus; D-amino-D-arginine INTERVENTIONS RATIONALES
vasopressin (DDAW) is a nasal spray that has Assess and monitor vital signs. Tachycardia and hypocension
prolonged antidiuretic effects with minimal side may result from hypovolemia.
effects. Measure intake and output every Provides information to identiFy
1-2 hours, and notify physician fluid imbalances and volume
for changes. Record specific grav- depletion. I&O should be con-
ity measurements per hospital tinued in postoperative patients,
protocol. especially neurosurgical pacieno,
Laboratory: serum osmolality elevated, usually
INTERWNTIONS RATIONALES INTERVENTIONS RATIONALES

to ensure that DI has not tran- vasopressin tests by obtaining and that procedure data will be
siently resolved and then accurate weights, vital signs, accurate. The water deprivation
reappear only to become perma- I&O, lab specimens at proper test is usually terminated if the
nent. Urinary output may be as intervals, and maintaining depri- patient has a 3% weight loss.
much as 15 Llday, and specific vation for required amount of
gravity is usually between 1.001 time.
and 1.005.
Instruct patient/family member Promotes knowledge and facili-
Administer IV fluids as ordered. Helps to restore circulating fluid in methods to prevent tates compliance with medical
If able to take oral fluids, encour- volume. dehydration when on long-term regimen.
age patient to take in PO. ADH therapy, as well as when
hospitalized.
Weigh patient daily. Provides identification of fluid
balances and water losses. Discharge or Maintenance Evaluation
Administer replacement therapy Aqueous pitressin (IV or SQ) is a
for central diabetes insipidus. short-acting ADH useful in tran- Patient will have stable vital signs and balanced
sient DI. Nasal spray vasopressin intake and output.
is also short-acting and may be
erratic in patients with respira- Patient will be able to maintain normal hemo-
tory infections or nasal problems. dynamic parameters.
DDAVP (nasal or SQ) is a syn-
thetic ADH that has a longer Patient will have weight restored and be able to
duration and can be given q12-
maintain weight.
24 hours. Vasopressin tannate in
oil can last 24-72 hours and is Patiendfamily will be able to verbalize
not utilized as initial treatment
due to inability to titrate dose. accurately any information related to them.
Administer medication therapy Chlorpropamide is used to stim- Knowledge deficit

for nephrogenic diabetes ulate ADH release and can
insipidus. augment the renal tubular Related to: potential self-care management for
response to ADH. Thiazide permanent diabetes insipidus
diuretics in conjunction with
sodium restriction will reduce Defining characteristics: newly diagnosed DI,
solute load and enhance water requests for information, questions, inaccurate
reabsorption.
follow-through with instructions or medications,
Information, Instruction, development of preventable complications, inabil-
Demonstration ity to recall information vital to disease process
~
Outcome Criteria
Ensure that vasopressin tannate Reduces pain from injection and
in oil is warmed and vigorously ensures complete mixture. Patient/family member will be able to accurately
agitated prior to injection.
verbalize medical regimen to manage diabetes
Observe for water intoxication May occur with shifting fluid insipidus.
with pharmacologic replacement balances.
therapies.
Assist with diagnostic procedures Ensures that correct sequence

such as water deprivation and will be maintained for specimens
RENAL/ENDOCRINE SYSTEMS 27 1
~~ ~ ~
Assess for patientlfamily member Provides baseline of knowledge

comprehension of disease and and facilitates plan for
medications. interventions.
Instruct in all medications, Promotes knowledge and facili-

action, side effects, adverse reac- tares compliance.
tions, schedule to be taken,
method of administration, and
importance of adherence to med-
ical regime.
Instruct to notie physician for Prompt identification may facili-

excessive water retention or uri- tate timely intervention and
nary frequency and increased treatment.
amount.
Discuss reasons for non-adher- Explores patient's rationale and

ence to medication, if patient has identifies any misconceptions he
previously been diagnosed with might have regarding his medical
DI. regimen.
Discuss obtaining medical alert Promotes fast recognition of

bracelet identifying patient as medical condition in cases where
having DI. patient is not able to identify
problems.

Patient will be able to accurately verbalize pur-
pose, side effects, and schedule of medications.
Patient will adhere to medical therapeutics and
take medication as prescribed.
Patiendfamily will be able to accurately recall all
information related to them.
Patient/family will be able to identify fluid bal-
ance alterations that should be reported to
physician.
Patient will be compliant in obtaining medical
identification bracelet.
DIABETES INSIPIDUS (DI)
Decreased ADH (Pitressin) or

low plasma ADH levels
4
Renal tubular unresponsiveness
JI
Decreased permeability to waters
4
Excess water excreted in urine
4
Decreased urine osmolality
Decreased urine specific gravity
4
Plasma volume loss
Increased plasma osmolality
Increased serum sodium
4
Dehydration
Hypovolemic shock Polydipsia

Weakness
Fever
Confusion
RENAIJENDOCRINE SYSTEMS 273
be ruled out. Pheochromocytoma always leads to

death if untreated.
Pheochromocytoma is a vascular tumor, composed
of chromafin cells that secrete catecholamines or MEDICAL CARE
their precursors (epinephrine, norephinephrine, or Medications: use of alpha- and beta-blockers
dopamine). This, in turn, causes severe persistent (phenoxybenzamine and propranolol, or
or intermittent hypertension due to the severe phenoxylbenzamine and metyrosine) to control
vasoconstriction in response to the catecholamine catecholamine excess symptoms; IV infusions of
excess. trimethaphan camsylate or sodium nitroprusside
Usually the tumor is encapsulated and located to control vasopressor effects
within the medulla of the adrenal glands, but can Laboratory: fasting serum glucose elevated,
occur in the sympathetic paraganglionic areas of increased hematocrit; 24-hour urine for
the abdomen, chest, brain, or cervical areas. These catecholamines, vanillymandelic acid and
tumors are usually benign, but can be malignant metanephrines to identify elevated levels
in up to ten percent of patients. Frequently occur-
ring between the ages of 30 and 50, attacks may Electrocardiogram: used to identify tachycardia,
occur paroxysmally if the tumor releases bradycardia, LV enlargement and strain from ele-
catecholamines on an intermittent basis. These vated blood pressure, cardiac dysrhythmias
episodes may range from once per year to several Radiography: chest and abdominal x-rays used to
times per day. Attacks may be spontaneous, or be localize and identify tumor; CT scans, IVP,
caused by palpation of the tumor, emotional stress radionuclide imaging and selective venographic
or trauma, exposure to cold, beta-blockers, angiography also used to localize tumors; caution
postural changes, abdominal compression, anes- must be used due to potential for test to exacer-
thesia induction, urination, defecation, or heavy bate hypertensive crisis
lifting.
Surgery: surgical removal of the pheochromocy-
The tumor’s hallmark symptom is high blood toma may be required
pressure with fluctuations up to 220/150 or
higher. The catecholamine secretion causes symp-
toms of “flight or fight” reactions, typically
NURSING CARE PLANS
beginning with palpitations, headache, pallor, Altered tissue pe&sion: cardiopulmonary,
cool, moist hands and feet, flushing, profuse cerebral, gastrointestinal, peripheral, and
sweating, and extreme anxiety. renal
Pheochromocytoma is also a part of the Multiple Related to: excessive catecholamine secretion
Endocrine Neoplasia (MEN) Syndromes and may
Defining characteristics: pulse and blood pressure
be found in conjunction with neurofibromatoses,
changes, changes in cardiac output, changes in
hemangiomas, and medullary thyroid cancers.
peripheral resistance, impaired myocardial
Other diagnoses, such as angina, essential hyper-
oxygenation, chest pain, cardiac dysrhythmias,
tension, hyperthyroidism, acute anxiety reactions,
EKG changes, dyspnea, tachypnea, palpitations,
transient ischemic attacks, and menopause, must
nausea, vomiting, epigastric pain, constipation,
slow digestion, weight loss, headaches, visual dis- INTERVENTIONS RATIONALES

turbances, paresthesias, oliguria, anuria, electrolyte
Administer medications as Alpha- and beta-blockers may
imbalances, cold and clammy skin, decreased stabilize the condition prior to
ordered.
peripheral pulses, flushing, diaphoresis surgical intervention. Metyrosine
interrupts the catecholamine
synthesis, decreases levels of nor-
Outcome Criteria epinephrine production,
decreases levels of VMA, and
Patient will maintain adequate perfusion to all decreases BI?
vital organs and will have adequate peripheral and Titrate IV meds as needed to Reduces risk of complications
systemic circulation. keep systolic blood pressure less from severely elevated pressure.
than 170 mmHg, and diastolic
pressure less than 100 mmHg.
INTERVENTIONS RATIONALES Weigh every day. Weight loss may occur due to
increased metabolism, decreased
Monitor vital signs, including Provides information about heart
appetite, nausea, or vomiting.
lying, sitting, and standing BP. rate and perfusion pressure
which will affect blood flow and Monitor intake and output, and Decreased renal perfusion may
tissue perfusion. Chronic exces- notify physician far urine output lead to decreased urinary output,
sive secretion of catecholamines less than 30 cc/hr. renal impairment, and failure.
will affect the reflexes that are
responsible for maintaining Avoid palpation of abdomen; Prevents possible palpation of
upright blood pressure and may post sign near bed to refrain cumor and triggering of acute
result in orthostatic hypotension. from palpation during crisis.
assessments.
Monitor functional abilities in Interrelationships of the body
relation to the affected system. systems can cause overlapping Monitor labwork, especially FBS, Catecholarnine release can
signs and symptoms associated hematocrit and renal function increase glycolysis and inhibit
with tissue perfusion and can levels. insulin release. Excess
cause changes in oxygenation, catecholamines can also increase
cardiac output, metabolic erythropoierin stimulation and
demands, neurologic function, can elevate hematocrit, as well as
renal function, and nutrition. decrease blood flow to the
kidney resulting in renal impair-
Assess for presence and character May indicate decreased perfusion ment.
of pulses, capillary refill time, related to the particular body
skin color and temperature, urine system.
output, mentation, gastric dis-
tention, presence of bowel Demonstration
sounds, and appetite.
Position patient in Fowler’s Helps to decrease the blood
position. volume returning to the heart by Assist with obtaining 24-hour Elevated levels may be diagnostic
pooling blood n,i dependent parts urine specimen for diagnosis. for pheochromocytorna, but
of the body. Decreases BP by use coma and increased stress states
of orthostatic changes associated must be ruled out. Normal
with the chronic catecholamine values for VMA are < 10 mgl24
secretion. hrs, metanephrines < 1.3 mg/24
hrs, free epinephrine and norepi-
Avoid any non-essential activi- Ambulation, exercise, and val- nephrine < 100 mcg124 hrs.
ties, especially pressure-causing salva-type efforts may provoke an
movement. Avoid straining with attack, increasing blood pressure Avoid use of rauwolfia alkaloids, These substances may interfere
bowel movements or urination. and decreasing tissue perfusion. tetracycline, quinine, methyl- with the results and hamper
INTERVENTIONS RATIONALES Organ function will be within patient’s normal
dopa, catecholamines, large determination of diagnosis.

quantities of vanilla, coffee, Extremities will be warm, with normal color
chocolate, nuts, bananas, guaife- and sensation, and have equally palpable pulses.
nesin, and salicylates for at least
2 days prior to 24-hour test, if Patient will have adequate urinary output with
possible.
equivalent intake and output.
Instruct parientlfamily in causes Promotes understanding of the
of exacerbations or attacks, and condition and risk of decreased Patient will be free of abdominal or epigastric
methods to reduce frequency of perfusion to vital organs. pain, and able to ingest adequate nutritional
occurrence.
intake to maintain weight.
Instruct to avoid exposure to Cold may cause vasoconstriction,
cold temperatures. decreases circulation, and perfu- Anxiety
sion, as well as precipitate an
attack. Related to: excessive catecholamine release, threat
to health status, changes in health status, life-
Instruct in medications, effects, Promotes knowledge and facili-
tates compliance with medical
threatening crisis, possibility of surgical
side effects, adverse reactions,
complications, and symptoms to regimen. intervention
report to physician.
Defining characteristics: apprehension, sense of
Instruct in methods to decrease Reduces stress and lessens precip- impending doom, fear of death, restlessness, fear,
emotional stress, such as relax- itating factors with intermittent
ation techniques. attacks by facilitating vasodila-
fear of death, fear of surgery, fear of the unknown,
tion. feelings of helplessness, anxiousness, worry, com-
Instruct in having frequent blood Primary indicator of the tumor
munication of uncertainty, voiced concern over
pressure checks, keeping log of activity is blood pressure changes in life events
trends, ranges to report to physi- increases, which cause decreased
cian. etc. perfusion to tissues and organs.
Increased knowledge will Outcome Criteria
decrease fear and increase com-
pliance with treatment, and Patient will have less anxiety or anxiety will be
provide opportunity for prompt within an acceptable and manageable level.
treatment to prevent serious
complications.
Instruct in avoiding rapid Facilitates body’s attempt to cope INTERVENTIONS RATIONALES

changes in position. with orthostatic hypotension by ~
allowing time for body and cir- Assess anxiety level, noting ver- Catecholamine increases can
culatory system to adjust to balizations of fear or sense of produce marked anxiety which
changes. doom. then increases oxygen demand
on tissues.
Instruct to avoid wearing any May result in an attack by com-
clothing that may be tight or pression of abdomen or tumor Provide calm environment for Provides an opportunity to vent
constrictive. region. patient to express fears, concerns, feelings and to obtain informa-
and feelings. Allow time for tion. Decreases anxiety and
patient to ask questions. promotes a caring and trusting
Discharge or Maintenance Evaluation atmosphere.
Patient will have normalized vital signs. Encourage visits from family and Provides emotional support and
friends who do not increase or relieves anxiety when familiar
INTERVENTIONS RATIONALES Defining characteristics: increase in body temper-

provide patient with emotional people are available.
ature greater than normal range, flushed warm
s t ress . skin, increased heart rate, increased respiratory
rate, diaphoresis, delirium
Decrease stimuli in environment. Prevents further stressors.
Administer medications as Assists to allay fear and anxiery

ordered. Outcome Criteria
Information, Instruction, Patient will have temperature within normal

Demonstration range.
Instruct patientlfamily members Decreases anxiety caused by fear INTERVENTIONS RATIONALES
about disease process, what to of the unknown, and promotes Monitor temperature every 1-2 Fluctuations in temperature can
expect with procedures, pre- and knowledge and understanding. hours or use continuous moni- occur rapidly and temperature
postoperative care. coring. elevations can increase metabo-
Instruct on emotional stress and Reduces anxiety and provides lism needs.
other precipitating triggers for patient with some measure of Adjust room temperature for Assists patient with comfort and
attacks, and methods to reduce control over the situation. patient comfort and maintain at decreases temperature.
stress and anxiety. or below 72 degrees.
Instruct on medications, effects, Promotes knowledge and
Administer antipyretics as Decreases fever.
side effects, contraindications, understanding which facilitates
ordered.
and symptoms to report to compliance with medical
physician. regimen. Provide frequent tepid sponge Promotes patient comfort and
baths and change linens if reduces temperature by
Discharge or Maintenance Evaluation patient is diaphoretic. evaporation.
Avoid chilling or shivering of Shivering may increase metabolic

Patient will have reduced anxiety and be able to patient. requirements and actually
vent feelings and concerns. increase temperature,
Patiendfamily will be able to verbalize Place covered ice packs to groin, Decreases temperature by means
axillae, andlor behind neck, if of conduction.
understanding of disease process, medications, warranted.
and treatments, and will be compliant with reg-
Use cooling blanket for tempera- Assists in lowering temperatures
imen. tures greater than 103 degrees if by conduction. Blankets should
warranted. Cool body slowly- be covered ro prevent burns and
Patient will be able to avoid stressful visitors,
no faster than 1 degreell5 tissue injury. Cooling that is
situations, or other provoking events, and will minutes. Blanket should be cov- done too rapidly can produce
be able to perform relaxation exercises when eted and continuous monitoring ventricular ectopy.
stressed. of temperature should be
performed.
Hypertherm ia Administer thorazine IM/IV as Thorazine is an alpha-adrenergic-
ordered. blocking agent chat causes
Related to: increased metabolic rate in response to
peripheral vasodilation which
catecholarnines, decreased heat loss due to vaso- helps heat to dissipate and also
constriction can assist in decreasing shivering.
Information, Instruction, cular resistance, altered oxygen-carrying capacity

Demonstration of blood, shift of the oxyhemoglobin dissociation
curve, hypermetabolic state
Instruct patiendfamily in proce- Promotes knowledge and reduces
hypercapnia, hypoxia, cyanosis, dyspnea, tachyp-
dures, what to expect with anxiety.
cooling blanket application, etc. nea, changes in ABG values, changes in A-a
gradient, changes in vital signs, activity
Discharge or Maintenance Evaluation intolerance, changes in mental status
Patient will achieve and maintain normal body Constipation

temperature. Related to: inadequate dietary/fluid intake, GI
Patient will be compliant with medical regimen. distress, changes in level of activity, decreased
blood flow slowing digestion, malabsorption
Sensor -perception alteration (visualj
[See
d
thoug t processes, kinesthetic)
CVA]
Defining characteristics: nausea, vomiting,
decreased appetite, epigastric pain, hard-formed
stool, absence of stool, abdominal pain
Related to: altered sensory reception, chemical
alterations due to hypoxia, chemical alterations
Outcome Criteria
due to glucose/insulin and electrolyte imbalances,
restrict environment, psychologic stress, vasocon- Patient will have normal elimination pattern
striction reestablished and maintained.
Defining characteristics: confusion, anxiety, fear,
disorientation, change in behavior patterns, hyper-
esthesia, restlessness, irritability, impaired INTERVENTIONS RATIONALES
decision-making Determine patient’s bowel habits, Assists with identification of an
lifestyle, ability to sense urge to effective bowel regime andlor
Alteration in nutrition: less than body defecate, painful hemorrhoids, impairment and need for assis-
requirements and history of constipation. tance. GI function may be
decreased as a result of decreased
digestion.
Related to: hypermetabolic state, nausea, vomit- Auscultate bowel sounds for Presence of abnormal sounds,
ing, anorexia, malabsorption presence and quality. such as high-pitched tinkles,
suggest complications like ileus.
Defining characteristics: inadequate food intake,
Monitor diet and fluid intake. Adequate amounts of fiber and
weight loss, muscle weakness, fatigue roughage provides bulk and ade-
quate fluid intake (greater than 2
Impaired gas exchange Llday) is importanr in determin-
[See Mechanical Ventilation] ing stool consistency.
Related to: increased respiratory workload, Monitor for abdominal pain and Gas, abdominal distention, or
impaired oxygen to heart, hypoventilation, altered distention. ileus could be a factor. Lack of
peristalsis from impaired diges-
oxygen supply, altered blood flow, change in vas- tion can create bowel distention
and worsen to the point of ileus.
Defining characteristics: increased blood pressure

and pulse, cold and clammy skin, jugular vein dis-
Provide bulk, stool softeners, May be required to stimulate tention, dyspnea, crackles, edema, cough, frothy
laxatives, or suppositories as war- evacuation of stool.
blood-tinged sputum, confusion, restlessness, noc-
ranted.
turia, decreased urinary output, increased mean
Provide high-fiber, whole grain Improves stool consistency and arterial pressure, increased systemic vascular resis-
cereals, breads and fresh fruits. promotes elimination.
tance, decreased cardiac output and cardiac index
Demonstration Outcome Criteria
INTERVENTIONS RATIONALES Patient will have adequate cardiac output to main-
tain hemodynamic stability and perfusion to all
Determine preexisting habits of Laxative dependence can predis-
laxativelenema usage. pose patient to constipation. organs.
Instruct patient to avoid frequent Promotes enema dependence and
use of enemas. causes fluid loss which results in
more difficult elimination. INTERVENTIONS RATIONALES
Provide activity or exercise Promotes peristalsis. Identify other pre-existing condi- Other factors and disease states
within limits of disease process. tions and assess cardiac function. may further stress an already
compromised heart and place an
extra burden of myocardial
Discharge or Maintenance Evaluation oxygen supply.
Patient will have improved dietary and fluid Monitor blood pressure, heart Cardiac output and blood
intake. rate and rhythm, apical and volume is decreased with elevated
peripheral pulses, pulse deficits, blood pressure. Afterload
Patient will achieve bowel elimination pattern respiratory status, presence of increases, pulse increases, and
cough or adventitious breath changes in contracriliry and con-
establishment and be able to maintain elimina-
sounds, presence and character of duction occur. Respiratory
tion of soft-formed stool without cramping or any sputum, and oxygenation. changes may result in decreased
straining. oxygen intake and hypoxia.
Daily exercise will be maintained within level of Measure cardiac outpurlcardiac Cardiac output < 5 L/min or
index and other hemodynamic cardiac index < 2.5 Llminlm’
confinement in ICU. parameters as indicated. indicates severe vasoconstriction
and decrease in myocardial oxy-
genation, leading to myocardial
ischemia, cardiac failure, and
Decreased cardiac output death.
Related to: altered preload, altered afterload, Monitor EKG for presence of Dysrhythmias decrease the heart’s
inotropic changes in the heart from increased dysrhythmias, and treat accord- pumping efficiency which affects
blood pressure and TPR, left ventricular enlarge- ing to hospital protocol. the cardiac output.
Dysrhythmias may indicate inad-
ment and strain, and from accumulation of extra equate myocardial perfusion.
fluid in the lungs or systemic venous system, Tachydysrhythmias decrease ven-
myocardial compromise due to vasoconstriction, tricular filling time and coronary
decreased coronary blood flow, increased myocar- blood flow; bradydysrhythmias
decrease cardiac output and
dial oxygen demands, hyperthermia, increased result in left ventricular failure.
catecholamine receptor sensitivity

