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 Foundations
of Adult Health
Nursing
Third Edition

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 DEDICATIONS
Lois White:
To my beloved husband, John, who is on his last great adventure and learning
experience.

Gena Duncan:
To my husband, who gives me unconditional love and brings balance, calmness, and
excitement to my life.
To Lois White, who modeled the role of an author and committed much of her life
to this textbook.
To Wendy Baumle, for her hard work and dedication in developing this textbook.
Thanks.
To future nurses who are caring and competent.

Wendy Baumle:
This book is dedicated to my beloved family—Patrick, Taylor, Madeline, Blair,
Connor, Janet, and Robert—for their love and support, to Juliet Steiner for inspiring
me and for making a difference in my life, to Gena Duncan for her guidance and
friendship, and to my friends, colleagues, and students for their support and valuable
insight into today’s nursing education.

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 Foundations
of Adult Health
Nursing
Third Edition
Lois White, RN, PhD
Former Chairperson and Professor Department of Vocational
Nurse Education, Del Mar College, Corpus Christi, Texas

Gena Duncan, RN, MSEd, MSN

Former Associate Professor of Nursing, Ivy Tech Community
College, Fort Wayne, Indiana

Wendy Baumle, RN, MSN

James A. Rhodes State College, School of Nursing, Lima, Ohio

Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States

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Foundations of Adult Health Nursing, Third © 2011, 2005, 2001 Delmar Cengage Learning
Edition
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BRIEF CONTENTS

Unit 1: Essential Concepts / 1 Unit 6: Nursing Care of

1 Anesthesia ...........................................................2 the Client: Body
2 Surgery .............................................................. 15
3 Oncology ...........................................................44 Defenses / 499
15 Integumentary System....................................500
Unit 2: Nursing Care of the 16 Immune System...............................................543

Client: Oxygenation Unit 7: Nursing Care of the

and Perfusion / 69 Client: Physical and
4 Respiratory System...........................................70
5 Cardiovascular System................................... 119 Mental Integrity / 581
6 Hematologic and Lymphatic 17 Mental Illness ..................................................582
Systems ........................................................ 163 18 Substance Abuse ............................................ 617

Unit 3: Nursing Care of the Unit 8: Nursing Care of

Client: Digestion and the Client: Older
Elimination / 195 Adult / 645
7 Gastrointestinal System ................................. 196 19 The Older Adult ...............................................646
8 Urinary System ................................................238
Unit 9: Nursing Care of the
Unit 4: Nursing Care of the Client: Health Care in
Client: Mobility, the Community / 677
Coordination, and 20 Ambulatory, Restorative, and Pallative
Regulation / 275 Care in Community Settings ......................678
9 Musculoskeletal System ................................. 276
10 Neurological System.......................................305 Unit 10: Applications / 697
11 Sensory System ..............................................359 21 Responding to Emergencies .........................698
12 Endocrine System ...........................................388 22 Integration .......................................................725

Unit 5: Nursing Care of the

Client: Reproductive
and Sexual Health / 429
13 Reproductive System......................................430
14 Sexually Transmitted Infections .....................481

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 CONTENTS

Contributors / xxxi General Anesthesia ..................................................8

Reviewers / xxxiii Induction and Airway Management ................................. 8
Market Reviewers and Class Test Participants / xxxiv Maintenance ................................................................... 8
Skeletal Muscle Relaxation .......................................... 9
Preface / xxxvii
Emergence ..................................................................... 9
About the Authors / xli Recovery ......................................................................... 9
Acknowledgments / xlii Oxygenation and Ventilation ......................................... 9
How to Use This Text / xliii Heart Rate and Blood Pressure ................................... 9
How to Use StudyWARE™ / xlvii Temperature Regulation and Shivering ........................ 9
Fluid Balance ..............................................................10
Postoperative Pain Management........................... 10
Patient-Controlled Analgesia..........................................10
UNIT 1 Regional Analgesia ........................................................10
Local Anesthetics ........................................................10
Opioids ........................................................................11
Essential Concepts / 1 Case Study .............................................................. 12
CHAPTER 1: ANESTHESIA / 2
Introduction...............................................................3 CHAPTER 2: SURGERY / 15
Preanesthetic Preparation .......................................3 Introduction............................................................. 16
Oral Intake ...................................................................... 3 Preoperative Phase ................................................ 16
Preoperative Medication ................................................. 4 Preoperative Physiologic Assessment ...........................16
Consent .......................................................................... 4 Age ..............................................................................17
Sedation ....................................................................5 Nutritional Status .........................................................17
Sedation and Monitoring ................................................. 5 Fluid and Electrolyte Status ........................................18
Residual Effects of Sedation ........................................... 5 Respiratory Status .......................................................18
Regional Anesthesia ................................................5 Cardiovascular Status .................................................18
Types of Regional Anesthesia......................................... 5 Renal and Hepatic Status ...........................................18
Local Anesthesia .......................................................... 5 Neurological, Musculoskeletal, and Integumentary
Nerve Blocks ................................................................ 6 Status ..........................................................................18
Spinal and Epidural Blocks .......................................... 6 Endocrine and Immunological Status .........................19
Residual Effects of Regional Anesthesia ........................ 7 Medications.................................................................19
Residual Motor Block ................................................... 7 Psychosocial Health Assessment ................................. 20
Residual Sensory Block ............................................... 7 Surgical Consent .......................................................... 20
Residual Sympathetic Block ........................................ 8 Preoperative Teaching................................................... 20