Auscultate heart sounds for pres- Accumulations of extra fluid can decreased, heart rate is slowed,
ence of gallops andlor murmurs. be heard as these abnormal heart and oxygen consumption is pre-
sounds. served. Blood pressure decreases
and coronary perfusion and
Monitor for edema to extremi- May indicate decreased venous myocardial oxygen supply is
ties, sacral region, or other return to the heart and a decrease increased due to the decrease in
dependent areas; assess for jugu- in cardiac output. Fluid retention the heart rate.
lar vein distention, cold may result in a decrease in uri-
peripheral extremities, decreased nary output as a result of
urinary output, and sluggish decreased venous return and Information, Instruction,
capillary refill. perfusion. Demonstration
Weigh every day. Weight gain may indicate fluid
retention.
Instruct to elevate legs when Promotes venous return.
Monitor intake and output every Intake and output should
sitting or lying down.
2 hrs and prn. approximate each other. A fluid
deficit between output and Instruct in signs to report: May indicate complications as a
intake indicates fluid retention edema, weight gain, chest pain, result of decreased cardiac
and a weight gain (500 cc headache, blood pressure or pulse output and facilitate prompt
approximately = 1 Ib). rate changes. intervention.
Position in semi-Fowler’s or Semi-Fowler‘spositioning pre-
high-Fowler’s position. vents blood pooling and
facilitates breathing and
improved air exchange. High-
Fowler’s positioning reduces Patient will have stable vital signs and hemody-
preload quickly by pooling blood namics will be within patient’s acceptable
but does not decrease stroke parameteirs.
volume significantly.Afterload
decreases by dilating peripheral Patient will have stable cardiac rhythm with no
arteries and decreasing LVEDl?
dysrhythmias, and perfusion to organs will be
Balance rest with short, planned Prevents increased demand on maintained.
periods of activity; provide heart and myocardial oxygen
atmosphere that is conducive to supply. Patient will have clear lung fields with no
rest. adventitious breath sounds.
Monitor for mental status Central nervous system distur-
bances can occur with decreased
Patient will have palpable peripheral pulses with
changes, decreases in orientation,
restlessness, agitation, or dizzi- cardiac output due to decreases warm, dry extremities.
ness. in perfusion to these areas.
Patient will have adequate urinary output, with
Administer vasoactive drugs as These agents promote optimum no edema or extra weight gain.
ordered, with titration based on cardiac output by changing
ordered parameters. blood pressure, and can reduce
afterload and preload.
Administer anti-dysrhythmic These agents decrease pacemaker

drugs as ordered. activity, modig areas of impaired
conduction, and blocks sympa-
thetic effects of the heart:
myocardial contractility is
PHEOCHROMOCYTOMA
Increased secretion of catecholamines

c
Increased erythropoietin “Fight or flight” reflex Chronic excess of
stimulation Sense of impending doom catecholamines
c 4
Increased hemotocrit Impaired reflexes to maintain
upright BP
4 4
Vasoconstriction Orthostatic hypotension
c
.I c c J,
Hemodynamic GI Neurologic Renal Metabolic
Increased TPR Decreased blood flow Decreased baroreceptor Increased urine Increased metabolism
Increased SVR slows digestion sensitivity excretion of in response to
Increased CO catecholamines catecholamines
3. c c c
Hypertension Nauseahomi ting Pounding headaches Increased
I
and epigastric pain Visual disturbances catecholamine
Paresthesias by-products (VMA
Anxiety & metanephrines)
Tremors
c c c
Impaired oxygen Constipation Increased cerebral Angio tension
in the heart capillary pressure Aldosterone release
I
JI JI 4 c
LV strain Increased respiratory Cerebral edema Increased renal
LV enlargement workload Cerebral hemorrhage blood flow
J c c c
Cardiac Shortness of breath DEATH Ischemia of renal tissue
decompensation on exertion c
(decreased cardiac output) Tachypnea Retention of water.
e D yspnea sodium, potassium & chloride
c c
Chest pain, palpitations Respiratory failure Increased blood pressure
with bradycardia c Hypovolemia
or tachycardia DEATH c
J Kidney failure
Decreased peripheral 4
perfusion with cold DEATH
clammy skin, pallor
e Inadequate nutrition Increased glycosis Increased heat loss
Cardiogenic shock for body’s needs Alpha receptor insulin Increased temperature
e Weight loss release inhibited Flushing diaphoresis
Impaired immunity Hyperglycemia Seizures
DEATH
RENAL/ENDOCRINE SYSTEMS 28 1
Thyrotoxicosis ances; thyroid antibodies positive in Graves’ dis-

ease; glucose levels elevated from insulin
resistance, increased glycogenolysis, or impaired
insulin secretion; serum cortisol decreased due to
lower adrenal reserve; alkaline phosphatase
Hyperthyroid crisis, also known as thyroid storm
increased; serum calcium increased; liver function
and thyrotoxicosis, is a life-threatening emergency
abnormal, decreased serum catecholamines; urine
characterized by greatly exaggerated signs of
creatinine increased
hyperthyroidism. Mortality is high, and symptoms
appear rapidly when triggered by infection, TRH test: used in some cases to identify TSH
trauma, surgery, diabetes, or abrupt withdrawal of suppression with administration of TRH
thyroid medication. Thyroid storm may be diffi- hormones
cult to diagnose because the precipitating illness
Electrocardiogram: used to identifjr elevated thy-
may mask its detection.
roid levels or electrolyte imbalances; atrial
Hyperthyroid patients are more susceptible to cat- fibrillation may be present; cardiomegaly in elderly
echolamines because of the increased number of with masked hyperthyroidism
catecholamine receptors they possess. A triggering
Oxygen: used to provide supplemental oxygen due
illness creates an outpouring of catecholamines,
to increased oxygen consumption and increased
and so the elevated levels of thyroid and increased
metabolic demands
number of receptors create the crisis. A hyperme-
tabolic state then ensues causing increased oxygen Radiography. chest x-rays used to identify cardiac
and nutrient consumption, fluid and electrolyte enlargement that may occur in response to
imbalances, and a catabolic state. increased circulatory demands, to identify
presence of cardiac overload and congestion, respi-
Patients in crisis typically have hyperthermia,
ratory infiltrates or other precipitating causes
tachydysrhythmias, dehydration, nausea, vomit-
ing, weight loss, and neurologic changes. Radioactive iodine uptake test: used to differenti-
Treatment is usually begun without waiting for ate types of thyroid problems; usually high in
confirmation of lab tests and is aimed at support- Graves’ disease and toxic goiter, but low in
ing vital functions. Reversal of excessive thyroid thyroiditis
hormone decreases the hypermetabolic state, and
Thyroid scan: may be used to aid diagnosis when
reduction of the circulating thyroid hormones fur-
thyrotoxicosis is caused from cancer or a
ther decreases the crisis. Once vital functions are
multinodular goiter
preserved, treatment of the precipitating cause is
begun. If the crisis is untreated, heart failure, Iodine solutions: used to slow the release of thy-
exhaustion, and death will ensue. roid hormones; common solutions are Lugol’s
solution and sodium iodide
MEDICAL CARE Beta-adrenergic blockers: used to reverse periph-
Laboratory: serum and serum free T4and T, are eral effects of excessive thyroid hormones and to
increased; TSH levels are decreased; thyroglobulin decrease the hypermetabolic state; commonly used
is increased; electrolytes are used to identify imbal- is propranolol; reserpine IN also helps to reduce
peripheral effects and may help decrease the tachy-
cardias
Corticosteriods: high doses of hydrocortisone help Outcome Criteria

support body functions during hypermetabolic state
Patient will have normal body temperature
Digoxin: may be required for congestive heart fail-
restored and be able to maintain temperature
ure patients prior to initiating beta-blockade
within acceptable range.
Diuretics: may be required if congestive heart fail-
ure occurs, and may also help decrease calcium
level if neuromuscular function is compromised INTERVENTIONS RATIONALES
Monitor temperature for eleva- Hyperthermia up to 106 degrees
Nutrients: high doses of vitamin B complex are may result from the acceleration
tion andlor pattern of elevation,
used to provide necessary nutrient support for the chilling, shaking, or diaphoresis. of the metabolic rate caused from
catabolism state, as well as to facilitate increased excessive thyroid hormone secre-
glucose, protein, and carbohydrate absorption tion. Chills may precede
temperature elevation.
Thyroid hormone antagonists: used to block the Monitor other vital signs and Elevated temperatures may result
thyroid hormone production and effects; usually heart rhythm for alterations. in elevations of blood pressure,
propylthiouracil (PTU) or methimazole (Tapazole) respiration, and pulse. Cardiac
are used; lithium carbonate can also inhibit thy- dysrhythmias as a result of heart
failure, electrolyte imbalance, or
roid hormone synthesis and may be used in fluid overload may be noted
patients who cannot tolerate the other drugs promptly to allow timely inter-
vention.
Sedatives: may be required to help patient rest and
If required, use cooling methods Assists in reducing temperature,
reduce myocardial oxygen consumption and car-
such as cooling blankets, ice but may cause shivering which
diac workload, as well as control of shivering that packs, etc., being careful to not increases metabolic rate and may
may increase metabolic rate cause shivering. worsen condition.
Surgery: thyroidectomy or subthyroidectomy may Administer antipyretic medica- Assists with reduction of remper-
tions as ordered by physician, ature. Aspirin should be avoided
be required but avoid the use of aspirin. because it increases free thyroid
hormone levels and may worsen
NURSING CME PLANS condition.
Administer antithyroid medica- P T U or rnethimazole inhibits

Hyperthemia tions as ordered. thyroid hormone synthesis, and
PTU inhibits conversion ofT, to
Related to: accelerated metabolic rate secondary to
T, in peripheral tissues. Iodine-
excessive thyroid hormone secretion, increased containing agents inhibit the
beta-adrenergic responses, increased sodium-potas- release of stored thyroid
sium exchange in cells hormones and help to inhibit
synthesis. Glucocorticosteroids
Defining characteristics: increase in body temper- block conversion of T4 to T3.
ature over 100 degrees, flushed warm skin, Administer beta-adrenergic Propranolol and nadolol block
diaphoresis, tachypnea, tachycardia, delirium, blockers as ordered. the peripheral effects from exces-
lethargy sive thyroid hormone and may
block conversion ofT4 to T,.
Administer IV fluids and elec- Replaces fluid losses from fever

trolytes as ordered. and diaphoresis.
RENAWENDOCRINE SYSTEMS 283
INTERVENTIONS RATIONALES resistance, decreased cardiac output or cardiac

index, tachycardia, decreased or absent peripheral
Administer antibiotics if ordered. Assist in fighting infection when
that is believed to be a precipitat- pulses, EKG changes, hypotension, gallops,
ing factor in the crisis. decreased urinary output, diaphoresis, deteriora-
Ensure comfort of patient by Assists in reducing and maintain- tion in mental status, impending cardiovascular
frequent repositioning, changing ing temperature. collapse.
of linens and clothing, cool
clorhs, lowering room
temperature, etc. Outcome Criteria
Information, Instruction, Patient will be able to maintain cardiac output at
Demonstration an acceptable level for tissue perfusion.
Instruct patiendfamily in all Promotes knowledge and facili- INTERVENTIONS RATIONALES
medications being utilized. tates compliance with regimen.
Monitor vital signs, especially Peripheral vasodilatation and
Observe for depression, tremors, Symptoms may indicate adverse blood pressure for widening decreased fluid volume may
nausea, vomiting, or increased effects from lithium carbonate. pulse pressures. result from excessive
urine output. catecholamine secretion.
Instruct in watching for fever, May be indicative of an agranu- Widening of pulse pressure may
sore throat, or rashes, and to locytosis caused from indicate compensatory changes
notify physician if he develops medication. in stroke volume and decreasing
rhese symptoms. systemic vascular resistance.
Observe heart rate and respira- Provides accurate assessment of

Discharge or Maintenance Evaluation tory rate while patient is tachycardia without increase
sleeping. demand of activity.
Patient will have stable vital signs and be able to
Auscultate heart tones for extra Hypermetabolic states create
maintain values within normal ranges. sounds, gallops, and murmurs. prominent S1 sounds and mur-
Patient will have no adverse reactions to medica- murs due to the forcefulness of
the cardiac ourput, and S3 gallop
tions or treatment. development may indicate
impending cardiac failure.
Patient will be able to accurately recall all
instructed information. Monitor cardiac rhythm for Excessive thyroid hormone secre-
changes, and treat accordingly tion creates excessive
Risk for decreased cardiac output per hospital protocol. catecholamine srimulation to
myocardium which can result in
Related to: excessive demands on cardiovascular tachycardia and dysrhythmias,
and may worsen condition by
system due to hypermetabolic state, increased car-
decreasing cardiac output.
diac workload, hyperthermia, increased sensitivity
of catecholamine receptors, changes in venous Assess for weak or thready pulses, May indicate dehydration and
decreased capillary refill, reduction in circulating volume
return, changes in peripheral and systemic vascular decreased urinary output, and which compromises cardiac
resistance, changes in heart rhythm or conduction. deueased blood pressure. output.
Defining characteristics: elevated blood pressure, Auscultate lung fields for changes Adventitious breath sounds may
in breath sounds. indicate early signs of pulmonary
elevated mean arterial pressure, elevated systemic congestion or impending cardiac
vascular resistance, elevated peripheral vascular failure.

Administer IV fluids as ordered. Fluid replacement may be'indi- Monitor lab studies, i.e., potas- Hypokalemia may cause cardiac
cated to increase circulating dysrhythmias and hypercalcemia
sium, calcium, etc.
volume, but may result in cardiac may interfere with contractility,
failure or overload. both of which decrease cardiac
Administer atropine if indicated. Beta-blockers that are given to output and function.
control tachycardia and tremors Identifies causative organism that
Monitor cultures for infection.
during the crisis may decrease may be responsible for thyroid
heart rate, and may result in crisis. The most frequent factor
symptomatic bradycardia requir- of thyrotoxicosis is respiratory
ing treatment. infection.
Administer digoxin if indicated. CHF patients may require digi- Assist with hemofiltration, May be used in severe crisis to
talization prior to initiating
hemodialysis, or plasmapheresis rapidly decrease thyroid
beta-blockers. procedures. hormone.
Administer sedatives andlor Reduces metabolic demands by Prepare patientlfamily for Subtotal or total thyroidectomy
muscle relaxants as ordered. promoting rest, and may be
surgery as indicated. may be required once ruthyroid
helpful to reduce shivering that
state is attained.
occurs with fever.
Administer supplemental oxygen Assists to support increased

as ordered. metabolic needs and with Discharge or Maintenance Evaluation
increased oxygen consumption.
Assist patients by restricting Reduces energy expenditure Patient will have stable vital signs and hemody-
activity or assisting with activity which increases oxygen namic parameters will be within normal limits.
when required. consumption and contributes to
increase metabolic needs. Patient will have stable cardiac rhythm with no
dysrhyt hmias .
Information, Instruction, Patient will exhibit no signs/symptoms of car-
Demonstration diac failure.
INTERVENTIONS RATIONALES Patient will be able to tolerate activity without
Identify patients who may be at Allows for closer assessment and circulatory compromise.
most risk from complications of monitoring of patients who may
disease, such as elderly, preexist- develop cardiovascular compro- Patient will be able to accurately verbalize
ing coronary disease or cardiac mise from therapeutic measures instructed information.
risk, pregnancy, asthma, or bron- designed to relieve thyroid crisis,
choconstrictive diseases. and enable appropriate choices of Risk for altered nutrition: less than body
beta-blockers or other agents. requirements
Once PTU therapy has begun, May result in further thyroid [See DKA]
avoid abrupt withdrawal of drug. crisis. PTU may not have rapid
effect on thyroid crisis. Related to: hypermetabolic state, excessive thyroid
hormone secretion, nausea, vomiting, elevated glu-
If oral iodine solution is utilized, Minimizes hormone formation
it should be started 1-3 hours from the iodine. Iodine may cose levels
after beginning anti-thyroid interfere with radioactive iodine
medication. treatment and has been known Defining characteristics: weakness, fatigue, weight
to exacerbate the crisis in some loss, lack of inadequate food intake, increased glu-
individuals. cose level
Risk fir injuy Information, Instruction,

Related to: cognitive impairment, altered protec- Demonstration
tive mechanisms of body, hypermetabolic state
~ ~~~~
Defining characteristics: diminished attention Discuss patient’s feelings regard- Assists patient in verbalizing con-
span, agitation, restlessness, impaired judgment, ing alterations in appearance, cerns regarding perceptions of
weakness, impaired body functions methods to enhance self-image, unattractiveness and allows for
and exercises for eyes. discussion of methods to
enhance appearance with
Outcome Criteria makeup, shaded glasses, and
exercises for extraocular muscles
that can help maintain mobility
Patient will be free of personal injury with all
of eyelids.
body systems functioning normally.
Patient will be free of personal injury to any
body system.
Monitor patient for complaints May result from excessive cate-
of eye pain, photophobia, eye cholamine stimulation, and may Patient‘s eyes will remain moist, with decreased
irritation, tearing, dificulty clos- require care until crisis is edema, and will have the ability to completely
ing eyelids, and presence of resolved. close the eyelids.
periorbital edema.
Assess for decreasing visual acuity May be a result of Graves’ disease Patient will be able to freely discuss concerns
or blurring of vision. in which increased tissue behind and problems and be able to utilize problem-
the orbit causes exophthalmos solving skills.
and infiltration of extraocular
muscles and weakness. Vision Anxiety
may worsen or improve without [See Pheochromocytoma]
basis on medical therapy or dis-
ease progression. Related to: hypermetabolic state, increased cate-
Administer medications as indi- Prevents eyes from drying and cholamine stimulation
cated, especidly eye lubricant protects cornea when patient is
drops and ointment. unable to close eyelids Defining characteristics: apprehension, loss of
completely because of edema. control, panic, shakiness, distorted perception,
Ensure interventions to prevent Prevents injury due to physical restlessness, tremors, mental changes, lack of
injury to patient are in place, risks in environment. attention
such as bed in lowest position,
side rails raised, restraints when Fatipe
necessary, etc. [See DKA]
Assess for changes in mental Assists with identification of
Related to: hypermetabolic state, increased
status and ability; reorient changes that may occur as a
patient as necessary. result of exhaustion, electrolyte thyroid hormone secretion, increased energy
or other chemical imbalance, or requirements, changes in body chemistry, central
physiological problems and nervous system irritability, increased oxygen con-
allows for prompt intervention.
sumption and demand
Defining characteristics: lack of energy, inability INTERVENTIONS RATIONALES

to perform normal activities, inability to concen-
Instruct to avoid taking over-the- Antithyroid medicines can affect
trate, lethargy, irritability, nervousness, tension, counter medications unless andlor be affected by several
apathy, depression advised to do so by physician. OTC drugs and may cause dan-
gerous interactions.
Knowledge &fieit
Instruct in diet needs, avoidance Hypermetabolic states require
Related to: lack of information, unfamiliarity with of caffeine, artificial preservatives increased nutrients to maintain
resources, misinterpretation of information, lack and dyes. well-being and meet demand.
Stimulants and additives may
of recall result in systemic problems.
Defining characteristics: requests for information, Instruct in needhationale for Compliance with monitoring
questions, misrepresentation of facts, inaccurate continued medical follow-up. medical regimen and identifca-
follow-through of instructions, development of tion of potential complications
can be assessed for timely inter-
preventable complications vention.
Patient will be able to accurately recall measures Patient/family members will be able to
for managing hyperthyroidism and be able to accurately recall all instructional information
decrease risk of complications. provided to them.
Patient will be free of preventable
complications.
Patient will be able to correctly recall all med-
Discuss patient's perceptions and Establishes knowledge base of
knowledge of disease. patient and helps identify inter-
ications and effects.
ventions and appropriate plan of
Patient will be able to manage hyperthyroidism
care.
without crisis.
Ensure that family members are Patient's physical condition may
included in discussions and interfere with his ability to con-
allowed to verbalize their concentrate which can hinder the
cerns and questions. learning process. Instruction to
the family can assist with rein-
struction when needed.
Instruct in all medications, Provides knowledge and facili-

effects, side effects, complica- tates compliance with regimen.
tions. and symptoms to report to Antithyroid therapy will require
physician. long-term use in order to inhibit
hormone production. Alternate
drugs may be chosen if the
patient develops symptoms of
agranulocytosis from his therapy.
Instruct to notify physician for May be indicative of adverse

fever, sore throar, or rashes. reactions to thiourea rherapy and
facilitates prompt treatment.
THYROTOXICOSIS (THYROID STORM)
Underlying hyperthyroidism
c
Precipitating factor
c
Thyroid hormone levels increase
(T3 and T4)
Increased sympathetic 7Unregulated hypermetabolic

adrenergic responses responses
c JI
Increased cardiac output Fever
Wide pulse pressures Flushing
Increased heart rate Diaphoresis
Increased contractility GI irritability
Cardiac dysrhythmias Nauseahomiting
Heart failure Diarrhea
Increased oxygen consumption

4
Irritability
Confision
Angina
Dysrhythmias
Heart failure
MUSCULOSKELETM SYSTEM 289
SYSTEM
Fractures
Amputation
Fat Embolism
.WC"' '
MUSCULOSKELETAL SYSTEM 29 1
occurs to the arm or leg, the fascia surrounding

the muscles form compartments with small open-
A fracture is a break in a bone that occurs when ings for major arteries, nerves, and tendons,
direct or indirect pressure is placed on the bone in Edema can compress these structures and cause
a force sufficient to exceed the bone's normal elas- ischemia to muscle tissues. The initial ischemic
ticity and causes deformation. There are many changes result in a histamine release that causes
types of fractures, but the major classifications dilation of the capillary bed and edema to the
include open or compound, closed or simple, area. The edema further compresses the larger
complete, incomplete, and pathologic fractures. arteries, which in turn creates further ischemia,
further histamine release, and a vicious cycle is
In closed fractures, there is no contact of the bone formed. The nerves, veins, arteries, and muscles
with the environment. In open fractures, the skin may receive irreversible damage within 6 hours,
surrounding the area of the break is open and the and contractures, paralysis, and paresthesia may
bone is exposed to the environment. The major occur within 24-48 hours without intervention.
goal in these types of fractures involves the preven-
Healing begins when the blood around the end of
tion of infection in conjunction with achieving
proper alignment. Many patients have severe the bone forms a clot and is related to the revascu-
larization process. An inflammatory response
bleeding associated with this type of fracture. A
complete fracture is one that involves the occurs with blood vessel dilatation, then the
complete cross-section of the bone and it is visibly increased permeability of the capillaries allow pro-
tein and granulocytes to leak into the tissue.
misaligned. In an incomplete fracture, the actual
Fibrinogen converts to fibrin that collects proteins
break may only involve a part of the cross-section
of the bone in which one side of the bone is
and other types of cells, and the granulation tissue
allows for debris removal. When the pH of the
broken and the other part is merely bent.
fluid surrounding the bone fragments decreases,
Pathologic fractures occur without or with mini-
calcium goes into the solution and this begins the
mal trauma and are usually seen in diseases such as
process that helps to form new bone. After a
osteoporosis and cancer.
couple of weeks, the pH of the tissues rises, and
Fractures not only cause damage to the bone calcium precipitates into the meshwork and a
involved, but to the soft tissues, nerves, tendons, callus is formed as a bridge within the fragments
and vascular system as well. These structures are in of bone.
close proximity to the bones and help to support
Frequently, if open fractures are present, fat partic-
skeletal weight and to facilitate joint movement.
ulate may embolize, and the patient must be
When the fracture occurs, this stability is lost, and
monitored for this complication.
in turn, results in pain, swelling and splinting.
[See Fat Embolus]
The surrounding muscles are usually flaccid ini-
tially after the injury, but within an hour or less,
may commence to spasm and this may impair MEDICAL CARE
venous circulation and displace the fracture X-rays:used to identify type, location, and sever-
further. ity of fractures or traumatic injuries and to
Another complication that frequently occurs is evaluate healing process stage
called compartmental syndrome. After a fracture Bone scans, CT scans, MRI scans: used to iden-
ti$ fractures and/or soft tissue damage
Arteriography: may be used to identify presence INTERVENTIONS RATIONALES

and severity of vascular damage associated with Administer analgesics as war- Reduces pain, promotes muscle
fracture ranted, and especially prior to relaxation, and facilitates patient
painful activities. cooperation with medical treat-
Laboratory: CBC may identify hemorrhage or ment.
hemoconcentration; WBC is usually increased due Provide backrubs, massage, posi- Helps to reduce pressure areas,
to the stress response after an injury but may indi- tion changes, and other comfort enhances circulation, and may
cate infection; coagulation profiles may be used to measures. decrease pain.
identify problems related to blood loss, liver Administer muscle relaxants as Reduces muscle spasms which
injuries, or after blood transfusions warranted. can decrease pain.
Surgery: may be required to repair and realign

bone structure, nerve injury, soft tissue injury, or Information, Instruction,
vascular injuries; may be required to stabilize Demonstration
skeletal integrity; may be required to relieve com- ~ _ _ _ _ ~
partmental syndrome compression INTERVENTIONS RATIONALES

Instruct on relaxation Redirects attention from pain
Traction: used to realign fractured bones and to techniques, deep breathing exer- and provides patient with feel-
facilitate healing in proper alignment cises, visualization, guided ings of control; may assist patient
imagery, therapeutic touch, etc. in coping with discomfort.
NURSING CARE PLANS Instruct patient in use of PCA as Provides patient with control
over his pain relief and has been
warranted.
Alteration in comfort shown to reduce the amount of
narcotic analgesic the patient
Related to: pain, muscle spasm, fracture, trauma, requires for pain control.
soft tissue injury, nerve injury, vascular injury,
Instruct patient to notify nurse May indicate infection, ischemia,
tendon injury, traction apparatus or MD of sudden different pain or compartmental syndrome.
or pain that is unrelieved with
Defining characteristics: communication of pain, analgesics.
moaning, facial grimacing, guarding of injured
area, inability to be distracted, anxiety Discharge or Maintenance Evaluation
Patient will have no complaints of pain.
Outcome Criteria
Patient will be able to control pain management
Patient will be free of pain or pain will be by use of PCA with satisfaction.
controlled to patient’s satisfaction.
rately and will notify medical personnel for
INTERVENTIONS RATIONALES signs/symptoms of complications.
Immobilize injured body part. Reduces pain and prevents fur- Patient will be able to demonstrate accurately
ther skeletal displacement.
and effectively the use of relaxation activity
Support injured extremity gently Decreases edema, promotes skills for use with controlling pain.
and elevate using pillows as war- venous return, and may help to
ranted. decrease pain.
MUSCULOSKELETAL SYSTEM 293
Impaired physical mobility INTERVENTIONS RATIONALES

Related to: fractures, pain, immobilization, trac- Evaluate integrity of traction Traction provides for a pulling
apparatus and set-up. force on the long axis of a frac-
tion, neurovascular impairment tured bone to facilitate proper
alignment and healing.
limited range of motion, decreased muscle Maintain free hanging weights Ensures that the prescribed
and unobstructed ropes when amount of weight is maintained
strength, decreased muscle control, reluctance to
traction is utilized. on traction and reduces muscle
move injured body part spasms and pain.
Apply antiembolic hose and Prevents venous stasis and

Outcome Criteria remove for 1 hour every 8 hours. decreases potential for throm-
bophlebitis.
Patient will achieve and maintain optimal mobility
Observe for redness, tenderness, May indicate thrombophlebitis.
and function of injured area. pain, or swelling to the calf;
assess for positive Homan's or
Pratt's signs.
Evaluate degree of immobility After trauma, patient's percep-
that has resulted from injury tion of limitations may be out of Information, Instruction,
and patient's perception of his proportion with their physical Demonstration
limitations. levels of activities and may
require further information to INTERVENTIONS RATIONALES
dispel false concepts.
Instruct patient in use of spirom- Prevents atelectasis and facilitates
Maintain bedrest and move Decreases potential for further eter and coughing and deep lung expansion.
injured limbs gently, supporting injury and impairment in align- breathing exercises to be done
areas above and below the frac- ment while stabilizing the every 2 hours.
ture. injured area.
Do not routinely elevate the Elevation may place pressure on
Reposition patient every 2 hours Prevents formation of pressure knees. the lower extremities and
and prn. areas and improves circulation. decrease venous return and blood
flow.
Assist patient with range of Prevents muscle atrophy,
motion exercises of all extremi- increases blood flow, improves
ties as warranted. joint mobility, and helps prevent Discharge or Maintenance Evaluation
reabsorption of calcium due to
disuse. Patient will achieve and maintain increased
Encourage isometric exercises Helps to contract muscles with- mobility and function of injured area.
once bleeding and edema has out bending joints or moving
resolved. extremities to facilitate mainte- Patient will be free of complications that may
nance of muscle strength. These occur as a result of immobility.
exercises can exacerbate bleeding
or edema if these problems are Patient will be able to effectively demonstrate
not resolved. exercises to increase mobility.
Ensure that adequate numbers Casts andlor traction apparatus
may be cumbersome and heavy
Patient will be able to recall accurately all infor-
of personnel are present for
repositioning. and may require increased per- mation instructed.
sonnel to avoid injury to the
patient or the nurses.
Risk f i r peripheral neurovascuhr INTERVENTIONS RATIONALES

dysfinction decreases in muscle movement will require emergency interven-
distal to the injury, and notify tion to restore circulation.
Related to: vascular injury, soft tissue injury, inter-
M D as warranted. Compartmental syndrome can
ruption of blood flow, edema, thrombus, result in permanent dysfunction
hypovolemia and deformity within 24-48
hours and irreversible damage
Defining characteristics: decreased or absent may occur after 6 hours without
pulses, cyanosis, mottling, pallor, cold extremities, intervention.
mental changes, abnormal vital signs, decreased Assist with monitoring of com- Increases in pressure above 30
urinary output partmental pressures as mmHg requires immediate inter-
warranted. vention to prevent permanent
damage.
Outcome Criteria
Assess skin around cast edges for Rough edges of the cast may
redness or pressure points, or for produce pressure and result in
Patient will be able to maintain adequate tissue complaints of burning under the ischemia or tissue breakdown.
perfusion. cast. Cover rough edges of cast Burning pain may indicate pres-
with tape. sure areas that are inside cast and
not visible.
INTERVENTIONS RATIONALES Monitor cast for presence of flat- May indicate that the cast is
tened or dented areas. placing pressure to areas and may
Monitor vital signs. Systemic perfusion will be
result in tissue necrosis.
impaired if circulating blood
volume is inadequate. Cutlbivalve cast as needed per Relieves circulatory impairment
hospital/MD protocol for circu- that may occur from edema and
Palpate peripheral pulses and Decreased or absent pulse may
latory impairment. swelling to injured area.
identify changes in equality or indicate vascular injury that
character of pulses distal to requires immediate intervention. Apply ice packs to fracture site as Reduces edema and hematoma
injury. warranted. formation.
Monitor extremity involved for Circulatory impairment may Remove patient’s jewelry from May impair circulation when
rapid capillary refill, skin color, result in delayed refill times injured extremity. extremity swells.
warmth, and sensation. greater than 5 seconds. Arterial
compromise may occur when Perform testing for tendon May indicate superficial tendon
skin is cool to cold and white, damage: Immobilize the two damage if the patient cannot
and venous compromise may fingers on either side of the wiggle his finger, and deep
occur with cyanosis. Sudden patient’s middle finger and ask tendon damage if the patient
ischemic signs may be caused him to wiggle the middle finger; cannot flex the finger.
with joint dislocation due to immobilize the proximal inter-
injury to adjacent arterial struc- phalangeal joint of a
tures. laceratedlinjured finger and ask
him to flex the finger.
Monitor for changes in neurovas- Paresthesias, numbness, tingling,
cular integrity every 1-2 hours as or diffused pain may occur when
warranted. Notify M D for signif- nerves have been damaged or
icant changes. when circulation is impaired, and Demonstration
may require intervention.
Evaluate complaints of pain that Hemorrhage andlor edema
are abnormal for the type of within the muscle fascia can Prepare patient for surgery as Surgical intervention may be
injury sustained, pain with pas- impair blood flow and cause warranted. required to relieve compartmen-
sive muscle stretching, or compartmental syndrome that tal pressure in order to avoid
permanent dysfunction.

Instruct patient in signslsymp- Provides knowledge and allows during movement. Positioning
toms to notify nurse/MD: for patient involvement in care. helps ro decrease pressure to skin
increased pain, decreased sensa- Provides method for prompt areas.
tion or movement, or changes in detection of potential complica-
temperature or color of injured tions to facilitate prompt Monitor integrity of traction set- Improper set-up or positioning
part. intervention. up, pad areas that come in con- of apparatus may result in tissue
tact with patient’s skin. injury or skin breakdown.
Padding prevents pressure areas
Discharge or Maintenance Evaluation from forming on skin and
enhances moisture evaporation to
Patient will have equally palpable pulses, warm prevent skin excoriation.
and dry skin, and stable vital signs. Cover the ends of any traction Prevents injury to other skin
pins or wires with cork or other tissues.
Patient will have normal sensation to injured protectors.
part.
Apply skin traction as ordered. Benzoin provides a protective
Patient will be able to recall information accu- Apply traction tape lengthwise layer to prevent skin abrasion
on both sides of the injured limb with removal of tapes. Traction
rately and will be able to avoid potential
after applying tincture of benzoin tape that encircles a limb may
complications. and extend the tape beyond the impair circulation.
limb.
Impaired skin integrz.9
Mark a line on the tapes at the Provides identification marker to
Related to: compound fracture, traumatic injury, point when the tape extends assess whether traction tape has
surgery, use of traction pins or other devices, use beyond the limb. slipped.
of fixation devices, immobilization Using elastic bandage, wrap the Allows prescribed traction with-
limb and tape (and padding, if out impairing circulation.
Defining characteristics: disruption of skin sur- needed) being careful to avoid
face or other tissue layers, open wounds, pain, wrapping too tight.
paresthesias Remove skin traction at least May provide evidence of any
daily and observe for any red- skin impairment and allows for
dened or discolored areas. cleansing of area to remove
Outcome Criteria Provide skin care. debris or drainage.
Patient will achieve optimal wound healing and If cast is present, cleanse plaster Dry plaster can flake and result
off skin while still damp. in skin irritation.
have no skin breakdown.
Use padding, tape, and/or plastic Prevents skin breakdown and
to protect cast near perinea area. helps to prevent contaminants
from adhering to cast.
INTERVENTIONS RATIONACES
Changes may indicate problems Avoid use of lotions or oils These agents can creare a seal
Observe skin for open wounds,
around cast edges. and prevent the casr from
redness, discoloration, duskiness, with circulation that may be
“breathing.” Powder should be
cyanosis, mottling, or pallor. caused by traction, casts, or
splints, or by edema. avoided because of the potential
for accumulation inside the cast.
Apply eggcrate mattress, flotation Helps prevent formation of pres-
mattress, air mattress, sheepskins, sure areas caused by immobility.
or use kinetic rype bed.
Encourage patient to use trapeze May minimize potential for abra-

bar and reposition frequently. sions to elbows from friction

Demonstration Observe wounds for redness, May indicate presence of
drainage, dehiscence, failure to infection.
INTERVENTIONS RATIONALES heal, etc.
Instruct the patient to avoid Objects used for scratching may Perform wound carelpin care Removes drainage and debris
purring objects inside cast, such damage tissue. utilizing sterile technique. from wound which may prevent
as fly swarters, coat hangers, etc. infection.
Instruct patient in cast care. Provides knowledge for future Obtain cultures as ordered. Identifies causative organism and
patient care and involves the allows for specific antimicrobial
patient in his medical treatment. therapy to eradicate the infec-
tion.
Discharge or Maintenance Evaluation Observe prescribed isolation Isolation may be required

techniques. depending on type of infective
organism. Precautions will pre-
Patient will have no further skin breakdown.
vent cross-contamination and
Patient will have healed wounds without com- spread of infection.
plications. Observe wounds for presence of May indicate the presence of gas
crepitus or fruity-smellinglfrothy gangrene infection.
Patient will be able to avoid complications of drainage.
immobility. Evaluate patient’s complaints of May indicate development of
sudden increase of pain or diffi- comparrmenral syndrome or
Patient will be able to accurately recall all
culty with movement in injured osteomyelitis.
instructive information. area.
Risk for infection Observe for hyperreflexia, muscle May indicate development of
rigidity, spasticity in facial and tetanus.
Related to: broken skin, disrupted tissues, exposed jaw muscles, and decreases in
bone structure, traction devices, surgery, invasive ability to speak or swallow.
procedures
Defining characteristics: temperature elevation,
Demonstration
elevated white blood cell count, shift to the left,
purulent drainage, redness, warmth, and tender- INTERVENTIONS RATIONALES
ness
Instruct patient to avoid touch- Decreases potential for spread of
ing wounds or pin sites. infection.
Outcome Criteria Instruct patientlfarnily in kola- Provides knowledge and ensures
tion procedures. compliance with procedures and
Patient will be free of signs/symptoms of infection decreases chance of cross-conta-
and wounds will heal without complications. mination.
Prepare patient for surgical pro- Surgical intervention may be

cedures as warranted. required to remove necrotic bone
INTERVENTIONS RATIONALES or tissue to facilitate healing
process and to prevent further
Monitor vital signs. Observe for Increased temperature and heart infection.
fever, chills, and lethargy. rate may indicate impending or
present sepsis. Gas gangrene may
result in hypotension and mental
changes.
Discharge or Maintenance Evaluation INTERVENTIONS RATIONACES

Instruct in signdsymptoms to Provides for prompt identifica-
Patient will have appropriate wound healing
notify MD: pain, elevated tern- tion of problem to ensure
with no signdsymptoms of infection. perature, chills, paresrhesias, prompt intervention.
paralysis, color changes, edema,
Patient will be able to accurately recall all dislodged fixator, cracks in casts,
instructions and avoid potential complications. etc.
Knowledge deficit
Related to: lack of information, misunderstanding
of information, inability to recall information
Defining characteristics: verbal requests for infor-
mation, questions, inaccurate statements, lack of Discharge or Maintenance Evaluation
compliance with instructions, lack of follow-
through, development of preventable Patient will be able to accurately recall all
complications instructional information.
Patient will be free of preventable
Outcome Criteria complications.
Patient will be able to accurately verbalize under- Patientlfamily will be able to accurately perform
standing of disease process and treatment. demonstration of wound/pin care.
~~ ~
~~ ~~
Evaluate patient’s understanding Provides baseline of patient’s

of disease process, injury, and knowledge and helps identiFy
treatment. need for instruction.
Instruct patientlfamily regarding Fractures usually require casts or

mobility concerns. splints during healing, and
improper use may delay
woundlbone healing.
Instruct patient in exercises to Prevents joint stiffness and

perform. muscle wasting.
Instruct in wound care/fLuator Enables patient to understand

pin care. need for sterile/aseptic wound
care to prevent further injury
and infection.
Instruct patient to keep all Provides for identification of

follow-up appointments. complications and promotes
patient compliance with medical
regimen.
FRACTURES
Trauma
I
Skeletal instability
3
Soft tissue injury
I
Loss of weight support Bleeding
I
Loss of attachments for
muscles and ligaments
3
Joint motion disabled
I
Muscle contractions
4
Inflammatory response
Vasodilation
Increased capillary permeability
I
Protein and granulocytes leak
into tisssues
3
Edema
L Blood clots at injury site

I
Granulation tissue invades clot
4
Reticuloendothelial cells remove debris
I
Calcium goes into solution
I
New capillaries grown into clot
I
New bone cells formed
I
Calcium salts precipitate into cell meshwork
I
Collagen formed
3
Callus formation
Angiography, arteriography: used to assess blood

Amputation flow and to identify the optimal amputation level
Amputation may be caused by trauma, disease, or CT scans: used to identify neoplasms,
congenital problems. It may be required for osteomyelitis, or hematoma formation
uncontrolled infection, intractable pain, or
Doppler ultrasound or flowmetry: used to assess
gangrene due to inadequate tissue perfusion, and
blood flow to tissue areas
is usually performed as distally as possible to pre-
serve viable tissue and bony structure for use with
prosthetics. NURSING CARE PWNS
A closed amputation utilizes a flap of skin for clo- Alteration in comfort
sure over the residual limb, and an open [See Fractures]
amputation requires future revisions and the Related to: injury, trauma, surgical procedure
wound heals by granulation. The open
amputation is utilized in patients who are poor Defining characteristics: complaints of pain,
surgical candidates and with the presence of infec- guarding of area, facial grimacing, moaning, dis-
tion. Traumatic amputation is an accidental loss of comfort
a body part and is classified as complete when the Alteration in tissue petfksion: peripheral
part is totally severed, and partial when there is
some connection with soft tissues. Related to: disease, surgical procedure, decreased
blood flow, edema, hypovolemia
Amputation may be considered as a last option
when trying to salvage an extremity, and the sur- Defining characteristics: absent or diminished
geon may try revascularization, resection, or pulses, color changes, mottling, blanching,
hyperbaric oxygenation in an attempt to save the cyanosis, necrosis, gangrene, temperature changes,
limb. A lower extremity amputation is still consid- swelling
ered a life-threatening procedure, especially when
the patient is elderly or has peripheral vascular dis- Outcome Criteria
ease. With the advances in microsurgery,
reimplantation of severed digits and limbs have Patient will have adequate peripheral perfusion
become more successful. with equal pulses, warm, pink skin, and optimal
wound healing.
MEDICAL CARE
Laboratory. culture and sensitivity of the wound INTERVENTIONS RATIONALES
~ ~~
may be done to identify the infection organism Assess presence of peripheral Changes in equality between
and the optimal antimicrobial agent required to pulses, strength, equality, and limbs, diminished strength or
eradicate the infection; sedimentation rate usually character. Notify MD for signifi- absence indicates problems with
cant changes. perfusion.
increased due to inflammatory response; CBC
with differential used to identify elevated white
blood cell count and presence of a shift to the left
representing an infection process

Perform neurovascular checks Circulation may become Monitor vital signs and notify Sepsis may result in temperature
every 1-4 hours, noting changes impaired due to edema or tight MD for significant changes. elevation, tachycardia, and
in color, temperature, movement, dressings and may result in tachypnea.
or sensation. necrosis of tissues. Prompt detec-
tion of problems will allow for Observe wound for signs of Prompt recognition of infection
prompt intervention. infection: redness, warmth, may result in prompt interven-
drainage changes, swelling, or tion and decrease the porential
Evaluate non-operative leg for Peripheral vascular disease may deh iscence, for further complications.
edema, inflammation, erythema, increase the incidence of post-
or positive Homan’s or Pratt’s operative thrombus formation. Culture wound drainage as war- Identifies causative organism and
signs. ranted, and as per hospital allows for choice of optimal
protocol. antimicrobial agent to eradicate
infection.
Demonstration Change dressing using aseptic or Reduces spread of or introduc-
sterile technique as warranted. tion of bacteria to wound.
INTERVENTIONS RATIONALES Ensure that drainage systems are Drainage systems facilitate
Instrucr patient to report changes Paresthesias may occur as a result functioning properly, and that removal of drainage from wound
in sensarion to operative site or of nerve damage or with measurementlemptying of which can decrease the chance of
any swelling. impaired circulation. Swelling drainage is being performed. infection from stagnant body
may result from fluid shifting or fluids. Measurement of drainage
from continued bleeding which provides a trend to identiG loss
would require intervention. of fluid as well as potential heal-
ing or deterioration of wounds.
Discharge or Maintenance Evaluation Administer antimicrobials as Drug rherapy may be given pro-
ordered. phylactically using a
Patient will have strong, equal peripheral pulses, broad-spectrum antibiotic until
specific sensitivity reports are
with no changes in sensation or temperature.
available to identify organism-
+ Patient will be able to accurately recall specific antimicrobials.
signs/symptoms to report to nurse/MD. Information, Instruction,