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vi CONTENTS

Physical Preparation ..................................................... 20 Ascites .......................................................................... 58

Intraoperative Phase ..............................................24 Sexual Alterations ......................................................... 58
Physical Description of the Operating Room Medical Emergencies .............................................58
Environment .................................................................. 24 Hypercalcemia ........................................................58
Members of the Surgical Team ..................................... 24 Spinal Cord Compression......................................58
Asepsis ......................................................................... 24 Superior Vena Cava Syndrome ..............................58
Surgical Hand Scrub ..................................................... 25 Cardiac Tamponade ................................................59
Surgical Skin Preparation.............................................. 25
Psychosocial Alterations .......................................59
Intraoperative Nursing Care .......................................... 25
Nursing Process .....................................................59
Postoperative Phase...............................................26 Assessment .................................................................. 59
Postoperative Nursing Care .......................................... 26
Subjective Data .......................................................... 59
Continuing Nursing Care in the PACU .......................... 29
Objective Data ........................................................... 59
Later Postoperative Nursing Care ................................. 29
Sample Nursing Care Plan: The Client with
Ambulatory Surgery ...............................................36
Lung Cancer............................................................61
Elderly Clients Having Surgery .............................39
Case Study ..............................................................64
Case Study ..............................................................41

UNIT 2
CHAPTER 3: ONCOLOGY / 44
Introduction.............................................................45
Incidence .................................................................45
Nursing Care of the Client:
Pathophysiology .....................................................45 Oxygenation and Perfusion / 69
Risk Factors ............................................................46
Environmental Factors .................................................. 46 CHAPTER 4: RESPIRATORY
Lifestyle Factors ............................................................ 46
SYSTEM / 70
Genetic Factors ............................................................. 47
Viral Factors .................................................................. 47 Introduction.............................................................71
Detection .................................................................48 Anatomy and Physiology Review ..........................71
Common Diagnostic Tests .....................................48 Thoracic Cavity ............................................................. 71
Staging of Tumors...................................................48 Conducting Airways ...................................................... 71
Grading of Tumors ..................................................48 Respiratory Tissues ...................................................... 72
Respiration .................................................................... 72
Treatment Modalities ..............................................49
Neuromuscular Control of Respiration .......................... 72
Surgery ......................................................................... 49
Gas Exchange .............................................................. 73
Radiation Therapy ......................................................... 50
External Radiation ...................................................... 50 Assessment ............................................................73
Internal Radiation ....................................................... 50 Health History ............................................................... 73
Chemotherapy .............................................................. 52 Inspection ......................................................................74
Biotherapy ..................................................................... 54 Palpation and Percussion ..............................................74
Photodynamic Therapy ................................................. 54 Auscultation ...................................................................74
Hormone Therapy ......................................................... 54 Normal Breath Sounds ................................................74
Targeted Cancer Therapy.............................................. 54 Adventitious Breath Sounds....................................... 75
Bone Marrow Transplantation ....................................... 54 Common Diagnostic Tests .....................................75
Symptom Management ..........................................55 Infectious/Inflammatory Disorders .......................75
Bone Marrow Dysfunction ............................................. 55 Infectious/Inflammatory Disorders of the Upper
Nutritional Alterations .................................................... 55 Respiratory Tract .....................................................78
Anorexia ..................................................................... 55 Medical–Surgical Management .................................... 78
Nausea and Vomiting ................................................. 55 Medical ...................................................................... 78
Altered Taste Sensation .............................................. 56 Surgical ...................................................................... 78
Mucosal Inflammation ................................................ 56 Pharmacological ........................................................ 78
Dysphagia .................................................................. 56 Diet ............................................................................. 79
Pain ............................................................................... 56 Activity ........................................................................ 79
Fatigue .......................................................................... 57 Nursing Management ................................................... 79
Alopecia ........................................................................ 57 Nursing Process .....................................................79
Odors ............................................................................ 57 Assessment .................................................................. 79
Dyspnea ........................................................................ 57 Subjective Data .......................................................... 79
Bowel Dysfunctions....................................................... 57 Objective Data ........................................................... 79
Pathological Fractures .................................................. 58 Pneumonia ..............................................................79