Patient will experience optimal wound healing. Demonstration
Risk for infection INTERVENTIONS RATIONALES
Related to: trauma, surgical incisions, open skin, Instruct patient on signslsymp- Allows for prompt recognition of
invasive procedures, disease, decreased nutritional toms of infection to report, problems to facilitate prompt
intervention.
status
Instruct on antimicrobial Provides knowledge and facili-
Defining characteristics: temperature elevation, effects, side effects, and tates cooperation in the medical
elevated white blood cell count, shift to the left, contraindications. regimen.
sepsis, purulent drainage, reddened wound site, Instruct patient/family on infec- Provides knowledge and facili-
swelling, wound dehiscence tion control procedures, isolation tates compliance with treatment;
requirements, etc. involves rhe family in parienr
care and reduces the potential for
Outcome Criteria spread of infection.
Patient will be free of infection with no threat to

wound healing.
~~
Impaired skin integrity INTERVENTIONS RATIONALES

~~~ ~
Related to: amputation, surgical procedure, inva- Leave wound open to air, or Helps to facilitate healing; a light
cover with a light gauze dressing dressing may be required to pre-
sive procedures, broken skin as soon as feasible. vent sutures or wound from
becoming irritated by linens,
Defining characteristics: surgical wounds, punc- clothes, etc.
ture sites, abraded skin, disrupted skin or tissues
Outcome Criteria Demonstration
Patient will have healed wounds with no skin or INTERVENTIONS RATIONALES

tissue disruption. Instruct patient to avoid touch- Prevents spread of infection or
ing wound. contamination of the wound.
Instruct patient in wound care as Promotes knowledge and pro-

INTERVENTIONS RATIONALES warranted. vides for patient involvement in
his care.
Inspect wound daily to assess for Prompt detection of changes can
healing, deterioration, color, facilitate prompt intervention for Instruct in use of abdominal Provides additional support for
character and amount of complications. Decreases in binder or supportive device as incisions at risk of dehiscence.
drainage, signslsyrnptoms of drainage amounts may indicate warranted.
infection, etc. appropriate healing, whereas
increasing amounts of drainage,
or purulentlodiferous drainage Discharge or Maintenance Evaluation
may indicate the presence of
fistulas, hemorrhage, or infective Patient will have healed wounds with no
process.
impairment of skin integrity.
If drainage amount is large, Helps reduce skin trauma by
apply collection deviceslbags over reducing surface area in contact Patient will be able to accurately perform
sites, recording amounts every 8 with drainage, and facilitates wound care utilizing appropriate infection con-
hours. more accurate measurement of trol techniques.
drainage.
Cleanse wound per protocol at Helps reduce potential for infec-

Patient will be able to use supportive devices as
ordered frequency utilizing sterile tion: removes debris and caustic needed to prevent wound dehiscence.
or aseptic technique. (Many drainage from skin surface to
facilities use hydrogen peroxide preserve skin integrity and pro- Patient will be able to demonstrate appropriate
followed by normal saline rinse.) mote healing. behavior to prevent wound healing complica-
Utilize benzoin or other slun Protects skin from abrasion with tions.
barrier products prior to the removal of tape. Use of netting
application of tape during dress- or Montgomery straps prevent
Risk for fluid volume deficit
ing changes, or use Montgomery repeated removal of tape which
can further disrupt skin integrity.
Related to: nauseahomiting, fever, excessive
straps or stretch netting for dress-
ings that may require more wound drainage, urine output, changes in vascular
frequent changes. integrity, fluid shifts, oral fluid restriction
Defining characteristics: imbalance between
intake and output, dehydration, poor skin turgor,
tenting of skin

Concurrent administration with
Patient will achieve and maintain an adequate analgesics may potentiare the
fluid balance, with stable vital signs and hemody- analgesic in addition to control-
namic parameters, and palpable pulses. ling nausea and vomiting related
to the pain medication.
~~ ~
Monitor lab values for hemoglo- Hematocrit provides an indicator
INTERVENTIONS RATIONALES bin and hernatocrit, and notify of fluid volume status and hydra-
MD for significant changes. tion. Blood losses that are not
Monitor viral signs every 1-2 Fluid deficit symptoms may be replaced may result in further
hours. manifested in low blood pres- fluid deficits.
sure, and increases in respiratory
and heart rates. Changes in pulse
quality or cool and clammy skin
may indicate decreased perfusion Information, Instruction,
and peripheral circularion and Demonstration
the need for replacement fluids. ~~ ~~~
Monitor intake and output q 1-2 Prompt recognition of imbalance

hours, and notify MD of signifi- and fluid loss provides for Instruct patient to report Pressure sensation may result
cant fluid imbalances or urine prompt intervention and replen- increases in wound drainage, from retroperitoneal hemorrhage
output less than 30 cclhr for 2 ishment of necessary fluids. leakage, or feelings of pressure and should be evaluated immedi-
hours. sensation to wound areas. ately. Including the patient in his
Evaluate for presence of Immediate postoperative nausea care provides for cooperation
nausedvomiting; medicate as may result due to length of anes- with medical regimen and pro-
warranted. thesia and predisposition for vides for prompt recognition of
nausea. Nausedvomiting lasting potential problems that may lead
to circulatory collapse from
longer than 3 days may result
from adverse reactions to anal- hypovolemia.
gesics or other medications.
Observe wound sites for Sudden cessation of previously
increases in drainage, swelling to noted wound drainage may indi-
area, or lack of drainage in drain cate an obstruction in the
Patient will be adequately hydrated, normoten-
tubes. drainage system, with potential sive, with equal palpable pulses.
drainage then routed to tissues
and other cavities. Edema to Patient will have a balanced fluid intake with
wound sites may indicate the adequate urinary output.
formation of a hematoma or
hemorrhage from the wound. Patient will have normal skin turgor and moist
Lack of swelling does not mean mucous membranes.
that hemorrhage is not occur-
ring-retroperitoneal bleeding Patient will be able to accurately recall
may not be visually noted until
signs/symptoms to notify nurse/MD.
long after the patient has shown
vital sign changes.
Administer IV fluids, blood and Replaces necessary fluids and Body image disturbance
blood products as warranted. increases circulating volume.
Related to: loss of body part, disease process, dis-
Administer antiemetic drugs as Relieves nausea and vomiting
warranted; may administer these which can result in the ability to
figurement, loss of function
in combination with analgesics. ingest adequate fluid amounts.
Defining characteristics: negative feelings about

body, preoccupation with missing part, avoidance
Encourage family members to Provides opportunity for family
of looking at missing part, perceptions of changes assist with care and assess their members to deal with the loss
in lifestyle, preoccupation with previous function ability to support patient. and to help in the rehabilitation
of missing part, feelings of helplessness phase.
Outcome Criteria
Patient will be able to adapt and cope with Demonstration
changes in body image and demonstrate ability to
accept self.
Instruct patientlfamily as to pre- Promotes knowledge and pro-
~~ and postoperative care, rehabili- vides opportuniry for patient to
INTERVENTIONS RATIONALES tation, and use of prosthetics. verbalize concerns and questions,
May enhance postoperative
Evaluate patient’s ability to deal Provides input as to level of recovery and facilitate compli-
with amputation and his percep- understanding of patient. ance with medical treatment.
tion of need for amputation. Traumatic amputees most often
have trouble in dealing with Obtain consultations as May enhance patient’s rehabilita-
body image problems, as warranted with counselors or tion and ability to adapt to new
opposed to those who have rec- therapists. body image.
onciled that amputation may Discuss concerns regarding sexu- Provides knowledge and helps
have been a life-saving proce-
ality as warranted. with adjustment to body image,
dure. as well as provides opportunity
Patients may not be able to deal to dispel any misconceptions.
Observe for withdrawal, denial,
or negativity regarding self. with the trauma initially and
may require time to come to
terms with their new self.
Recognition of stages of grief Discharge or Maintenance Evaluation
provides opportunity for inter-
ventions. Patient will adapt and accept new situation and
Provide time to discuss patient’s Provides opportunity to dispel body image changes.
concerns over the change in body false concerns and allows time
structure and his perceptions of for problem solving with realistic Patient will be able to identify methods to adapt
needs for a new/different goals. to changes and will be able to have positive self-
lifestyle. esteem.
Encourage patient to help partic- Promotes feelings of indepen-
dence and allows time for patient
Patient will be able to identify realistic goals and
ipate in his care and provide
opportunities for patient to to accept his body image. plans for rehabilitation and adapting to modifi-
observe stump. Positive reinforcement regarding cation in body image.
the progress toward healing may
hrther help his self-worth. Anticipatory grieving
Discuss the availability of visits Another person who has gone Related to: actual loss of physical well-being
by another amputee. through the same experience may
facilitate recovery and help the Defining characteristics: expressions of anger or
patient to recognize how he may
attain a normal lifestyle.
distress at loss, crying, sadness, guilt, alterations in INTERVENTIONS RATIONALES

sleep patterns, activity, eating or libido
Assist patient to focus on needs Reduces frustration of facing an
Outcome Criteria he has now before changing uncertain future, and allows the
focus to long-term goals. patient some control in dealing
Patient will be able to express feelings Encourage patient to take con- with current problems.
trol in decisions regarding his
appropriately and work through the stages of grief
care whenever possible.
and grieving.
Provide acceptance of anger, Acceptance of the patient‘s feel-
hopelessness, and depression, but ings acknowledges him as being
set limits on unacceptable behav- worthwhile and a non-judgmen-
INTERVENTIONS RATIONALES ior when warranted. ral attitude is important in
establishing trust and care.
Evaluate emotional status. Anxiety, depression, and anger
Limits may be needed to protecr
are normal reactions to loss of
the patient and others from vio-
body parts. The patient may
lent behavior while allowing the
progress through the various
patient to express his negative
stages of grief at their own rate
feelings.
and changes may be related to
their physical condition as well. Provide consultation with thera- Physical and spiritual distress will
pists, social workers, or minister be faced by the patient and hls
Identify patient‘s stage in the Shock may be the initial response
as warranted. family and they will require long-
grieving process. associated with the amputation,
term assistance and counseling in
especially if it was traumatic. The
order to cope with the changes
patient may be so acutely ill that
required by this injury.
he is unable to express his feel-
ings and concerns. Denial may
initially be useful for patient’s
ability to cope with the injury, Discharge or Maintenance Evaluation
but continued denial may impair
the patient’s ability to effectively Patient will be able to progress through the vari-
deal with the problem. Anger ous stages of grief and grieving effectively.
may be expressed either verbally,
non-verbally, or physically, and Patient will be able to express his feelings and
the patient may displace his
concerns appropriately without unacceptable
anger by placing blame.
Depression may last from weeks violent behavior.
to years and acceptance and sup-
port for these feelings will Patient will be able to access community
facilitate recovery. resources for long-term counseling and
Provide factual information to Family may be where the initial
assistance to deal with his injury.
patientlfamily in regard to the instruction is directed if the
diagnosis/prognosis. Do not give
Patient and family will be able to gain adequate
patient’s awareness is diminished
false reassurance. due to his injury. The final out- support throughout the grieving process.
come of a patient’s injuries may
not be initially known and so
information should be kept
simple.
AMPUTATION
Trauma or end result of disease process

4
Loss of body part
I
I I I I
Hemorrhage Edema Decreased mobility Infection
J 4 4
Decreased fluid Decreased venous Pain
volume return 4
Decreased perfusion Respiratory insufficiency
L I Hypoxia
4
Inability for wound to heal
4
Cellular ischemia/death
Systematic infection 4
4
Sepsis
4
DEATH
~
Fat Embolism Dextran: low molecular weight dextran may be

used to alter platelets and decrease intimal adhe-
A fat embolism usually occurs in patients with sions
multiple fractures or fractures that involve the X-rays: serial chest x-rays are used to evaluate pul-
long bones or pelvis, when particles of bone monary improvement or deterioration; x-rays of
marrow, tissue fat droplets, or combinations of the bones involved in injury are used to evaluate
platelets and free fatty acids are released and healing process or alignment problems
migrate to the lungs or brain. Embolization can
occur within the first 24 hours up to 72 hours
after injury.
NURSING CARE PLANS
The first signs/symptoms are usually changes in
the mental status, with apprehension, confusion Related to: altered blood flow due to embolism,
and restlessness noted. Petechiae to the chest, shunting
anterior axillae, shoulders, conjunctiva and buccal
Defining characteristics: abnormal acid-base bal-
membranes occur due to capillary occlusion and
ance, hypoxemia, hypoxia, tachypnea, tachycardia,
are usually seen later. Respiratory distress with
air hunger, dyspnea, cyanosis, decreased oxygen
hypoxemia and hypoxia, pulmonary edema, and
saturation
interstitial pneumonitis occur. The pulse rate
increases, temperature elevates above 100 degrees
and PaO, decreases. Outcome Criteria
Patient will be able to achieve and maintain ade-
MEDICAL CARE quate respiratory function with arterial blood gases
Laboratory: serum lipase is elevated, sedimenta- within normal ranges and with no evidence of res-
tion rate is increased; urine tests used to evaluate piratory distress.
presence of free fat
Arterial blood gases: used to evaluate acid-base INTERVENTIONS RATIONALES
balance, presence of adequate oxygenation, and ~~
Monitor vital signs, especially Dyspnea and tachypnea may be

response to oxygen therapy respiratory status; assess for dysp- early signs of respiratory insuffi-
nea, use of accessory muscles, ciency. Other signs usually result
Electrocardiogram: used to evaluate changes in retractions. nasal flaring, or stri- from advanced respiratory dis-
heart rate as well as cardiac changes, such as inver- dor. tress, and all require prompt
sion of T waves and prominence of S wave in lead intervention.
I showing myocardial and right ventricular failure Observe for changes in mental Changes in mental status often
status, irritability, apprehension, are the very first signs in respira-
Corticosteroids: use is controversial, but may or confusion. tory insufficiency.As hypoxernia
decrease inflammation and swelling and acidosis worsen, the level of
consciousness may deteriorate to
Heparin: use is controversial, but low dose the point of lethargy or stupor.
heparin may be used to clear lipemic plasma and Monitor pulse oxirnetry for Oximetry may provide early
stimulate lipase activity oxygen saturation and notify warning of decreasing oxygena-
MD for levels below 90%. tion and allow for prompt and
timely intervention. In patients

who have decreased peripheral Monitor lab studies. Patients with far emboli
circulation however, the accuracy frequenrly have anemia, elevated
of pulse oximetry will be com- sedimentation rates, elevated
promised and cannot be relied lipase levels, fat in body fluids,
on totally. hypocalcemia, and thrombocy-
topenia.
Administer oxygen via nasal can- Provides supplemental oxygcn
nula or mask as warranted. and increases available supply of Administer corticosteroids as Some physicians use steroids to
oxygen to ensure optimal tissue ordered. prevent and treat fat emboli.
oxygenation.
Obtain ABGs as warranted. Decreased PaO, and increased

PaCO, indicate impending respi- Discharge or Maintenance Evaluation
ratory failure and impaired gas
exchange. Patient will have no respiratory dysfunction or
Adventitious breath sounds may
distress.
Auscultate breath sounds for
changes in equality and for pres- indicate progression of respira-
Patient will have arterial blood gases within his
ence of crackles (rales), rhonchi, tory insufficiency. Inspiratory
wheezing, inspiratory stridor or crowing may indicate upper normal range.
crowing, or hyperresonant airway edema frequently seen
sounds. with fat emboli.
Observe for presence of blood in May indicate hemoptysis that

spurum. occurs with pulmonary
embolism.
Observe for petechiae CO chest, Petechiae to these areas are fre-

axillae, buccal mucosa, and con- quently seen with fat emboli,
junctiva. and may occur 2-5 days after
injury.
Encourage coughing, deep Improves alveolar ventilation/

breathing exercises, and use of oxygenation and helps to mini-
incentive spirometer. mize atelectasis.
Demonstration
Prepare for placement on ventila- Deteriorating respiratory status
tor as warranted. may require mechanical ventila-
tion to facilitate oxygenation.
[See Mechanical Ventilation Care
Plan.]
Use great care in repositioning Gentle handling of injured bones

patient especially dxing the first and tissues may prevent the
days post-injury. development of a fat embolism.
MUSCULOS KELETm SYSTEM 309
FAT EMBOLISM
Fractures
4
Trauma
Increased catecholamine Increased pressure in long

and steroid release bones with high fat content
4 4
Causes serum lipids to Fat forced into blood stream
mobilize tissue stores of fat
into circulation
I
I I I
Marrow embolus Tissue fat globules Platelets & free fatty acids
I I
c
Embolize to pulmonary capillaries
4
Obstruction of pulmonary blood flow
4
Decreased tissue perfusion
4
Increased pulmonary vascular resistance
and back-up pressures
4
Pulmonary hypertension
4
Ventilation/perfusion mismatching
Right to left shunting
4
Pulmonary constriction
4
Decreased Pa02
Hypoxemia
4
Respiratory distress
4
4
DEATH
INTEGUMENTARY SYSTEM 31 1
Frostbite/Hypothermia
Malignant Hyperthermia
BurndTherrnal Injuries
INTEGUMENTARY SYSTEM 313
FrostbiteAiyuotherrnia The core temperature may be as low as 80"

Fahrenheit and below 900, the body loses its self-
Injuries from overexposure to cold, either air or warming mechanisms.
water, occur in two types-localized injuries, such Hypothermia may also preclude successful resusci-
as frostbite, and systemic injuries, such as tation. Cardiac arrest is difficult to overcome if the
hypothermia. Untreated, both may be fatal. core temperature is less than 85" Fahrenheit due to
Frostbite occurs after exposure to cold the increased ventricular fibrillation threshold.
temperatures, usually below freezing. The severity Treatment is aimed at rewarming the body to
of the injury is dependent on the,amount of body increase the core temperature to adequate ranges,
heat lost, age and exacerbating factors such as and to preserve organ and tissue viability.
wind chill, presence of wet clothing, and impair-
ment of the circulatory status. MEDICAL CARE
In frostbite, ice crystals form in the tissue fluids in Laboratory: CBC may indicate infection with
and between the cells, causing injury to the red shift to left; electrolytes will be required to restore
blood cells, which then develop sludging, and vas- balance from fluid shifts
cular damage. Blood is shunted to the heart and
the brain. Skin is cold, hard, ashen white and IV fluids: used to restore circulating volume and
numb, and with rewarming, becomes splotchy red prevent dehydration, and may be used to assist
or grayish in color, edematous, and very painful. with rewarming
Frostbite can be either superficial, affecting skin Dextran: low molecular weight dextran may be
and subcutaneous tissues, or deep, extending used to improve microcirculation to tissues
below subcutaneous tissues. With deep frostbite, Reserpine: may be used to decrease sludging from
the skin becomes white until thawed and then it injured cells and tissues
becomes purplish-blue, with painful skin blisters,
tissue necrosis, and development of gangrene Antibiotics: may be necessary to treat infection if
when the tissue dies. At this point, amputation of patient has open wounds or systemic infection
the extremity may be required. Analgesics: morphine and other drugs may be
The most frequently seen sites that are involved used to relieve severe pain from cold injuries;
with frostbite are the nose, ears, hands, and lower aspirin may be used to decrease platelet aggrega-
extremities. The goal of treatment is to restore tion and sludging
body temperature to normal and prevent vascular Surgery: fasciotomy may be required to reduce
damage to tissues. Supportive care is also impor- tissue pressure caused from edema; amputation
tant in restoring electrolyte imbalances and may be necessary for gangrenous injuries, or
preventing hypovolemia. debridement may be required for necrotic tissues
Hypothermia occurs when the body's core temper- Dialysis: peritonea1 or hemodialysis may be used
ature drops below 95" Farenheit and is noted by depending on severity of injury, in order to
lethargy, mental dullness, decreasing level of con- rewarm body
sciousness, visual and auditory hallucinations,
decreases in respirations and heart rate, and coma.
Rewarming techniques: warming blankets, INTERVENTIONS RATIONALES

warmed solutions for chest lavage or bladder irri-
gation, and warmed IV solutions may be utilized Observe for mental changes and Shivering is suppressed at tem-
return of shivering response. peratures below 90 degrees F and
to increase temperature
is che body's normal response to
facilitate self-warming. Patients
NURSING CARE PLANS have decreased mental abilities
and levels of consciousness
Inefective thermorepltion dependent on severity of
hypothermidinjury, with
Related to: exposure to cold, suppressed shivering hypoxia and hypoxemia occur-
response ring due to decreased perfusion.
Defining characteristics: temperature below 95"

Fahrenheit, cold skin, mottling, cyanosis, pallor, Information, Instruction,
poor judgment, apathy, decreased mental ability, Demonstration
level of consciousness changes, coma, lack of shiv-
ering, cardiopulmonary arrest, anuria, oliguria, ~
Instruct patient/family on appro- Provides knowledge and reduces

decreased peripheral perfusion
priate procedures for rewarming. anxiety.

Patient will achieve and maintain an acceptable
Patient will be normothermic, with stable vital
temperature with no complications.
signs.
Patient will be awake, alert, and oriented, with
INTERVENTIONS RATIONALES no alterations in abilities.
Patient will be able to maintain thermoregula-
Obtain baseline temperature, and Temperatures below 90 degrees
monitor every 15 minutes until result in suppression of normal tion.
stable. body mechanisms to self-warm-
ing. Rewarming that is done too
Patient will exhibit no complications from
rapidly may cause peripheral hypothermia.
vasodilation and may actually
impede rewarming efforts. Alteration in tissue pe@sion: peripheral,
Rewarm patient per hospital Early rewarming decreases tissue
cerebral, curdiopulmonuy, renal, gastroin-
protocol. (Whole body or partial damage from ice crystal forma- testinul
immersion into water that is 99- tion, and helps to decrease
105 degrees, hypothermia cardiac instability and predisposi- Related to: exposure to cold temperatures, frozen
blankets, gastric lavage with tion to ventricular fibrillation. body parts, hypothermia, tissue necrosis, sludging
warmed solutions, peritonea1 or of red blood cells, tissue ischemia
hemodialysis, and IV infusions
that are warmed are some meth- Defining characteristics: skin mottling, grayish
ods currently used.) skin color, purplish-blue color, cold skin, burning,
tingling, numbness, pain, skin blisters, gangrene,
diminished or absent pulses, decreased capillary
refill, cardiac dysrhythmias, cardiac standstill, INTERVENTIONS RATIONALES

apnea, dyspnea, mental changes, unconsciousness,
changes in consciousness level, coma, gangrene, Move and handle patient and Excessive movement may trigger
oliguria, anuria, absent bowel sounds, ileus handle him gently when lethal dysrhythmias or may cause
required. tissue damage.
Administer warmed IV solutions Restores circulating volume,

as ordered. helps to maintain hydration and
output, assists with rewarming
Outcome Criteria efforts, and assists with treatment
of hypotension.
Patient will achieve and maintain normal body
Monitor hourly intake and Anuria or oliguria may indicate
temperature with no lasting complications of
output, and notify M D for sig- decreased perfusion CO renal ves-
decreased perfusion. nificant changes or sels or dehydration.
abnormalities.
Evaluate patient's level of con- Patients may have weakness,

INTERVENTIONS RATIONALES sciousness and mental status, and incoordination, apathy, drowsi-
notify M D for significant ness, and confusion with
Monitor EKG for rhythm Hypothermia affects heart rate
changes. hypothermia. When body tem-
changes, dysrhythmias, and car- and rhythm and may cause heart
perature is below 90 degrees F,
diac standstill, and treat irregularities due to hypoxemia
stupor and coma are common.
according to hospital policy. and conduction problems. Heart
rhythm may be difficult to Observe for muscle tremors, Neurologic symptoms may occur
restore to sinus when body tem- decreased reflexes, seizures, and due to hypothermic influences.
perature is less than 85" F Parkinson-like muscle tone.
because of the increased ventric-
ular fibrillation threshold. A Remove constricting clothing Constriction especially in the
12-lead EKG may show an early and jewelry from patient. presence of edema may impair
J wave in the left ventricular circulation and perfusion.
leads.
Rewarm involved extremity in Prompt rewarming teverses ice
Monitor vital signs every 15 During initial period after tepid water (37-40"Centigrade) crystal formation in tissues.
minutes until stable, then every exposure, pulses and blood until the tips of the injured part Warmer water is not indicated
1-2 hours. pressure may be too weak to be flush. due to the potential for burns.
detectable. Rewarming too The appearance of skin flushing
rapidly may result in heart indicates that circulatory flow
irregularities. has been reestablished.
Administer oxygen as ordered, PaOz should be maintained Avoid rubbing the injured Helps to prevent further tissue
with warmed humidification. above normal levels to treat extremity, and handle the area damage.
hypoxia and hypoxemia that gently.
occurs with acidosis as a result of
Encourage patient to take warm Assists with rewarming.
the injury and exposure.
liquids if possible.
Monitor pulse oximetry levels Facilitates prompt identification
Monitor vital signs; palpate for When extremity has rewarmed,
and notif) MD if level drops of acid-base imbalances and
presence and character of pulses pulse should be able to be pal-
below 90%. Monitor ABGs for changes in ventilation/
to extremities. Notify MD if pated. Absence of pulse may
changes. oxygenation.
pulse is absent after rewarming is indicate decreased or absent
Monitor peripheral pulses for Decreased or absent pulses may accomplished. circulation.
presence, character, quality, and indicate impairment in circula-
changes. tion to extremities and may
preclude tissue ischemia and
necrosis.

Demonstration
Evaluate pain level, and medicate Rewarming process is extremely
INTERVENTIONS RATIONALES with analgesics as ordered. painful.
Prepare patient for fasciotorny or Ederna may impair circulation Elevate injured extremity on Decreases edema which can
amputation as warranted. requiring a fasciotomy to relieve pillows as warranted. result in pressure to tissues and
pressure. If gangrene is present, pain.
amputation of the involved area
will be necessary. Provide backrubs, repositioning, Helps to refocus attention and
deep breathing exercises, visual- enhances relaxation and ability to
Instruct patient regarding long- Provides knowledge and identi- ization, guided imagery, etc. cope with pain.
term effects: increased sensitivity fies symptoms that patient may
to cold, tingling, burning, be faced with during his lifetime.
increased sweating, etc. Discharge or Maintenance Evaluation
Instruct patient to avoid Smoking causes vasoconstriction
smoking. and may inhibit healing process. Patient will be. pain free.
Patient will be able to utilize comfort measures
Discharge or Maintenance Evaluation and techniques effectively to reduce or alleviate
pain.
Patient will achieve optimal circulation and
peripheral perfusion with equal palpable pulses.
Risk for infection
Patient will be able to recall and adhere to Related to: frozen tissue, open wounds, decreased
tissue perfusion, edema
’instructions and avoid preventable
complications. Defining characteristics: elevated temperature,
Patient will be able to recall instructions accu- elevated white blood cell count, shift to left on
differential, tachycardia, drainage, gangrene,
rately.
edema
Alteration in comfirt
Related to: tissue damage, surgical procedures, Outcome Criteria
rewarming
Patient will be free of open wounds and infection
Defining characteristics: communication of pain, process, and/or wounds will heal in a timely
facial grimacing, moaning, guarding, abnormal manner.
focus on pain, anxiety

When extremity has been Dressings between digits reduce
Patient will be free of pain, or pain will be rewarmed, apply a bulky sterile moisture and help prevent tissue
controlled to patient’s satisfaction. dressing to the area. Place gauze damage. Dressings help protect
between toes or fingers. the area to reduce further injury.
If blisters are present, avoid rup- Reduces the risk of infection.

turing them.
Use sterile or strict aseptic tech- Frostbite makes the patient sus-
nique for all dressing changes. ceptible to infection.
Assist with whirlpool treatments Treatments help CO improve cir-

for the injured extremity. culation, remove dead tissue, and
help prevent infection.
Monitor vital signs and patient Fever, tachycardia, and tachypnea

for presence of fever and chills. may indicate presence of infec-
tion.
Administer antimicrobials as Eradicates infective organism and

ordered. may be given prophyiacticdly.
Administer tetanus toxoid as Concurrent trauma may necessi-

ordered. tate administration to prevent
onset of tetanus.

Patient will be free of drainage from injury.
Patient will be afebrile, with normal vital signs,
and no symptoms of infection.
Patient will have no systemic infection, or pre-
ventable complication.
FROSTBITE/HYPOTHERMIA
Exposure to cold
JI
Vasoconstriction
4
Failure of autoregulatory warming mechanisms
4
Shunting of blood to vital organs
4
Ice crystals form in and between cells
c
RBCs form sludge
c
Capillary ihrombosis
4
Tissue ischemia
I
I Decreased Axygenation
Tissue necrosis
4 4
Gangrene '7 Hypoxia
1 I
I 1 I
Acidosis Lethargy Decreased Cardiac
c respiratory dysrhythmias
effort 4
1 4
Sepsis Confusion Bradypnea Cardiac
arrest
4 4
Hallucinations Apnea
4 4
DEATH
Malignant Hmerthermia Hypothermic treatment: cooling blankets, iced

lavages and enemas, infusions of cooled IV solu-
Malignant hyperthermia is a condition occurring tions may be required to reduce temperature
from surgical procedures in which inhalation
agents or muscle relaxants, such as NURSING CARE PLANS
succinylcholine, enflurane, fluroxene, ether, or
Hypertbermiu
halothane, are used. Although it occurs only about
once in every 20,000 patients, the consequences Related to: reaction to anesthetic agents; hyper-
may be lethal. Malignant hyperthermia results metabolic state
from excessive stores of calcium in the intracellular
Defining characteristics: elevated temperature,
spaces that causes a hypermetabolic state with
tachycardia, tachypnea, muscle rigidity, tetany,
increased muscle contractions.
cyanosis, presence of heart failure, acidosis,
The inherited trait for this condition can be iden- dysrhythmias, shock
tified by increased creatine phosphokinase levels
and/or muscle biopsy for histiochemistry and in Outcome Criteria
vitro exposure to halothane. When this condition
trait is identified in a patient who requires surgery, Patient will be free of fever, with stable vital signs,
the preferred option is for local anesthesia. and will exhibit no evidence of muscle tetany.
The patient will notably have muscle rigidity, fol-
lowed by tachycardia, dysrhythmias, rapidly
increasing temperature, acidosis and shock. If left
untreated, it has a mortality rate of 70%. Monitor vital signs frequently; if Provides for prompt identifica-
able, continuously monitor tem- tion of worsening condition and
Treatment is aimed at recognition of the perature for changes. allows for observation for effec-
tiveness of therapy.
condition, with discontinuation of all anesthetic
agents, and administration of dantrolene Monitor EKG for changes and Dysrhythmias may occur as a
treat dysrhythmias per hospital result of the marked
intravenously to slow down rate of metabolism.
protocol. hyperkalemia that may occur, or
Supportive therapy to correct acidosis and fever with electrolyte imbalances from
should also be performed. fluid overload.
Administer dantrolene as Normally given from 2-4 mg/kg

MEDICAL CARE ordered. IV rapidly through fast-running
IV line; repeated every 15 min-
Electrocardiogram: used to identify conduction utes until a total of 10 mg/kg has
problems or dysrhythmias that may occur been given, or symptoms sub-
side. Dantrolene inhibits calcium
Oxygen: used to supplement oxygen supply due release.
to increased metabolic state Monitor ABGs for changes. May indicate metabolic or respi-
ratory acidosis, and patients
Dantrium: drug used to reverse effects of excessive frequently have noted base excess
calcium in intracellular areas; usually given until -10 mmol.
symptoms abate Administer cooled IV solutions Methods may be required to
as ordered, utilize iced solutions decrease remperature to prevenr
Sodium bicarbonate: may be used to treat severe
acidosis
INTERVENTIONS RATIONALES Related to: hypermetabolic state, fluid shifting

Defining characteristics: increased blood pressure
for gastric lavage or enema, further complication and body
and/or place patient on cooling exhaustion.
and pulse, dyspnea, edema, confusion, restlessness,
blanket. decreased urinary output, increased systemic vas-
cular resistance, decreased cardiac output and
Observe for shivering and Shivering is a normal reaction to
administer Thorazine as ordered. applications of cold, but is coun- cardiac index
terproductive because it increases
metabolism to try to compensate Risk for altered nutrition: less than body
for temperature changes. requirements
Thorazine is given to decrease [See Pheochromocytoma]
shivering and reduce metabolic
workload. Related to: hypermetabolic state, anorexia
Defining characteristics: inadequate food intake,
Information, Instruction, weight loss, muscle weakness, fatigue
Demonstration
INTERVENTIONS RATIONALES [See Pheochromocytoma]
Instruct patientlfamily in need May identify potential for anes-
Related to: increased respiratory workload,
of testing other members of the thetic complications and avoid
family for autorecessive trait. potentially life-threatening impaired oxygen to the heart, hypoventilation,
condition. altered oxygen supply, altered blood flow, change
Instruct in utilization of Assists with understanding and
in vascular resistance
hypothermic therapy methods. facilitates compliance with
discomfort.
hypercapnia, hypoxia, cyanosis, dyspnea, tachyp-
Discharge or Maintenance Evaluation nea, changes in ABG values, metabolic acidosis,
respiratory acidosis, activity intolerance
Patient will be normothermic with stable vital
signs.
Patient will have EKG with no rhythm aberran-
cies or conduction problems.
Patient will exhibit no abnormal muscle
contractions or tetany.
of treatment and comply with regimen.
Patient’s family will comply and be tested for
presence of trait that predisposes them to compli-
cations from anesthetic.
Risk for decreased cardiac output
[See Pheochromocytoma]
~
MALIGNANT HYPERTHERMIA
Inherited autosomal dominant

PLUS
Muscle relaxants and/or general inhalation agents used for surgical procedures
4
Excessive intracelldar accumulations of calcium
4
Increased metabolism rate Hyperkalemia

4 4
Increased muscle rigidity Cardiac dysrhythmias
4 4
Increased muscle contractions Cardiac insufficiency
4
Muscle tissue breakdown with
increased CPK and myoglobin
c
- -
Increased workload on renal system
Impaired oxygenation of tissues

4
Metabolic acidosis
4
Cardiovascular and renal compromise
J,
Organ failure
J,
DEATH
body surface area is involved. The burn injury
Burns/Thermal Injuries causes dilation of the capillaries and small vessels

which leads to increased capillary permeability and
Burns may be caused from thermal, chemical, increased plasma loss. As edema increases, the
electrical, or radioactive sources and may involve destruction of the epidermis becomes a breeding
complex forms of trauma to multiple body ground for bacterial invasion and dead tissue
systems. The depth of the injury is partially deter- sloughs off.
mined by the duration and intensity of exposure
to the burning agent.
The initial treatment of a burn patient is to stop Laboratory: CBC will initially show elevated
the burning process. This may be accomplished by hematocrit due to hernoconcentration, and later
cooling the skin, removal of contact with chemi- decreased hematocrit may mean vascular damage
cals, removal from electrical current, or removal to endothelium; white blood cell count may
from radioactive environment. Often, inhalation increase due to inflammatory response to the
injury also occurs because of inspiration of heated trauma and wound infection; electrolytes may
soot particles, chemicals and corrosives, or toxic show initially hyperkalemia due to injury, later
fumes. changing to hypokalemia when diuretic phase
begins; sodium initially decreased with fluid loss
A severe burn, one in which the patient has 30%
and later changes to hypernatremia when renal
of his body involved, may take months to years to
system attempts to conserve water; alkaline phos-
heal, and mortality is very high. Full-thickness, or
phatase elevated, glucose elevated due to stress
third degree, burns involve all the layers of the
reaction; albumin decreased; BUN and creatinine
skin and sometimes underlying tissues. Partial-
elevated due to renal dysfunction; carboxyhemo-
thickness burns involve the epidermis and upper
globin may be done to identify carbon monoxide
portions of the dermis. Fourth degree burns
poisoning with inhalation injury
involve not only the epithelium, but fat, muscula-
ture, and bones, requiring extensive debridement Radiography: chest-x-rays used to identify compli-
and skin grafting. cations that may occur as a result of inhalation
injury or with fluid shifting from rapid
There are several methods available for determina-
replacement
tion of the percentage of body burn involvement,
but the “rule of nines” is frequently utilized. The Arterial blood gases: used to identify hypoxia or
body is sectioned off with each arm and head/neck acid-base imbalances; acidosis may be noted
area equaling 3%, front, back, and each leg equal- because of decreased renal perhsion; hypercapnia
ing 18%, and the perineum equaling 1%. Extent and hypoxia may occur with carbon monoxide
of thickness, age, and other factors also play a sig- poisoning
nificant role with treatment options. For acutely
Lung scans: may be used to identify magnitude of
severe burns, transport to a burn center is recom-
lung damage from inhalation injury
mended.
Electrocardiogram: used to identify myocardial
Shock may occur in adults who have burns cover-
ischemia or dysrhythmias that may occur with
ing greater than 15% of their body surface area,
burns or electrolyte imbalances
and with children when greater than 10% of their
Analgesics: required to reduce pain associated INTERVENTIONS RATIONALES

with tissue damage and nerve injury
Measure hemodynamics if pul- C W , or right atrial pressure,
Tetanus toxoid: required to provide immunity monary artery catheter has been gives estimate of fluid volume
against infective organism placed. Notify MD for abnormal status. Dehydration may be
parameters. reflected by CVP of less than 5 ,
Antimicrobials: may be required to treat infection while overhydration may be
reflected at levels over 18 cm
Surgery: may be required for skin grafting, H 2 0 . Hemodynamic values may
fasciotomy, debridement, or repair of other help to evaluate the body’s
response to the circulating vol-
injuries umes.
lV fluids: massive amounts of IV fluids may be Observe for restlessness, anxiery, Changes may reflect the severity
required for fluid resuscitation immediately post- mental changes, changes in level of fluid loss.
of consciousness, or weakness.
burn, and will be required for maintenance of
fluid balance as shifting occurs Observe for bleeding from all May indicate impaired coagula-
orifices and puncture sites, and tion, impending or present DIC,
for presenceldevelopment of or inadequate replacement of
NURSING CARE PLIINS ecchymoses, hematomas, or clotting factors.
petechiae.
Risk for fluid volume &ficit
Monitor intake and output May indicate fluid volume
Related to: burn injury, loss of fluid through hourly and notify M D for signif- deficit, and establishes a guide
injured surfaces, hemorrhage, increased metabolic icant imbalances. for fluid and blood product
replacement. Fluid replacement
state, fluid shifts, third spacing, shock, increased is titrated to ensure urinary
cellular membrane permeability output of at least 30-40 cdhr.
Myoglobin may discolor the
Defining characteristics: tachycardia, urine red to black, and if present,
hypotension, changes in mental status, restlessness, urinary output should be at leas
decreased urine output, prolonged capillary refill, 75-100 cc/hr to reduce potential
for renal tubular necrosis.
pallor, mottling, diaphoresis, poor turgor
Administer IV fluids as ordered. Replaces fluid loss, allows for
Two IV sites should be main- administration of vasoactive
Outcome Criteria tained. drugs, plasma extenders, and
emergency medications, as well
Patient will achieve and maintain fluid balance as the administration. Two sites
with adequate urinary output. are recommended to facilitate
simultaneous fluid and blood
resuscitation in critical settings.
Crystalloids, such as Ringer’s
INTERVENTIONS RATIONALES lactate, are used during the first
24 hours, then colloids are used
Monitor vital signs, and notify Hypotension may indicate that because colloids help to mobilize
MD of significant changes or the circulating fluid volume is extravascular fluids. Dextrose is
trends. decreased. Changes in vital signs usually not given during the first
may indicate the amount of 24 hours after injury because
blood loss but may not change dextrose does not remain in the
until loss is greater than 1000 cc. vascular space where it is needed.
Hypovolemic shock may occur
due to hemorrhage, third spac-
ing, or coagulopathy.
INTERVENTIONS RATIONALES apnea, cough with or without productivity,

cyanosis, fever, anxiety] restlessness
Administer blood andlor blood Whole blood may be required
products as ordered. for acute bleeding episodes with
shock due to the lack of clotting Outcome Criteria
factors in packed red blood cells.
Fresh frozen plasma andlor
Patient will have clear breath sounds with stable
platelets may be required to
replace clotting factors and to respiratory status.
promote platelet function.
Identify causative agent of burn. May reflect type of exposure to
toxic substances and potential for
Information, Instruction, inhalation injury.
Demonstration Monitor respiratory status for May indicate the presence or
changes in rate, character, or impending respiratory insuffi-
INTERVENTIONS
_ _ _ _ ~
RATIONALES depth; note tissue color changes ciency and distress. Cherry red
~~ ~~ ~ ~~
with cyanosis, pallor, or cherry color may indicate carbon

Prepare patient for placement of Provides knowledge to the red color. monoxide poisoning.
pulmonary artery catheter. patient, and catheter is invalu-
able for identifying changes in Auscultate lung fields for adven- Obstruction of aimay and respi-
fluid status and hemodynamic titious breath sounds. ratory distress may happen
responses to those changes. quickly, but may be delayed up
to 48 hours post injury.
Identification of abnormal crack-
les, wheezing, or stridor may
Discharge or Maintenance Evaluation indicate impending airway com-
promise and require immediate
Patient will have stable vital signs and urinary intervention.
output.
Observe for presence of cough, Inhalation injury may result in
Patient will have balanced intake and output. reflexes, drooling, or dysphagia. patient’s inability to handle sali-
vary or pulmonary secretions as a
Patient will have good turgor, moist result of pulmonary edema.
membranes, and adequate capillary refill times. Elevate head of bed 30-45 Promotes lung expansion and
degrees. improves respiratory function.
Patient will be free of hemorrhage or abnormal
coagulation. Administer supplemental oxygen May be required to correct
as warranted. hypoxemia and acidosis; humidi-
Patient will have no transfusion reactions. fication of oxygen prevents
drying out mucous membranes
Risk for ineffective airway clearance and keeps secretions less viscous.
Monitor ABGs and observe for May facilitate timely identifica-

Related to: airway obstruction, edema, burns to trends or deterioration. tion of respiratory insufticiency
the neck and chest, trauma to upper airway, pul- and hypoxemia that requires
monary edema, decreased lung compliance intervention.
Monitor oximetry continuously. Decreases in oxygen saturation

Defining characteristics: adventitious breath
may indicate impending hypox-
sounds, dyspnea, tachypnea, shallow respirations, emia or hypoxia.

[See Snakebite]
Monitor EKG continuously and Cardiac dysrhythmias may occur
treat dysrhythmias per protocol. as a result of hypoxia or Related to: burn injury, tissue destruction,
electrolyte imbalances, and some wounds, debridement, surgery, invasive lines
conduction problems may occur
in response to rapid fluid resusci- Defining characteristics: communication of pain,
tation. moaning, crying, facial grimacing, inability to
concentrate, tension, anxiety
Demonstration Impaired skin integn'ty
[See Snakebite]
Related to: burn injury, surgical procedures, inva-
Instruct on coughing and deep Increases lung expansion and sive lines
breathing exercises. helps to mobilize secretions.
Prepare patient/family for poten- May be required for respiratory

Defining characteristics: disruption of skin
tial placement on mechanical embarrassment and distress. tissues, incisions, open wounds, drainage, edema
ventilation.
FeadAnxiety
Discharge or Maintenance Evaluation [See Snakebite]
Related to: burn injury, threat of death, fear of
Patient will be able to breathe spontaneously on
disfigurement or scarring, hospitalization,
his own with no adventitious breath sounds and
mechanical ventilation
adequate oxygen saturation.
Defining characteristics: expressions of apprehen-
Patient will have arterial blood gases within
sion, tension, restlessness, insomnia, expressions of
normal limits.
concern, fear of unknown, tachypnea, tachycardia,
Patient will be able to comply with coughing inability to concentrate or focus
and deep breathing exercises to help clear
mucous secretions.
requirements
Patient will not develop complications from [See Pheochromocytoma]
injury.
Related to: burn injury, increased metabolic rate,
Risk for impairedgm exchange intubation
Defining characteristics: intake less than output,
Related to: carbon monoxide poisoning, smoke weight loss, abnormal electrolytes, weakness,
inhalation, upper airway obstruction, burn lethargy, catabolic state
Defining characteristics: increased work of breath- Impaired physical mobility
ing, dyspnea, abnormal arterial blood gases, [See Fractures]
hypoxemia, hypoxia, decreased oxygen saturation,
Related to: burn injury, dressings, imposed physi-
inability to effectively cough or clear secretions,
cal inactivity
viscous secretions, confusion, lethargy, restlessness,
anxiety

imposed inactivity, contractures, wounds, pain
Risk for infiction
[See Frostbite]
Related to: burn injury, tissue destruction, open
wounds, impaired skin integrity, ARDS
Defining characteristics: elevated white blood cell
count, differential shift to the left, fever, tachycar-
dia, tachypnea, wound drainage, necrosis, presence
of systemic infection
BURNS/THERMAL INJURIES
(thermal, electrical, chemical)
Contact with agent Electrical injury Inhalation injury

s s s
Dialation of capillaries and Physiological function Irritation to
small blood vessels altered respiratory mucosa
s s s
Platelets and leukocytes Muscle stimulation Inflammation
adhere to endothelium
s s .s
Increased capillary permeability Loss of reflex control Mucosal sloughing
s s s
Fluid shifts to interstitial spaces Ventricular fibrillation Pharngeal and laryngeal
swelling/edema
s s J,
Edema Respiratory paralysis Upper airway obstruction
Is
Fluid lost in Hypovolemia Seizures
s
Pulmonary edema
burned tissue
s s s s
4 s
Bacterial invasion Hypoxemia
J,
Increased metabolic rates

I
Multiple Organ Dysfunction Syndrome (MODS)
Acute Poisoning/Drug Overdose
Snakebite
Transplants
Cardiogenic Shock
OTHER 331
Multiole Orflan Dysfunction body systems are affected with decreased

perfusion, hypoxia, and anaerobic mechanisms
Syndrome (MODS) that the body tries to use to maintain metabolic
function.
Sepsis denotes the presence of microorganisms or The goal of treatment is to support
their by-products in the bloodstream that create a cardiopulmonary function and to identify and
fulminating infection with resultant systemic eradicate the organisms responsible for the infec-
involvement and shock. The hemodynamic tion in the first place. With two organ systems
changes that occur during septic shock may result involved, mortality is 50-60% despite treatment,
in inadequate perfusion and the development of with the percentage increasing to 90-100% mor-