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 CONTENTS vii

Medical–Surgical Management .................................... 80 Diet ............................................................................. 95

Medical ...................................................................... 80 Activity ........................................................................ 95
Pharmacological ........................................................ 80 Nursing Management ................................................... 95
Diet ............................................................................. 81 Nursing Process .....................................................96
Activity ........................................................................ 81 Assessment .................................................................. 96
Health Promotion ........................................................ 81 Subjective Data .......................................................... 96
Nursing Management ................................................... 81 Objective Data ........................................................... 96
Nursing Process .....................................................82 Pulmonary Edema ..................................................96
Assessment .................................................................. 82 Medical–Surgical Management .................................... 97
Subjective Data .......................................................... 82 Medical ...................................................................... 97
Objective Data ........................................................... 82 Pharmacological ........................................................ 97
Tuberculosis............................................................82 Diet ............................................................................. 97
Medical–Surgical Management .................................... 84 Activity ........................................................................ 97
Medical ...................................................................... 84 Nursing Management ................................................... 97
Surgical ...................................................................... 84 Nursing Process .....................................................97
Pharmacological ........................................................ 84 Assessment .................................................................. 97
Diet ............................................................................. 86 Subjective Data .......................................................... 97
Activity ........................................................................ 86 Objective Data ........................................................... 97
Health Promotion ........................................................ 86 Acute Respiratory Distress Syndrome .................98
Nursing Management ................................................... 86 Medical–Surgical Management .................................... 98
Nursing Process .....................................................86 Medical ...................................................................... 98
Assessment .................................................................. 86 Pharmacological ........................................................ 98
Subjective Data ......................................................... 86 Diet ............................................................................. 99
Objective Data ........................................................... 86 Activity ........................................................................ 99
Sample Nursing Care Plan: The Client Nursing Management ................................................... 99
with TB .....................................................................87 Nursing Process .....................................................99
Pleurisy/Pleural Effusion........................................90 Assessment .................................................................. 99
Medical–Surgical Management .................................... 91 Subjective Data .......................................................... 99
Medical ...................................................................... 91 Objective Data ........................................................... 99
Surgical ...................................................................... 91 Acute Respiratory Failure ......................................99
Pharmacological ........................................................ 91 Chronic Respiratory Tract Disorders ....................99
Activity ........................................................................ 91 Asthma .................................................................. 100
Nursing Management ................................................... 91 Medical–Surgical Management ...................................100
Nursing Process .....................................................91 Medical .....................................................................100
Assessment .................................................................. 91 Pharmacological .......................................................100
Subjective Data .......................................................... 91 Diet ............................................................................100
Objective Data ........................................................... 92 Activity .......................................................................100
Severe Acute Respiratory Syndrome ....................92 Nursing Management ..................................................100
Nursing Management ................................................... 92 Nursing Process ................................................... 101
Acute Respiratory Tract Disorders ........................92 Assessment ................................................................. 101
Atelectasis...............................................................92 Subjective Data ......................................................... 101
Medical–Surgical Management .................................... 93 Objective Data .......................................................... 101
Medical ...................................................................... 93 Chronic Obstructive Pulmonary Disease ........... 102
Surgical ...................................................................... 93 Chronic Bronchitis ............................................... 102
Pharmacological ........................................................ 93 Medical–Surgical Management ...................................102
Diet ............................................................................. 93 Medical .....................................................................102
Activity ........................................................................ 93 Pharmacological .......................................................102
Nursing Management ................................................... 93 Diet ............................................................................102
Nursing Process .....................................................93 Activity .......................................................................102
Assessment .................................................................. 93 Nursing Management ..................................................102
Subjective Data .......................................................... 93 Nursing Process ................................................... 103
Objective Data ........................................................... 93 Assessment .................................................................103
Pulmonary Embolism .............................................94 Subjective Data .........................................................103
Medical–Surgical Management .................................... 95 Objective Data ..........................................................103
Medical ...................................................................... 95 Emphysema .......................................................... 104
Surgical ...................................................................... 95 Medical–Surgical Management ...................................104
Pharmacological ........................................................ 95 Medical .....................................................................104