multiple organ dysfunction syndrome (MODS). tality with four or more systems involved.
Another syndrome which may lead to MODS is
systemic inflammatory response syndrome (SIRS). The most frequent precipitating factor is usually a
Both sepsis and SIRS utilize the same inflamma- temporary episode of a shock state that results in
tory cascade with differing sources of infectious body cell ischemia. The typical pattern of MODS
versus non-infectious causes, and can both poten- includes a hypotensive episode that is apparently
tially lead to MODS. successfully resuscitated, with elevation of heart
rate and progressive respiratory failure. The
As the bacterial infection progresses, the immune patient is then intubated and appears to be doing
system attempts to destroy the causative microor- better, but is in a hypermetabolic and
ganism, and the endotoxins within the cell hyperdynamic state that produces progressive
membrane are released into the vascular system. changes in labwork. Inotropic support is required,
The endotoxins then trigger systemic then pseudomonas, yeast, or viral organisms
inflammation, activation of the complement cas- progress, causing renal failure and involvement of
cade, and histamine release. This results in all systems, with death ensuing approximately one
vasodilation, increased capillary permeability, and month after the initial event.
leakage of the protein-rich plasma into the intersti-
tial tissues.
MEDICAL CARE
As the plasma seeps into the alveoli, and platelets Laboratory: CBC used to identi5 hemorrhage,
and white blood cells embolize in the microcircula-
platelet dysfunction, infection, shifts to the left on
tion, resulting in release of more vasoactive
differential; electrolytes with sodium decreased;
materials, the lung's compliance decreases and renal profiles used to evaluate renal dysfunction
ARDS develops. The liver is unable to detoxify the and therapeutic response to treatment; hepatic
circulating endotoxins because of microemboliza- profiles to evaluate hepatic dysfunction; coagula-
tion in the liver itself as well as sludge in the tion profiles to identifjr clotting dysfunction and
hepatic system. As fluid volume decreases, the DIC; fibrinogen elevated with DIC; cultures done
heart rate increases and cardiac output is raised. As to identify causative organism and determine
the abdominal organs are constricted from emboli appropriate antimicrobial therapy; glucose
in the microcirculation, myocardial toxic factor elevated due to metabolic state; lactate level
(MTF) is released and blocks the calcium ion increased with metabolic acidosis, shock, or
action and contractility decreases. As more and hepatic dysfunction
more endotoxins are circulating, more and more
Electrocardiogram: used to identify conduction Defining characteristics: increased temperature,

disturbances or cardiac dysrhythmias; may have fever, flushed, warm skin, tachypnea, tachycardia
ST and T wave changes mimicking MI
Risk for alteration in tissue p e f i i o n : cere-
Arterial b1,ood gases: used to identify hypoxia, bral, gaseointestinal, cardiopulmonary,
hypoxemia, acid-base imbalances and evaluate renal, and peripheral
effectiveness of therapy; initially may have respira-
tory alkalosis and hypoxemia, and in later stages,
Related to: vasoconstriction, microembolism, vas-
metabolic and respiratory acidosis with compen-
cular occlusion, hypovolemia, increased oxygen
satory mechanism failure
consumption, inadequate oxygen delivery, alter-
Radiography: chest x-rays used to identify ation in utilization of oxygen by tissues
pulmonary or cardiac changes in vasculature,
Defining characteristics: decreased peripheral
edema, complications; abdominal x-rays used to
pulses, prolonged capillary refill time, pallor,
identifi potential sources of infection, i.e., free air
cyanosis, erythema, paresthesias, pain, tissue
in abdomen
edema, lethargy, confusion, oliguria, anuria,
Antibiotics: may be used to treat infectious cause abnormal ABGs
of sepsis
Narcan: has been used to counteract some of the Outcome Criteria
endotoxins that are circulating in system
Patient will have adequate perfusion to all body
Corticosteroids: have been used to decrease systems.
inflammatory response to toxins
Risk for in$iction Moniror vital signs, noting Hypotension occurs when
[See Renal Failure] trends. microorganisms enter the blood-
stream and activate chemical
Related to: progression of sepsis to septic shock, substances that result in vasodila-
secondary infections, compromised immune tion, decreased systemic vascular
resistance, and hypovolemia.
system, invasive lines, malnutrition, debilitation Tachypnea may be the first
symptom of sepsis as the body
Defining characteristics: increased white blood
responds to endotoxins and
cell count, shift to the left, fever, chills, cough developing hypoxia.
with or without sputum production, wound
Monitor hernodynamic pressures When shock progresses to cold
drainage, hypo tension, tachycardia, impaired skin if available, at least every 1-2 stage, cardiac output decreases in
integrity, wounds, positive blood, urine or sputum hours and pm. response to decreased contractil-
cultures, cloudy concentrated urine ity and alterations in afterload
and preload. Fluid shifting may
Hypertbermia cause third spacing and fluid
[See Pheochromocytoma] overload, and monitoring hemo-
dynamics can facilitate early
Related to: circulating endotoxins, dehydration, identification of changes in
trends.
hypermetabolic state
OTHER 333

Demonstration
Monitor EKG for changes and Tachycardia occurs in response to
treat according to hospital proto- hypovolemia and circulating
col. endotoxins. Dysrhythrnias may
occur from hypoxia, acid-base Observe for oozing at puncture May indicate presence or
imbalances, electrolyte imbal- sites, petechiae, ecchymoses, or impending DIC or coagulation
ances, or shock. bleeding from any area. problem.
Monitor mental status and level May indicate impending or pre- Monitor for drug toxicicy signs Decreased perfusion may
of consciousness for changes. sent hypoxia or acidosis leading and symptoms. increase half-life and decrease
to decreased cerebral perhsion. metabolism of therapeutic drugs
and cause toxic reactions.
Auscultate lung fields for adven- May indicate fluid overload in
titious breath sounds. response to fluid resuscitation or
presence of congestive failure.
Observe for changes in periph- Vasodilation may occur in the
eral skin color and temperature. early phase of shock with warm, Patient will have stable vital signs and hemody-
pink, dry skin, but as shock pro-
namic parameters.
gresses, vasoconstriction occurs
and reduces peripheral blood Patient will have warm skin, with palpable
flow resulting in mottling, or
pale to dusky skin that is cold peripheral pulses that are equal bilaterally.
and clammy.
Patient will be neurologically stable, and have
Monitor intake and output every As renal perfusion is compro- adequate perfusion to all body systems.
hour. mised by vasoconstriction or
microemboli, oliguria or anuria Risk for impziredgas excbunge
may develop.
Palpate abdomen and auscultate Absence of bowel sounds may
for bowel sounds. indicate decreased perfusion to Related to: endotoxins in circulation, hyperventi-
the mesentery from vasoconstric- lation, hypoventilation, respiratory alkalosis,
tion that may result in paralytic increased capillary permeability, alterations in
ileus.
blood flow due to microembolism, capillary
Administer IV fluids as ordered. Large volumes may be required damage
to maintain circulating volume
from hypovolemic state, but Defining characteristics: dyspnea, tachypnea,
must be monitored to identify hypoxia, hypoxemia, hypercapnia, confusion, rest-
and treat fluid overloading.
lessness, cyanosis, inability to move secretions,
Administer oxygen as ordered. Provides supplemental oxygen tachycardia, dysrhythmias, abnormal ABGs,
necessary for cellular perfusion
and to relieve hypoxia.
Administer vasoactive drugs as May be required to maintain Risk for fluid volume &$kit
ordered. pressure and hemodynamics at [See GI Bleeding]
adequate levels to maintain per-
h i o n to body systems. Related to: vasodilation, third spacing, fluid shift-
ing, increased capillary permeability
Defining characteristics: weight loss, output

greater than intake, hypotension, tachycardia,
decreased central venous pressure, decreased
hernodynamic pressures, increased temperature,
dilute urine with low specific gravity, oliguria with
high specific gravity, weakness, stupor, lethargy
OTHER 335
MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)
I I
Increased capillary permeability Coagulation

J, 4
Fluid shiftinglthird spacing Capillary occlusion
L
Release of vasoactive peptides and
toxins for complement activation
Decreased tissue perfusion
J,
I
Tissue ischemia
Organ' failure Lysis of clotted blood
J,
I
Decreadd cardiac Vasobotor Rkal Decreased DIC
output center ischemia GI blood
depression flow
J, J, 4 4
MDF released Decreased Decreased Decreased Depressed
sympathetic blood flow antibacterial
stimulation defenses
J, J, J, 4
Decreased Decreased Relld Endotoxins
calcium ion function venous return insufficiency released
J, J, J, J,
Cardiac Failure Lethargy Renal Vascular

Coma failure dilation
Acute PoisoninaDrug MEDICdL CARE
Overdose Laboratory: drug screens may be used to identify
agent used for suicide attempt; alcohol level to
Attempts to end one's life by use of excessive assess concurrent use or toxicity; electrolytes may
amounts of medication may be executed for many be abnormal due to trauma or interaction with
reasons. Active self-destructive behavior usually medication; hematocrit may be decreased with
results from the patient's perception of an hypovolemia; drug levels, such as phenobarbital or
overwhelming catastrophic event in his life, in acetaminophen, may be elevated due to toxicity;
conjunction with the lack of appropriate coping renal profile may show renal insufficiency; liver
strategies, and is visualized as a means of escape profile may show hepatic dysfunction, especially
from the sensed threat to himself. with acetaminophen overdose; coagulation profiles
may be abnormal; urinalysis may show low
Suicidal patients are frequently ambivalent about specific gravity, increased protein, hematuria,
wanting to die, and may have visions of last- oxalate crystals, or metabolic by-products from
minute rescue. The suicidal person may feel drug overdose
despair, guilt, shame, hopelessness, boredom,
depression, weariness, or dependency, and when Radiography: chest x-rays may show aspiration
the point is reached when the person perceives pneumonia or pulmonary edema complications
that life no longer has meaning and despair is Electrocardiogram: used to identify conduction
overwhelming, the patient acts on those emotions. problems or dysrhythmias that may occur from
Suicide may be considered the last logical step drug overdosage, electrolyte disturbances, or with
when the person perceives that others do not want congestive failure
them around or that the problem can never be
reconciled. Dialysis: hemodialysis or hemoperfusion may be
performed to remove some drugs when levels are
Usually, an attempt at causing death is the culmi- severely elevated
nation of a process in which the person had
ideations about killing himself, verbal or nonver- Diuretics: may be required to force osmotic diure-
bal threats of his intention, and gestures in which sis with agents such as mannitol, to manage
attempts of causing self-injury without actual certain forms of overdose
intentions to cause death. Acetylcysteine: Mucomyst is treatment of choice
Suicide is the eighth leading cause of death in this with acetaminophen overdose
country today, and the second leading cause of Charcoal: used to bind poisons, toxins, or other
death in young people. Drug ingestion is the most irritants, increases absorption in the GI tract, and
frequent method utilized with suicide attempts, helps to inactivate toxins until excreted
partially because of the availability of medications,
and partially to avoid more violent means of
death, such as with weapons or by hanging.
NURSING CARE PWNS
Risk for inefective breathing pattern
Related to: respiratory depression from drug,

obstruction, pulmonary edema, pneumonia
striction or obstruction leading
Defining characteristics: apnea, dyspnea, lethargy, to respiratory arrest and death.
stupor, coma, abnormal arterial blood gases, Supplemental oxygen may be
required to offset acid-base
decreased oxygen saturation, shallow respirations,
imbalances that result from
tachypnea, stridor, adventitious breath sounds overdosage.
Risk for injury Auscultate lung fields for breath Pulmonary edema may result
sounds and presence of adventi- from overdoses of barbiturates,
Related to: toxic effects of ingested drugs tious sounds. sedatives, hypnotics, and tran-
quilizers. Changes in breath
Defining characteristics: respiratory arrest, sounds may identify impending
pulmonary edema, shock, cardiac dysrhythmias, edema or heart failure.
conduction changes, encephalopathy, amblyopia, Auscultate heart for tones and Gallops, murmurs, and rubs may
edema, bronchoconstriction, blindness, blurring of presence of abnormal sounds. indicate the presence or impend-
vision, hypotension, hypothermia, seizures, hyper- ing presence of complications
such as pulmonary edema or
tension, rhabdomyolysis, oliguria, anuria, heart heart failure.
failure
Administer IV fluids as ordered. Crystalloid solutions are nor-
mally used to treat hypovolemia
Outcome Criteria which may occur due to compro-
mised circulatory status.
Patient will achieve and maintain function of all Administer naloxone as ordered. Reverses effects of narcotic agents
organ and body systems and be able to eliminate and may be required to manage
ingested drug. CNS depression or respiratory
depression.
Monitor intake and output every Assists with estimation of fluid
INTERWNTIONS RATIONALES 2 hours; compare 24-hour totals, balance within body. Myoglobin
and observe for changes in urine may be present if rhabdomyolysis
Monitor vital signs every 1-2 Facilitates early identification of character and color. occurs as a result of overdose.
hours and prn. changes and prompt interven-
tions. Drug overdose may cause Insert nasogastric tube, aspirate Lavage is done to remove any
CNS depression with hypother- fluid for analysis, lavage stomach, drugs that may be left in stom-
mia, cardiac dysfunction from and administer activated charcoal ach to p.revent further absorption
toxic drug levels, and pressure as ordered. of the drug. Aspirate may be sent
changes with volume imbalances. to lab for analysis of drugs
ingested to provide identification
Monitor EKG for changes in Overdoses of tricyclic antidepres- for appropriate treatment.
rhythm, dysrhythmias, or con- sants may cause prolongation of Charcoal is given to absorb drugs
duction problems, and treat PR, QT, and QRS complex; ST from gastric contents to prevent
according to hospital protocol. segment and T wave abnormali- systemic absorption.
ties, intraventricular conduction
defects, bundle branch blocks, Administer osmotic diuretics as May be required to manage over-
and dysrhythrnias that may lead ordered. doses of ethanol, methanol,
to cardiac arrest. ethylene glycol, and isoniazid,
but must be done using caution
Maintain airway and provide Patients with overdoses may be to avoid fluid overload and elec-
supplemental oxygen as unable to protect their own trolyte imbalances.
warranted. airway and have bronchocon-
OTHER 339

Administer sodium bicarbonate May be required for manage-
Patient will have stable vital signs and neurolog-
as ordered. ment of salicylate poisoning to
alkalinize urine. ical status.
Administer ascorbic acid or May be required for manage- Patient will have stable function of all body
ammonium chloride as ordered. ment of amphetamine or PCP systerns.
overdoses to acidify urine.
Administer Mucomyst as May be required for manage-

Patient will have absorption of drugs minimized
ordered. ment of acetaminophen overdose and maximal elimination of absorbed drugs.
to decrease absorption and limit
hepatic dysfunction. Patient will remain free of other injury.
Administer physostigmine as May be required for manage- Risk f o r violence directed at self
ordered. ment of tricyclic antidepressant
overdoses to reverse the Related to: drug overdose, psychological status
anticholinergic effects, but
should be given cautiously to Defining characteristics: feelings of loneliness,
prevent cholinergic toxicity. hopelessness, helplessness, perceived or real loss of
significant person, job, health status, or control,
Information, Instruction, unpredictable behavior, threats, low self-esteem,
dependence on drugs or alcohol, withdrawal from
Demonstration
substances, communication of suicidal ideations,
INTERVENTIONS RATIONALES depression, hostility
Prepare patientlfamily for dialysis Hemodialysis or hemoperfusion
procedures. may be required for removal of Outcome Criteria
drugs from system in severe
intoxication when levels are Patient will achieve and maintain psychologic sta-
potentially lethal or the toxin
may be metabolized to a more bility and seek assistance with mental health
lethal substance. providers.
Ensure suicide precautions are Maintenance of precautions facil-
exercised-removal of all poten- itate a safe environment and
tially dangerous items from room allows for identification of INTERVENTIONS RATIONALES
and reach, close observation at all potential problems. A patient
who has made one attempt at Ensure environment is calming, Facilitates decreased fear and
times, keeping exiting windows
darkened, with enough light for anxiety which may result with
and doors impenetrable, provid- suicide may attempt to complete
observation of patient. violent behavior.
ing all medications in liquid the job and may be quite
form, accompanying the patient resourceful with items to per- Approach patient in a nonjudg- May have a calming effect on
to other ancillary areas, and form the deed. Medications mental, nonthreatening manner. patient.
avoidance of secret pacts with should be given in liquid form to
patient. ensure that the patient has swal- Listen to patient and what he has Allows patient to verbalize prob-
lowed the medication rather than to say about his current situation lems. Emotional responses from
saving it to use as suicide attempt without reacting emotionally. caregivers may exacerbate hostile
later. reactions from patient.
Provide padded side rails, with Provides safe environment and Confirm understanding of Fosters communication and facil-
rails elevated at all times. reduces risk of injury, especially patient’s problem, but do not itates realistic feelings and
if patient has a seizure. reinforce denial. methods for coping.
INTERVENTIONS RATIONALES Patient and family will be able to access avail-

able resources.
Assist patient to verbalize emo- Provides safe outlets for patient
tions, anger, and other stressors, to express feelings and helps to Risk for ineffective individual coping
and to develop a plan for dealing work out realistic solutions for
with them. solving problems. [See Mechanical Ventilation]
Related to: crisis, drug overdose, loss of control,
Information, Instruction, depression
Demonstration
Defining characteristics: verbal manipulation,
INTERVENTIONS RATIONALES inability to meet basic needs, inability to
Instruct patiendfamily on com- Provides knowledge and assis-
effectively deal with crisis, ineffective defense
munity resources, hot lines, crisis tance of resources available once mechanisms, irritability, hostility
centers, ministerial counselors, patient is discharged.
etc.
Consult mental health provider/ Allows for effective therapeutic

professional as warranted. psychological treatment to dis-
cern appropriate methods of
coping with crisis.
Encourage family members to Validates their feelings and

discuss their feelings and meth- responses and may assist them in
ods of coping. finding more appropriate meth-
ods to cope with crisis.
Discuss actions to take if patient Patient may be more likely to try
expresses suicidal ideations or suicidal attempt again if situa-
attempts. tions or coping strategies are not
changed. Understanding that if
the patient has a definite plan for
suicide, the more likely it is that
he will be successful at ending
his life, and that immediate
intervention will be required.

Patient will achieve psychological equilibrium
and have no further suicidal attemptdgestures.
Patient will be able to cope with crises in an
appropriate manner, and will be able to effec-
tively search out community resources for
assistance.
Patient and family will be able to verbalize feel-
ings and effectively achieve therapeutic
communication.
OTHER 34 1
ACUTE POISONING/DRUG OVERDOSE
Severe personal loss Psychiatric illness Substaice abuse Memory aberrations

I I I
I 1
Accidental or purposeful ingestion of substance
toxic to body
J,
Toxin identified
I I I
Appropriate treatment to Antidote available Appropriate treatment to enhance
. reduce absorption of drug removal of substance to body
c J,
Lavage Forced diuresis

Induction of emesis, if warranted Hemoperfusion
Charcoal Hemodialysis
Cathartics Repeated charcoal dosages
SYMPTOMS WILL BE DIFFERENT BASED ON ACTUAL SUBSTANCE INGESTED

System involved
CNS Cardiac Resp Kidney Liver
Decreased perfusion
Increased demand on tissues
Cerebral edema Dysrhythmias Metabolic acidosis Coagulation

Seizures Ischemia Respiratory failure problems
4 Cardiac failure Kidney failure J,
Coma Hemorrhage
I W DEATH-
OTHER 343
as presence of envenomation. Designation of

severity of the bite is commonly rated as minor,
In the United States, there are actually two types moderate, or severe, and depends on the presence
of poisonous snakes-coral snakes and pit vipers, of symptoms, depth of envenomation, and labora-
which include rattlesnakes, water moccasins, and tory findings.
copperheads. Coral snakes are usually nocturnal Treatment of snakebite involves administration of
creatures and less active than pit vipers, but tend antivenin after a test dose for horse serum sensitiv-
to bite with a chewing motion and cause signifi- ity is performed. If this sensitivity is present,
cant tissue damage. diphenhydramine may be given prior to the
Snakebites may occur on any portion of the body, antivenin. Swelling may necessitate surgical inter-
vention to relieve the pressure and to prevent
but usually are noted on the extremities. Pit viper
further vascular damage, and ensuing
bites with envenomation result in immediate pain
complications are usually related to secondary
and edema within 10-20 minutes. Other
infection, renal failure, disseminated intravascular
symptoms include fever, ecchymoses, blisters, and
coagulation, or gangrene.
local necrosis, as well as nausea, vomiting,
diarrhea, metallic or rubbery taste, tachycardia,
hypotension, and shock. Neurotoxins may cause MEDICAL CARE
numbness, tingling, fasciculations, twitching, con- Laboratory: CBC used to identify blood loss and
vulsions, dysphasia, occasional paralysis, hemoconcentration; fibrinogen level, platelets, PT,
respiratory distress, coma, and death. Pit viper PTT, and APTT to evaluate clotting; blood type
bites may also impair coagulation and cause inter- and cross-matching to provide blood products as
nal bleeding. warranted; renal and liver studies to identify dys-
Coral snake bites usually have a delayed reaction function, elevated BUN, creatinine, bilirubin, or
up to several hours, and may result in very little or creatine kinase
no tissue pain, edema, or necrosis. The neurotoxic Electrocardiogram: used to establish a baseline for
venom produces paresthesias, weakness, nausea, identification of problems that may occur with
vomiting, dysphagia, excessive salivation, blurred hernodynamic changes and to identify dysrhyth-
vision, respiratory distress and failure, loss of mias and conduction problems
muscle coordination, paralysis, abnormal reflexes,
shock, cardiovascular collapse, and death. Coral Surgery: fasciotomy may be required to relieve
snake bites may also result in coagulopathy prob- pressure caused from swelling or compartmental
lems. syndrome; amputation may be required for gan-
grene or necrosis
The snake venom is a mixture of several proteins,
enzymes, and polypeptides, and may produce sev- Analgesics: used to alleviate and/or control the
eral toxic reactions in patients who have been pain related to envenomation and swelling; mor-
bitten. Correct diagnosis is imperative to treat the phine is usually not given due to its vasodilator
specific envenomation accurately and in a timely action
manner. Snakebites are critical emergencies and Antivenin: required as the antidote for snakebite;
require precise identification of the snake as well amount of antivenin is dependent on the severity
of the reaction rather than patient weight, and
ranges from 3 to 15 or more vials; children usually
require more antivenin because of the ratio of INTERVENTIONS RATIONALES

venom to body size
until loss is greater than 1000 cc.
Sedation: may be required to alleviate anxiety and Hypovolemic shock may occur
due to hemorrhage, third spac-
to facilitate compliance with treatments
ing, as well as the release of
vasoactive substances and coagu-
Tetanus toxoid: given to prevent complication
lopathy from the snakebite.
that may be induced with infection from
snakebite Measure hernodynamics if pul- CW, or right atrial pressure,
monary artery catheter has been gives estimate of fluid volume
Corticosteroids: usually are not recommended in placed. Notify M D for abnormal status. Dehydration may be
parameters. reflected by CVP of less than 5 ,
the initial phase after snakebite because of the while overhydration may be
enhancement of the venom action and blocking of reflected at levels over 18 cm
antivenin; may be warranted to treat shock or H,O. Hemodynamic values may
allergic reactions help to evaluate the body’s
response to the circulating
Diphenhydramine: used when the patient has a volume and bleeding status.
reaction to the horse serum used for antivenin, or Observe for restlessness, anxiety, Changes may reflect the severity
for other anaphylactic reactions mental changes, changes in level of fluid loss.
of consciousness, or weakness.
NURSING CARE PLANS Observe for bleeding from all

orifices and puncture sites, and
May indicate impaired coagula-
tion, impending or present DIC,
Risk for fluid volume deficit for presenceldevelopment of or inadequate replacement of
ecchymoses, hematomas, or clotting factors.
Related to: hemorrhage, third spacing, altered petechiae.
coagulation, increased cellular membrane perme- Monitor intake and output May indicate fluid volume
ability, shock hourly and notify MD for signif- deficit, and establishes a guide
icant imbalances or urinary for fluid and blood product
Defining characteristics: tachycardia, output less than 30 cclhr for two replacemenr.
hypotension, changes in mental status, restlessness, hours.
decreased urine output, prolonged capillary refill, Administer IV fluids as ordered. Replaces fluid loss, allows for
pallor, mottling, diaphoresis, poor turgor Two IV sites should be administration of vasoacrive
maintained. drugs, plasma extenders, and
emergency medications, as well
Outcome Criteria as the administration of
antivenin. Two sites are recom-
Patient will achieve and maintain fluid balance mended to facilitate
simultaneous fluid and blood
with adequate urinary output.
resuscitation in critical settings.
Crystalloids do not work as well
~~ as colloids because of the
INTERVENTIONS RATIONALES increased capillary permeability.
Monitor vital signs, and notify Hypotension may indicate that Administer blood andlor blood Whole blood may be required
MD of significant changes or the circulating fluid volume is products as ordered. for acute bleeding episodes with
trends. decreased. Changes in vital signs shock due to the lack of clotting
may indicate the amount of factors in packed red blood cells.
blood loss but may not change Fresh frozen plasma andlor
platelets may be required to
replace clotting factors and CO
promote platelet function.
OTHER 345
Information, Instruction, Outcome Criteria

Demonstration
INTERVENTIONS RATIONALES organ systems.
Instruct on use of antivenin, Provides knowledge and
effects, side effects. Test dose for decreases anxiety. Skin test is
horse serum. required to identify hypersensi- INTERVENTIONS RATIONALES
tivities to the antivenin and
Observe puncture wound for Skin normally changes after a
frequently is repeated to ensure
bleeding, color, temperature, and snakebite from inflamed to a
that the results are not false. If a
note changes from baseline. dark, cyanotic color. Changes in
reaction is noted, the antivenin is
the wound and local tissues may
still given but is preceded by
reflect the action of the venom
diphenhydramine.
and potential complications.
Prepare patient for placement of Provides knowledge to the
Measure the circumference of the Monitors for swelling and
pulmonary artery catheter. patient, and catheter is invalu-
extremity involved initially and inflammation, and helps to iden-
able for identifying changes in
then every 2-4 hours. tify the need for fasciotomy.
fluid status and hemodynamic
responses to those changes. Palpate, or use doppler, to dis- Edema may result in compart-
cern peripheral pulses distal to mental syndrome and obstruct
the snakebite, and notify M D for circulation to the extremity caus-
Discharge or Maintenance Evaluation absence or decrease. ing ischemia, necrosis, and
gangrene.
Patient will have stable vital signs and urinary
Assist with fasciotomy or inser- Reduces tissue pressure and pre-
output. tion of catheter into the tissues vents tissue dehiscence and other
of the edematous extremity. complications.
Patient will have balanced intake and output.
Administer oxygen as warranted. Provides supplemental oxygen
Patient will have good turgor, moist which may be decreased due to
membranes, and adequate capillary refill times. hemorrhage or oxygen-carrying
capabiliry.
Patient will be free of hemorrhage or abnormal
Evaluate extremity and site of Venom effects may jeopardize
coagulation. snakebite for pain, ecchymoses, tissue perfusion. Swelling and
blisters, or blebs. discoloration usually begin to
Patient will have no transfusion reactions. dissipate after 48 hours, and con-
tinued problems may indicate
Risk for alteration in tissue petfhsion: the presence of other complica-
peripheral, cardiopulmonary, renal, tions.
cerebral May reduce swelling. Ice packs
Apply ice packs over dressings as
Related to: envenomation, edema, compartmental warranted. DO NOT apply ice may increase damage to skin
directly over snakebite and sur- tissues and cause necrosis.
syndrome, coagulopathy, hemorrhage, rounding tissues.
hypovolemia, neurotoxins
Monitor for complaints of pares- May indicate advancement of
Defining characteristics: hypotension, tachycar- thesias, weakness, muscle neurotoxic venom.
incoordination, or fasciculations.
dia, edema, decreased or absent pulses,
inflammation, reddened or cyanotic skin, necrosis, Observe for increases in saliva- May indicate advancement of
gangrene, mental changes, restlessness, anxiety, tion, dysphasia, dysphagia, or venom and further complications
lethargy. that will require life-saving
abnormal hemodynamic parameters, abnormal treatment.
arterial blood gases
[See Fractures]
Observe for changes in respira- May indicate impending respira-
tions, increased work of tory distress and may lead to Related to: snakebite, swelling, edema, surgical
breathing, nasal flaring, retrac- cardiovascular failure and death. procedures, decreased tissue perfusion, anxiety,
tions, dyspnea.
envenomation
Information, Instruction, Defining characteristics: communication of pain,
Demonstration moaning, crying, facial grimacing, inability to
concentrate
Prepare patient for fasciotomy. Provides knowledge and reduces
Impaired skin integr.9
anxiety. Incision may be required
Related to: snakebite, envenomation, surgical pro-
to prevent skin dehiscence from
edema. cedures, invasive lines, necrosis, gangrene
Instruct patient in signs to notify Provides for prompt identifica- Defining characteristics: disruption of skin
MD or nurse: swelling, paresthe- tion of problem and prompt tissues, incisions, open wounds, drainage, edema
sias, color changes, temperature intervention to prevent further
changes, etc. complications.
Prepare patient for amputation. Provides knowledge and facili-

Outcome Criteria
tates understanding of need for
procedure, risks, and benefits, Patient will have wound healing occurring in a
and allows the patient to make timely manner.
an informed choice. Amputation
may be required for
gangrendnecrosis.
Assess wound and surrounding Provides baseline fof comparison
tissues for appearance, drainage, and for identification of deterio-
Patient will achieve and maintain adequate per- swelling, healing, deterioration, ration.
fusion to all body systems. etc.
Patient will have palpable, equal peripheral Cleanse wound with soap and Removes debris and drainage
pulses, with no paresthesias or evidence of water, or other agents per hospi- from skin surfaces and helps to
tal protocol, as warranted. prevent infection.
ischemia.
Apply gauze dressing as Dressing may help to control
Patient will have adequate urine output and bal- warranted and change every day bleeding, absorbs drainage, and
anced intake/output. utilizing sterile technique. provides barrier for wound.
Using proper technique for
Patient will have adequate cerebral perfusion wound care prevents potential
with no mental status changes. complications.
Elevate extremity as warranted. Reduces swelling and pain, and

Patient will be able to accurately recall all infor- helps to keep skin tissues free of
mation. pressure that might cause
ischemia or necrosis.
Patient will be able to make an informed con-
Monitor extremity and wound Swelling and discoloration
sent for procedures and will comply with
for changes. should begin to subside by 48
treatment modalities. hours. If swelling increases, or
tissue perfusion is impaired, sur-
Patient will not exhibit any preventable compli- gical intervention may be
cations. required.
OTHER 347

Demonstration Obtain ABGs as warranted for Will identify acid-base imbal-
signs of respiratory distress. ances as well as hypoxemia,
INTERVENTIONS RATIONALES hypercarbia, and orher ventila-
Prepare patient for fasciotomy or Provides knowledge to patient to tory problems.
amputation, as warranted. facilitate an informed choice, and
Prepare for intubation and Hypoxemia that is not able to be
reduces anxiety.
mechanical ventilation, as war- corrected will require mechanical
ranted. ventilation to facilitate adequate
oxygenation
Patient will have healed wounds with no circu- Discharge or Maintenance Evaluation
latory impairment.
Patient will be free of respiratory distress and
Patient will be able to circumvent preventable able to maintain own airway and oxygenation
complications. on room air.
Impaired gas exchange Patient will have no respiratory complications.
Related to: envenomation, ARDS, neurotoxins, Fear/Anxiety
cardiotoxins, hematotoxins, lactic acidosis, edema,
snakebite, anaphylactic reactions, bronchospasm [See Mechanical Ventilation]
Defining characteristics: dyspnea, tachypnea, air Related to: snakebite, threat of death, fear of dis-
hunger, abnormal arterial blood gases, altered figurement or scarring, hospitalization, mechanical
acid-base balances, cyanosis, inadequate oxygen ventilation, envenomation
saturation levels Defining characteristics: expressions of apprehen-
sion, tension, restlessness, insomnia, expressions of
Outcome Criteria concern, fear of unknown, tachypnea, tachycardia,
inability to concentrate or focus
Patient will maintain own airway and have opti-
mal ventilation and perfusion.
Monitor respiratory status for May indicate hypoxemia and
changes: dyspnea, tachypnea, hypoxia.
levels, cyanosis, decreases in
mentation, restlessness, etc.
Administer oxygen as ordered. Provides supplementd oxygen to

increase availability, and to satu-
rate red blood cells with oxygen.
Observe for laryngeal spasm, May indicate worsening respira-

bronchospasm, or excessive sali- tory status which may require
vation. mechanical ventilation.
SNAKEBITE
Envenomation
e
Release of enzymes Release of toxic substance Local tissue damage
I I
I I I I
Cardiovascular Hemhytic Neuron-hscular Renal EdLma
4 c c c 4
Toxins alter Blood cell Nerve transmission Nephrotoxins Necrosis
vascular dynamics changes impairment alter perfusion
4 c c c
Hypotension Hemolysis Nerve conduction Decreased GFR
decreased
4 c e c
Decreased perfusion Coagulation Muscle Myoglobin
and circulating disturbances fasciculations
volumes
4 4 c J,
Hypoxemia Hemorrhage Paralysis Renal insufficiency

c c c e
Shock Respiratory
+
distress
Arrest Renal failure

DEATH 1
OTHER 349
graft heart is implanted. Frequently, a combined

heart-lung transplant is performed due to the
Transplants increased success rate as a result of fewer vascular
anastomoses being required.
Transplantation of living tissues, cells, or organs Renal transplants are performed to restore kidney
from one individual to another is one method of function in end-stage renal disease. Allografts are
treatment for several end-stage organ diseases. usually obtained from living relatives or cadavers.
Often, transplantation is the last resort for a vari- The kidney is usually implanted in a
ety of disorders after conventional medical or retroperitoneal position against the psoas muscle
surgical therapies have failed to provide adequate in the iliac fossa. When cadaver kidneys are used
functioning. Recent advances in technique and approximately half of the recipients may require
treatment have improved the rate of success, and dialysis because of the presence of acute tubular
transplantation has improved the quality of life for necrosis.
many patients who otherwise would either die or
be resigned to lives of dialysis or suffering. Liver transplants are performed to restore function
in patients with chronic active hepatitis, hepatitis
Transplants are categorized by the relationship B antigen-negative postnecrotic cirrhosis, primary
between the donor and the recipient. An autograft hepatocellular tumor, or congenital anomalies of
relates to the transplantation of tissue from one the bile duct or inborn errors of metabolism in
location to another in the same person. An children. The liver is implanted into the right
isograft is a graft between identical twins, and an upper abdominal quadrant and the vasculature is
allograft, or homograft, is a graft between mem- anastomosed. Biliary drainage anastomosis prob-
bers of the same species. A xenograft, or lems often result in bacteremia.
heterografi, is a graft between members of differ-
ent species. Pancreas transplants are performed on patients
with insulin-dependent diabetes mellitus to pro-
Bone marrow transplants are performed in order vide insulin-producing tissue. The pancreas, either
to restore immunologic and hematologic function total with a small amount of duodenum, or partial
to patients who have aplastic anemia, leukemia, or segment of the distal pancreas, is transplanted.
severe combined immunodeficiency disorder. This type of transplant is performed as a life-
Multiple aspirations of bone marrow are obtained enhancing procedure and is most successful prior
and then infused intravenously with red blood to the development of severe secondary diabetic
cells. complications.
Heart transplants are performed to attempt to The goal in transplantation is to maintain optimal
restore function in end-stage cardiac failure that functioning of the organ and to prevent rejection.
has been unresponsive to other medical therapeu- This goal is facilitated by antigen matching, tissue
tics, and usually involve patients who have typing for histocompatibility, tests for prior sensi-
cardiomyopathy, rheumatic heart disease, congeni- tization, transfusions of whole blood, and
tal heart disease, or coronary artery disease. After immunosuppressive therapy.
the patient is placed on cardiopulmonary bypass
and the diseased heart is removed, the donor allo- Despite a small increase in the available donor
organs, the number of candidates for transplant symptoms of increased glucose levels, polyuria,
far exceeds the organs available, and many patients polydipsia, polyphagia, weight loss, low grade
die prior to undergoing transplantation. fever, and tender or enlarged pancreas. Bone
Complications of infection, rejection, and marrow transplantation rejection is usually
immunosuppressive drugs are a very real part of evidenced by severe diarrhea, jaundice and skin
the process. changes.
Transplantation of almost any tissue is feasible but Rejection can be classified as being acute, hypera-
rejection is the most frequent complication when cute, or chronic depending on the mechanisms of
the body tries to destroy the graft tissue. Rejection rejection and the duration of time prior to the
occurs when the immune system recognizes the appearance of symptoms. Acute reactions may
graft as being foreign to the body and begins a occur anywhere from 7 days to several weeks after
responsive action to the antigens of the graft. Thus transplant. A cell-mediated acute reaction occurs
begins a cell-mediated immune response in the when the graft develops interstitial edema,
lymph tissues. Antibody-mediated immune ischemia, and necrosis, but high dose steroid ther-
responses, inflammatory responses, and comple- apy may reverse the reaction. Antibody-mediated
ment activation also play a significant role in the acute reactions occur when fibrin, platelets, and
rejection process. polymorphonuclear cells adhere to the graft cells,
resulting from recipient antibody-donor antigen
Rejection may occur immediately after transplan-
responses. This aggregation produces ischemia and
tation or up to years later, and most transplant
eventually necrosis. Hyperacute reactions develop
patients experience at least one rejection episode
immediately after the transplant up to a few days
during their lives. Signs/symptoms of rejection
after. Immediate hyperacute reactions happen
vary depending on the type of graft. Cornea1
when the recipient has preformed antibodies
transplant rejection is evidenced by corneal cloud-
against the donor antigens and is usually caused
ing, corneal edema, or conjunctival hyperemia.
by previous blood transfusions, previous
Cardiac transplant rejection is evidenced by
transplants, or from pregnancy. An accelerated
decreased QRS, right axis shift, atrial
hyperacute reaction happens when the recipient
dysrhythmias, conduction defects, S, gallop, jugu-
lymphocytes and neutrophils infiltrate the graft
lar vein distention, decreased exercise tolerance,
and may be prevented with the use of antisera to
low grade fever, malaise, weight gain, dyspnea,
T lymphocytes. Chronic reactions occur over
right ventricular failure, and peripheral edema.
many months and eventually leads to loss of graft
Liver transplant rejection may be manifested with
function. This occurs when the vascular endothe-
changes in urine or stool color, jaundice,
hum becomes inflamed, and the arterial lumen
hepatomegaly, ascites, pain in the center of the
decreases. Fibrin and platelets aggregate and over
back, right flank, or right upper quadrant of the
time, result in decreased blood flow to the organ
abdomen, low grade fever, malaise, or anorexia.
and ischemia and dysfunction prevail.
Renal transplant rejection may involve low grade
fever, decreased urine output, pain, swelling The principal mechanism of rejection is GVH
and/or tenderness in the kidney, increased blood (graft versus host) disease. This occurs when an
pressure, malaise, weight gain, or peripheral immunocompetent donor graft is transplanted
edema. Pancreas transplant rejection may show into an immune-impaired recipient. If the donor
OTHER 35 1
and the recipient are not histocompatible, foreign

cells will initiate an attack against the host cells,
NURSING CARE PLANS
which are then unable to reject them. This usually Risk f i r infection
occurs with bone marrow or liver transplants. Related to: immunosuppression, effects of trans-
plantation, invasive procedures, invasive
MEDICAL CARE linedcatheters, trauma, surgery
Laboratory: renal profiles used to assess kidney Defining characteristics: increased immature
function; hepatic profiles used to assess liver func- white blood cells, differential with a shift to the
tion; CBC used to evaluate anemia, infection, and left, fever, chills, cough, hypotension, tachycardia,
blood loss; glucose levels used to monitor pancre- presence of wounds, positive blood, urine, or
atic function; A B 0 blood grouping; Lewis sputum cultures, cloudy urine, purulent drainage
antigens used to evaluate compatibility for kidney
transplants; microtoxicity assays for evaluation of
Outcome Criteria
bone marrow; tissue typing for histocompatibility;
lymphocyte antibody screen to evaluate preformed Patient will have no signs/symptoms of infection
antibodies; lymphocyte cross-matching used after after transplant surgery.
a suitable donor is found; serology, HIV, hepatitis
screens to evaluate suitability for transplantation ~ ~~
Surgery: required for transplantation of
Patient should be in private Decreases potential of infection
tissueslorgans room, with appropriate isolation when patient is already immuno-
techniques in use. Visitors with compromised.
Biopsy: tissue biopsies used as the most accurate illness must be restricted from
diagnostic tool to determine the extent of lympho- visiting.
cyte infiltration and potential tissue damage; serial
Observe for signslsymptoms of Provides for prompt identifica-
biopsies can be used to monitor course of infection to all body systems. tion of complication and
treatment facilitates timely intervention.
Immunosuppressive drugs: used to decrease or Provide diet with appropriate Proper nutrition facilitates anti-
nutrients and fluids. Restrict body formation and prevents
eliminate the body's ability to reject new fresh fruits and vegetables. dehydration. Fresh fruidvegeta-
transplanted tissues; can increase the risk for bles may harbor parasitic spores
opportunistic organisms; usually a combination of or bacteria that may result in an
infection.
drugs are used rather than just one
Monitor CBC, especially WBC Sudden decreases in mature
Blood transfusions: used to improve graft survival count for abrupt changes in neu- WBCs may result from
of certain organisms trophils. chemotherapy and further com-
promise the immune response.
Radiation therapy: used in some instances for pre-
Use sterile/aseptic technique with Immunosuppressive drugs or
transplantation immunosuppression dressing changes, IV site changes, effects of the patient's disease
or other invasive care. process may slow wound healing.
Thoracic duct drainage: used in some instances
Drainage is a potential medium
for pretransplantation imrnunosuppression for bacterial growth.
Observe mouth and oral cavity Steroid and antibiotic adminis-

for presence of lesions or thrush. tration may result in an
Use nystatin as warranted. overgrowth of fungal coloniza-
tion resulting in candidiasis.

response. Imuran suppresses
Patient will exhibit no signs of infection post-
DNA and RNA synthesis;
transplant. cyclosporine block the release of
interleukin- 1 and gamma-inter-
Patient will have stable vital signs and hemody- ferons and block activated T
namics. lymphocytes; prednisone and
other corticosteroids inhibit T-
0 Patient will not develop any complication. cell proliferation, decreases
production of interleukin-2 and
Risk for injury gamma-interferons, and decreases
IgG synthesis; muromonab
Related to: rejection of transplanted organ, tissue, blocks T cells that foster renal
or bone marrow, allergic reaction to transplant rejection.
Defining characteristics: fever, chills, diaphoresis, Administer blood products as Anemia and blood dyscrasias
warranted. may be present after bone
peripheral edema, weight gain, decreased urine marrow transplants and require
output, hypertension, urticaria, enlargement of the supplementation of blood prod-
graft, oliguria, anuria, hypotension, right-sided ucts until transplantation is
heart failure, right flank pain, light-colored stools, successful and may occur up to 2
week after infusion. Granulocyte
anorexia infusion may be deemed neces-
sary if antibiotic therapy is not
effective to treat bacterial infec-
Outcome Criteria tions.
Patient will not have rejection of new transplant. Monitor lab studies for signifi- Provides data that may be indica-
cant changes. tive of impending or present
rejection.
Monitor patient for fever, chills, May indicate impending rejec-
hypotension, flushing, inflammation of transplant, or adverse
Demonstration
tion, thrush, cough, urinary reaction to immunosuppressants.
changes. Acute rejection is common and INTERVENTIONS RATIONALES
usually occurs during the first Prepare patient for biopsies as Cardiac transplants require peri-
weeks or months following the warranted. odic endomyocardial biopsies to
transplant. identify cellular rejection.
Monitor for increased bilirubin May indicate complication as a Instruct patient/family on Promotes knowledge, facilitates
levels, hepatomegaly, result of bone marrow transplant signslsymptoms of rejection of compliance, and allows for
encephalopathy, or heart failure. and is usually seen in 25% of particular transplanted prompt notification to decrease
patients. organ/tissue. severity of complications or
Observe for rash or skin May indicate presence of grafi- rejection episode.
ulcerations. versus-host ( G W ) disease and Prepare patient for surgery as If excessive immunosuppression
may occur up to 2 weeks post- warranted. is required or if rejection is
transplant. inevitable, kidney transplants
Administer immunosuppressive may require removal and patient
Drugs interfere with some step
will need placement back of
therapy as ordered. in the body’s response against the
dialysis.
graft to decrease the immune
OTHER 353
INTERVENTIONS RATIONALES Defining characteristics: feelings of loneliness,

~~
feelings of rejection, absence of family

Instruct patient on all medica- Decreases risk of self-medication,
tions taken, side effeccs, adverse and provides for prompt notifi- membedfriends, sad, dull affect, inappropriate
effects, contraindications, and cation of adverse reactions that behaviors
potential drug interactions. may require further intervention.
Outcome Criteria
Patient will be able to participate in activities as
Patient will have minimal rejection of tolerated and be able to have effective interaction
transplanted organ/tissue. with people within confines of medical disease
Patient will be able to comply with drug regi- process.
men to prevent rejection.
Patient will be able to verbalize understanding INTERVENTIONS RATIONALES
of signslsymptoms to report to physician, and
Determine patient’s comprehen- Identifies potential misconcep-
will be able to seek prompt medical care. sion of medical situation and tions and allows for realistic
rationales. input to facilitate understanding.
Patient will be cognizant of all medications
being taken, purposes, and potential side effects, Utilize appropriate isolation Facilitates providing safe environ-
techniques based on patient’s ment for patient yet providing
and will have no adverse reactions.
condition, and when possible, social interaction to decrease
Patient will avoid further surgery. limit use of protective feelings of social isolation.
equipment. Appropriate use of gcwns, mask;,
Alteration in tissue perfision: and gloves may be required due
to patient’s suppressed immune
curdiopulmonary, cerebra4 renai system.
gastrointestinal, peripheral
Encourage visitation of family as Transplantation costs are high
[See Renal Failure]
much as possible. Provide a tele- and done in major hospital set-
Related to: transplant rejection, allergic reactions, phone so that patient may tings, so that family members
contact family and friends. may not be able to travel great
infection, pulmonary edema, DIC distances for the length of time
the patient may be hospitalized.
Defining characteristics: oliguria, anuria, Methods of communication are
polyuria, fever, chills, increased white blood cell important to promote feelings of
count, differential shift to the left, bleeding, inclusion in family matters.
ecchymoses, hematuria, guaiac positive stools, Identify significant family mem- Support systems decrease sense of
DIC, blood dyscrasias, decreased platelet count, bers or friends who are isolation and loneliness and helps
important to patient and involve to reestablish communication.
headache, mental status changes, adventitious
them in care.
breath sounds, gallops, abnormal heart tones, dys-
rhythmias, rashes, ulcerations, nausea, vomiting Assist patient to develop strate- Promotes feelings of self-control
gies for coping with isolation. while developing goals for
Social isolation achievement.
Contact social services, coun- May be helpful to continue care

Related to: changes in health status, changes in once patient is discharged, and
selors, organizations, ministers,
physical status, imposed physical isolation, inade- or other resources. may be able to facilitate support-
quate support system ive encounters.

necessity for isolation procedures and will
comply.
Patient will have fewer feelings of loneliness and
isolation.
Patient will be able to meet sensory demands by
family and friends.
nity resources for referrals.
Related to: transplant operation, invasive lines and
catheters, immobility
Defining characteristics: communication of pain,
facial grimacing, increased blood pressure, increased
heart rate, diaphoresis, moaning, splinting
Alteration in skin integity
Related to: transplant operation, invasive lines and
catheters, biopsies, wounds
Defining characteristics: surgical incisions, disrup-
tion of skin surfaces, abrasions, redness, warmth,
drainage
Knowledge deficit
[See Renal Failure]
Related to: transplant operation, changes in health
status, anxiety
Defining characteristics: lack of knowledge, pres-
ence of preventable complications, verbalized
questions
OTHER 355
TRANSPLANTS
Organ dysfunction and failure

4
Transplant of organ
I
I I
Humoral immunity Cellular immunity
4 4
I +
Antigdantibody reaction
Hyperacute
rejection
Accelerated
rejection
T-lymphocytes activated
4
Antibody formation
I I
Antibody formation B-lymphocyte
activation
J,
Chronic rejection
Signs of rejection w
ill vary depending on particular organ that is transplanted.
OTHER 357
Cardiogenic Shock blood pressure may be masked by the nervous

system and compensatory mechanisms from the
Cardiogenic shock is a severe form of pump fail- baroreceptors, which attempt to compensate for
the increases in the body’s cardiac workload and
ure that occurs when damage to the heart muscle
is sufficient enough to impair contractility and myocardial oxygen demand. Unless the cycle is
interrupted, the scenario is always death.
reduce stroke volume and cardiac output. Usually
the patient must necrotize 40% or more of the left
ventricular myocardium to result in shock. In this
type of shock, blood volume is adequate and fluid Oxygen: to increase available oxygen supply
challenges will not improve cardiac output because
the problem is that the heart fails to pump effec- Alpha-adrenergic agonists: p henylep hrine (Neo-
tively. This decreases the stroke volume, and Synephrine) used to improve blood pressure
eventually tissue ischemia and hypoxia occurs. through vasoconstriction without inotropic effect
Cardiac output is decreased and hypotension Beta-adrenergic agonists: isoproterenol (Isuprel)
ensures. Because of inadequate tissue perfusion, and dobutamine (Dobutrex) used to act directly
anaerobic metabolism produces lactic acid, leading on the myocardium to improve contractility, and
to an acidotic state in the body. Despite treatment, to lower preload and afterload
80% of patients who suffer this shock state will
die. Alpha-beta adrenergic agonists: norepinephrine
(Levophed), epinephrine (Adrenalin), and
Cardiogenic shock may result from mechanical dopamine (Intropin) used to improve contractility
interference with ventricular filling, from interfer- through vasoconstriction and direct action on
ence with ventricular emptying, from disturbances myocardium
in heart rate or rhythm, or from inadequate
myocardial contraction. Other causes that may Vasodilators: nitroglycerin (Tridil) and nitroprus-
predispose the patient to cardiogenic shock side (Nipride) used to reduce venous return to the
include acute dysrhythmias, severe congestive heart by promoting peripheral pooling of blood,
heart failure, cardiac tamponade, papillary muscle reduces preload, afterload, and myocardial oxygen
rupture, rupture of the interventricular septum or consumption
wall of the ventricle, ventricular aneurysm, mural Diuretics: furosemide (Lasix) used to reduce car-
throm bi, cardiomyopathy, pulmonary embolism, diac congestion and pulmonary edema
tension pneumothorax, or damage to the myocar-
dial valves. Enzyme inhibitors: amrinone (Inocor) used to
inhibit the enzyme phosphodiesterase, increase
Patients with cardiogenic shock usually have available calcium, and increases cyclic adenosine
increased CVP with jugular vein distention, car- monophosphate, or CAME levels to strengthen
diac index less than 2.0 Llmin/m2, systolic blood con tractions
pressure less than 80 mmHg, mean arterial pres-
sure less than 60 mmHg, PCWP greater than 18 Cardiac catheterization: used to assess pathophysi-
mmHg, increased systemic vascular resistance, ology of the patient’s cardiovascular disorder, to
oliguria less than 20 cc/hr, peripheral edema, and provide left ventricular function information, to
pulmonary congestion. In the early stages of this
shock, the initial decrease in cardiac output and
allow for measurement of heart pressures and car- INTERVENTIONS RATIONALES

diac output, and to measure mixed venous blood
tive drugs. Maintain MAP at >GO sure, increased respiratory rate,
gas content mmHg. and can increase heart rate.
Compensatory mechanisms in
Intra-aortic balloon pump: used to decrease
the body can easily fail within a
workload on the heart by decreasing preload and short time. MAP < 60 is inade-
afterload, and to improve coronary artery perfu- quate to perfuse coronary or
sion cerebral vessels.
Monitor hemodynamic pressures Evaluates effectiveness of treat-

Ventricular assist devices: used when other mea- and calculate CI, SVR, TPR, left ment and allows for efficient
sures have failed; VADs allow blood to bypass the and right stroke work and stroke titration of vasoactive drugs.
ventricle(s) which allows the heart to rest and work index. Measure CO. Determines actual cardiac output
lowers myocardial oxygen demands by measurement. In cardiogenic
shock, CVP will be elevated >10
Arterial blood gases: used to evaluate hypoxia and mmHg, CO will be <2.2L/min,
SVR will be increased, PVR and
hypoxemia, metabolic acidosis, and other imbal- TPR will be increased, and stroke
ances volume will be decreased. A good
predictor of mortality is the
NURSING CARE PLANS LVSWI, with 95% death rate if

<25 gm m/m2.
Decreased cardiac output Administer oxygen as ordered. Provides supplemental oxygen to
Monitor oxygenation by use of increase available oxygen to us-
Related to: circulatory failure, bradycardia, tachy- pulse oximetry or ABGs. sues and reduce hypoxia.
cardia, congestive failure
Monitor for mental changes and Decreased cardiac output may
Defining characteristics: SBP < 80 mmHg, olig- changes in level of consciousness. decrease perfusion to cerebral
tissues.
uria, cold clammy skin, weak thready pulses,
dyspnea, tachypnea, cyanosis, confusion, restless- Monitor urine output every Decreased cardiac output results
hour and notify MD if <30 in decreased renal perfusion and
ness, mental lethargy, dysrhythmias, chest pain
cclhr. may lead to oliguria or renal fail-
ure.
Outcome Criteria Monitor for weadthready pulses, Decreased cardiac output results
capillary refill > 5 seconds, cool in decreased peripheral perfusion
Patient will have adequate cardiac output to main- clammy skin, pallor or cyanosis. and tissue compromise.
tain perfusion to all body systems. Auscultate lungs for crackles May indicate increasing fluid to
(rales) or wheezes, and heart lungs and impending congestive
tones for S3 gallop. heart failure.
INTERVENTIONS RATIONALES Observe for cough and pink May indicate pulmonary edema.
frothy sputum.
Monitor EKG for dysrhythmias Decreased cardiac output will
and changes in heart rhythm. decrease perfusion to the heart Auscultate heart tones for systolic May indicate ventricular septal
and dysrhythmias may occur. murmur. rupture or mitral insuGciency
which may cause cardiogenic
Monitor vital signs every 15 Bradycardia may result in
shock.
minutes, or every 5 minutes decreased cardiac output, which
during active titration of vasoac- leads to lowering of blood pres-
OTHER 359

Observe for abnormal precordial May indicate cardiogenic shock.
Patient will have cardiac output/cardiac index
movement at 3-5 intercostal
space. and hemodynamic pressures within normal
limits.
Place head of bed no higher than Elevation of the head of the bed
30 degrees if blood pressure is may promote lung expansion and Urine output will be adequate.
within acceptable parameters. facilitate easier breathing. Blood
Avoid trendelenburg position. pressure may be too low to have Vital signs will be normal and without overt
HOB elevated and patient
should be supine to maintain
signs of impaired perfusion to any body system.
blood pressure and perfusion to
Lung fields will be clear with adequate oxygena-
vital organs. Placement in trende-
lenburg position may increase tion.
preload, increase the workload on
the heart, inhibit lung expansion, Patient will be alert and oriented, with no
and prevent baroreceptors from mental changes.
sensing decreases in cardiac
output. Anxiety
Administer vasoactive drugs and Through a variety of actions,
[See MI]
titrate to maintain vital signs and these drugs allow alteration of Related to: change in health status, fear of death,
hemodynamic pressures within hemodynamic status to achieve
MD ordered parameters. and maintain optimal perfusion. threat to body image, threat to role functioning,
pain
Administer morphine IV as Relieves pain and helps to
ordered. improve blood pressure and car- Defining characteristics: restlessness, insomnia,
diac output by decreasing
preload.
Administer atropine as ordered. May be used to reverse bradycar- trating, dry mouth, poor eye contact, decreased
dia and help prevent some of the
vagal effects from morphine. energy, irritability, crying, feelings of helplessness
Avoid using isoproterenol with Isuprel increases myocardial KnowZedge &$kit

MI patients except for temporary oxygen consumption and work- [See MI]
use prior to transvenous pacing, load of the heart while it
and only if shock is associated increases heart rate. Related to: lack of understanding, lack of under-
with severe bradycardia. standing of medical condition, lack of recall
Prepare patient for placement on Provides knowledge and
IABP or for VAD usage. decreases fear. Defining characteristics: questions regarding
Demonstration
complications
Instruct on equipment, proce- Provides knowledge and
dures, medications. decreases fear.
CARDIOGENIC SHOCK
Left ventricular dysfunction
Loss of critical muscle mass
* Decreased pumping ability of the heart 4
Decreased stroke volume
Decreased blood pressure
Decreased perfusion pressure to coronary arteries
Increased myocardial ischemia
Cell necrosis
Impaired contractility / + \ Metabolic acid release

Humoral toxins released
SYMPATHETIC NERVOUS SYSTEM STIMULATION
I
NEURAL SYSTEM STIMULATED CHEMICAL SYSTEM ACTIVATED
- Skin Decreased cardiac output

Increased rate Vasoconstriction Decreased blood to lungs
Increased depth Cool clammy skin Increased capillary permeability
Decreased oxygen diffusion
Sweat glands Cardiac Increased physiological dead space
Increased sweat production Vasodilates arteries VentiIation/perfusion mismatch
Increased coronary artery blood flow Decreased P a 0 2
GU Increased heart rate Respiratory insuffciency
Vasoconstriction Increased strength of contractions Respiratory alkalosis
Decreased peristalis Increased cardiac output Vasoconstriction to cerebral arteries
Decreased perfusion to liver Increased blood pressure Cerebral ischemia
Ischemia to pancreas Changes in level of consciousness
GI
Vasoconstriction
Decreased peristalsis
Decreased perfusion to liver
Ischemia to pancreas
Myocardial depressant factor (MDF) released
HORMONAL SYSTEM ACTIVATED
Decreased renal blood flow

Increased renin
Increased sodiumlwater retention
Adrenal medulla
Increased epinephrine
Increased norepinephrine
Sustained stress response
Increased gluconeogenesis Acute tubular necrosis
Increased blood glucose
~ ~~
INDEX OF NURSING DIAGNOSES 361

INDEX OF NURSING DIAGNOSES 363
cerebral 26
Anticipatory grieving 303

Activity intolerance 92, 203, 235 Anxiety 10, 27, 36, 42, 63, 74, 86, 92, 128, 196, 248, 275,
285,359
Alteration in comfort 15, 26, 50, 63, 70, 79, 107, 163, 170,
182, 196,208,214,292,299,316,326,346, 354 Anxiety, fear 173
Alteration in nutrition: less than body requirements 204, Body image disturbance 302
208,214,218,235,244,253,326
Bowel incontinence 164
Alteration in skin integrity 62, 73, 190, 354
Constipation 277
Alteration in temperature regulation 161
Decreased cardiac output 6, 18, 27, 34, 86, 278, 358
Alteration in thought processes 152, 218
Disturbance in body image 221
Alteration in tissue perfusion: cardiopulmonary, cerebral GO
Disturbance in self-esteem 177
Alteration in tissue perfusion: cardiopulmonary, cerebral,
gastrointestinal, peripheral, renal 78 Disturbance of body image 64,75
Alteration in tissue perfusion: cardiopulmonary, cerebral, Dyshnctional ventilatory wean response 133
renal, gastrointestinal, peripheral 353 Fatigue 256
Alteration in tissue perfusion: cardiopulmonary, renal, cere- FearJAnxiety 326, 347
bral, gastrointestinal, peripheral 233
Fluid volume deficit 194, 208, 219, 251, 261,269
Alteration in tissue perfusion: cerebral 140, 149, 181, 186,
189 Fluid volume excess 4, 240, 265
Alteration in tissue perfusion: peripheral 47, 299 Grieving 178
Alteration in tissue perfusion: peripheral, cerebral, cardiopul- Hyperthermia 34, 176, 182, 282, 319, 332
monary, renal, gastrointestinal 314
Impaired gas exchange 8, 86, 92, 101, 107, 123,254, 277,
Alteration in tissue perfusion: renal, cardiopulmonary, cere- 307,347
bral, gastrointestinal, peripheral 242
Impaired physical mobility 64,74, 141, 154, 162, 169, 293,
Alteration in nutrition: less than body requirements 262, 326
277 Impaired skin integrity 219, 295, 301, 326, 346
Altered nutrition: less than body requirements 94, 131, 196
Impaired verbal communication 127, 141, 170
Altered oral mucous membrane 131, 247 Ineffective airway clearance 86, 92, 106, 118, 122
Altered tissue perfusion: cardiopulmonary, cerebral, gastroin-
Ineffective breathing pattern 8692, 100, 112, 124, 160, 220
testinal, peripheral, and renal 273
Ineffective individual/family coping 93, 129
Altered tissue perfusion: cardiopulmonary) cerebral, gastroin-
testinal, renal, peripheral 54 Ineffective thermoregulation 3 14
Altered tissue perfusion: cardiopulmonary, cerebral, periph- Inneffective in breathing pattern 1GO
eral 17
Knowledge deficit 10,23,28,36,43, 50,65,74, 81,86,
Altered tissue perfusion: cardiopulmonary, renal, peripheral, 94, 107, 135, 197,205,235,257,270,286,297,354,359
Knowledge deficit 10, 23, 28, 36, 43, 50, 65, 74, 81, 86, Risk for impaired swallowing 142
94, 107, 135, 197,205,235,257,270,286,297,354,359
Risk for ineffective airway clearance 175, 325
Potential for alteration in tissue perfusion: peripheral 262
Risk for ineffective breathing pattern 15 1 , 169, 337
Potential for infection 130
Risk for ineffective breathing pattedimpaired gas exchange
Potential for injury 63, 74, 208 71
Potential for injury: hypoglycemia 256, 262 Risk for ineffective individual coping 200, 340
Risk for alteration in nutrition: less than body requirements Risk for infection 35, 56, 94, 153, 188, 204, 212, 245, 255,
155, 170 296,300,316, 327,332,351
Risk for alteration in tissue perfusion: cardiopulmonary, Risk for injury 176, 181, 189, 200, 212, 220, 226, 230,
peripheral, renal 170 247,266,284,338,352
Risk for alteration in tissue perfusion: cerebral, cardiopul- Risk for peripheral neurovascular dysfunction 294
monary, gastrointestinal, renal, and peripheral 200
Risk for urinary retention 171
Risk for alteration in tissue perfusion: cerebral, gastrointesti-
nal, cardiopulmonary, renal, and peripheral 332 Risk for violence directed at self 339
Risk for alteration in tissue perfusion: peripheral, cardiopul- Self-care deficit: bathing, dressing, feeding, toileting 143
monary, renal, cerebral 345 Sensory-perception alteration (visual, thought processes,
Risk for altered nutrition: less than body requirements 284, kinesthetic) 277
320 Sensory-perceptual alteration 163
Risk for altered tissue perfusion: cardiopulmonary, cerebral, Sensory-perceptual alterations: visual, kinesthetic, gustatory,
renal, gastrointestinal, and peripheral 32, 41 tactile 170
Risk for altered tissue perfusion: cardiopulmonary, periph- Sensory-perceptual alterations: visual, kinesthetic, gustatory,
eral, cerebral 101 tactile, olfactory 142
Risk for altered tissue perfusion: gastrointestinal, cerebral, Social isolation 353
cardiopulmonary, renal, peripheral 196
Urinary retention 164
Risk for altered nutrition: less than body requirements 107
Risk for constipation 172
Risk for decreased cardiac output 40, 68, 101, 160, 189,
200,283, 320
Risk for dysreflexia 165
Risk for fluid volume deficit 57, 87,107, 176, 214, 226,
230,234,242, 301,324,333,344
Risk for fluid volume excess 20, 87,107
Risk for impaired gas exchange 175, 208, 226, 229, 320,
326,333
Risk for impaired skin integrity 9,49, 8 1 , 163, 204, 246
REFERENCES 365
REFERENCES
REFERENCES 367
Books
Berkow, Robert, Editor. The Merck Manual, 16th Ed., Merck, Sharp, & Dohme Inc., Rahway, NJ, 1993.
Guyton, Arthur. Human Physiolow and Mechanisms of Disease, 6th Ed., W. B. Saunders Co., Philadelphia,
PA, 1997.
Guyton, Arthur. Textbook of Medical Physioloc, 9th Ed., W. B. Saunders Co., Philadelphia, PA, 1995.
Minssen, Beth. Critical Care Core Curriculum, 6th Ed., Panhandle Education For Nurses, Lubbock, TX,
1995.
Minssen, Beth. Multi& Orvan Failure Syndrome, 2nd ed., Panhandle Education For Nurses, Lubbock, TX,
1995.
Skidmore-Roth, Linda. Mosbv’s 1997 Nursinc Druc Reference, Mosby Year-Book Inc., St. Louis, MO, 1997.
Suddarth, Doris Smith. The Lippincott Manual of Nursin? Practice, 6th Ed., J. B. Lippincott, Philadelphia,
PA, 1996.
Swearington, Pamela and Keen, Janet. Manual of Critical Care, 3rd Ed., Mosby, St. Louis, MO, 1995.
Tierney, Lawrence M., et al., Current Medical Diamosis and Treatment, 35th ed., Appleton and Lange,
Stamford, CT,1996.
Periodicals
Ahrens, Susan G. “Managing Heart Failure: A Blueprint for Success,” Nursing 95, 25 (12): 26-31, 1995.
Blanford, Nickie. “Renal Transplantation: A Case Study of the Ideal,” Critical Care Nurse, 13 (1): 46-55,
1993.
Bright, Linda D. “Deep Vein Thrombosis,” American Journal of Nursing, 95 (6): 48-49, 1995.
Huston, C. J. and Boelman, R. “Autonomic Dysreflexia,” American Journal of Nursing, 95 (6):55, 1995.
Mee, Cheryl L. “Ventilator Alarms-How to Respond with Confidence,” Nursing 95, 25 (7): 61-64, 1995.
Meissner, Judith E. “Caring for Patients with Meningitis,” Nursing 95, 25 (7): 50-5 1, 1995.
Merkley, Kathleen. “Assessing Chest Pain,” RN, 57 (6):58-62, 1994.
Teplitz, Linda. “Hypertensive Crisis: Review and Update,” Critical Care Nurse, 13 (6):20-35, 1993.
Weinman, Steven A. “Emergency Management of Drug Overdose,” Critical Care Nurse, 13 (6):45-5 1 ,
1993.
Career CollegesKomrnunity Colleges and Post Secondary Vo-Techs
For desk or review copies call: 1-800-477-3692 or fax 1-518-464-0301
For orders call: 1-800-347-7707 or fax 1-606-647-5023
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Attn: Order Fulfillment
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Florence, KY 41022
Email: info@delmar.com
Four-Year CollegeKJniversity
Mail to: ITP Higher Education
P.O. Box 6904
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Business, Industry and Government

For orders call: 1-800-347-7707, ext. 4 or fax 1-606-647-5963
Mail to: ITP Business, Industry, Government
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All other orders and inquiries
1-800-347-7707, ext. 4
Retail
Mail to: International Thomson Publishing
Attn: Professional/TechnicalOrder Fulfillment
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CRITICAL CARE

NURSING CARE PLANS

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Library of Congress Cataloging-in-PublicationData

NEUROLOGICAL SYSTEM ..................................................................................................................................... 137

GASTROMTESTINAUHEPATIC SYSTEM .................................................................................................................. 191

HEMATOLOGIC SYSTEM ..................................................................................................................................... 223

RENWDOCRINE SYSTEMS .............................................................................................................................. 237

MUSCULOSKELETAL SYSTEM .............................................................................................................................. 289

IHTEGUMarrARY SYSTEM ................................................................................................................................... 311

OTHER ............................................................................................................................................................. 329

INDEN OF NURSING DIAGNOSES ........................................................................................................................... 361

REFERENCES ..................................................................................................................................................... 365

Congestive Heart Failure

Congestive Heart Failure Right-sided heart failure is usually caused by left-

Vasodilators: hydralazine (Apresoline) PO or IV, decreases afterload, decreases preload, improves

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Position in semi-Fowler’s Promotes easier breathing and Information, Instruction,

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

INTERVENTIONS RATIONALES Outcome Criteria

Instruct on hazards of immobili- Bedrest promotes pressure to

Instruct on the use of lotions Prevents skin dryness and chance

Discharge or Maintenance Evaluation

LEFT-SIDED HEART FAILURE

Renal com ensatory changes occur

LV cannot pump blood from lungs into systemic circulation

Fluid backs U into pulmonary vasculature = pulmonary congestion

RIGHT-SIDED HEART FAILURE

Right heart cannot pump blood into pulmonary system

Congestion of portal circulation

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Obtain history (when possible) This provides information

Discharge or Maintenance INTERVENTIONS RATIONALES

Administer thrombolytic drugs Drugs Iyse the clot that may be

Defining characteristics: elevated blood pressure,

INTERVENTIONS RATIONALES INTERVENTIONS MTIONALES

Provide small, easy to digest, Large meals increase the work-

dyspnea, orthopnea, crackles (rales), oliguria, jugu-

Observe for jugular vein dis-

May indicate impending conges-

INTERVENTIONS RATIONALES Information, Instruction,

Provide private time for pa- Allows time for expression

Knowledge W c i t INTERVENTIONS RATIONALES

MYOCARDZAL INFARCTION (MI)

COMPLICATIONS RESULTING FROM MI THAT MAY LEAD TO DEATH IF NOT TREATED:

PerScarditis The main symptoms of pericarditis include sharp,

The visceral pericardium is a serous membrane Inotropic drugs: isoproterenol or dobutamine IV

NURSING CARE PLANS Obtain vital signs.

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Auscultate heart sounds for Suggestive of impending or

Assist patient with planned, Allows for balance between rest

Defining characteristics: restlessness, insomnia,

(NBTE). After this stage, the heart is then set up

Instruction, Information, Hyperthermia

Information, Instruction, Outcome Criteria

Reposition patient every 2 Frequent changes in position

INTERVENTIONS RATIONALES Discharge or Maintenance

INTERVENTIONS RATIONALES Patient will seek prophylactic antibiotic therapy