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viii CONTENTS

Pharmacological .......................................................104 Subjective Data ......................................................... 114

Diet ............................................................................104 Objective Data .......................................................... 114
Activity .......................................................................105 Case Study ............................................................ 115
Health Promotion .......................................................105
Nursing Management ..................................................105
Nursing Process ................................................... 105 CHAPTER 5: CARDIOVASCULAR
Assessment .................................................................105 SYSTEM / 119
Subjective Data .........................................................105
Objective Data ..........................................................105
Introduction........................................................... 120
Anatomy and Physiology Review ........................ 120
Bronchiectasis ...................................................... 106
Structure of the Heart ..................................................120
Medical–Surgical Management ...................................106
Circulation of Blood......................................................120
Medical .....................................................................106
Stroke Volume and Cardiac Output ..............................121
Pharmacological .......................................................106
Coronary Arteries.........................................................121
Diet ............................................................................106
Conduction System ......................................................121
Activity .......................................................................106
Heart Sounds ............................................................122
Nursing Management ..................................................107
Arterioles and Arteries .................................................122
Chest Trauma ........................................................ 108
Capillaries ....................................................................123
Pneumothorax/Hemothorax................................. 108 Venules and Veins........................................................123
Medical–Surgical Management ...................................108
Health History ....................................................... 123
Medical .....................................................................108
Surgical .....................................................................109
Assessment .......................................................... 123
Subjective Data ............................................................123
Pharmacological .......................................................109
Objective Data .............................................................124
Diet ............................................................................109
Activity .......................................................................109 Common Diagnostic Tests ................................... 125
Nursing Management ..................................................109 Cardiac Rhythm/Dysrhythmia.............................. 125
Nursing Process ................................................... 109 Normal Sinus Rhythm .......................................... 125
Assessment .................................................................109 Dysrhythmias ........................................................ 127
Subjective Data .........................................................109 Bradycardia ........................................................... 127
Objective Data ..........................................................109 Tachycardia ........................................................... 127
Neoplasms of the Respiratory Tract .................... 110 Atrial Dysrhythmias .............................................. 128
Benign Neoplasms ............................................... 110 Premature Atrial Contractions ......................................128
Lung Cancer.......................................................... 110 Atrial Tachycardia .........................................................128
Medical–Surgical Management ................................... 110 Paroxysmal Supraventricular Tachycardia....................128
Medical ..................................................................... 110 Atrial Flutter..................................................................128
Surgical ..................................................................... 111 Atrial Fibrillation ...........................................................128
Pharmacological ....................................................... 111 Ventricular Dysrhythmias .................................... 129
Health Promotion ....................................................... 111 Premature Ventricular Contractions .............................129
Nursing Management .................................................. 111 Ventricular Tachycardia ................................................129
Nursing Process ....................................................111 Cardioversion ............................................................129
Assessment ................................................................. 111 Defibrillation ..............................................................129
Subjective Data ......................................................... 111 Ventricular Fibrillation ..................................................130
Objective Data .......................................................... 111 Ventricular Asystole......................................................130
Laryngeal Cancer ................................................. 112 Atrioventricular Blocks ........................................ 130
Medical–Surgical Management ................................... 112 First-Degree AV Block ..................................................130
Surgical ..................................................................... 112 Second-Degree AV Block.............................................131
Nursing Management .................................................. 112 Third-Degree AV Block .................................................131
Nursing Process ................................................... 112 Medical–Surgical Management ...................................131
Assessment ................................................................. 112 Pharmacological .......................................................131
Subjective Data ......................................................... 112 Diet ............................................................................131
Objective Data .......................................................... 112 Nursing Management ..................................................131
Disorders of the Nose .......................................... 113 Nursing Process ................................................... 131
Epistaxis ................................................................ 113 Assessment .................................................................131
Medical–Surgical Management ................................... 113 Subjective Data .........................................................131
Medical ..................................................................... 113 Objective Data ..........................................................131
Pharmacological ....................................................... 114 Inflammatory Disorders ....................................... 132
Nursing Management .................................................. 114 Rheumatic Heart Disease .................................... 132
Nursing Process ................................................... 114 Infective Endocarditis .......................................... 132
Assessment ................................................................. 114 Medical–Surgical Management ...................................133

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 CONTENTS ix

Surgical .....................................................................133 Medical–Surgical Management ...................................143

Pharmacological .......................................................133 Medical .....................................................................143
Diet ............................................................................133 Surgical .....................................................................143
Activity .......................................................................133 Pharmacological .......................................................143
Health Promotion .......................................................133 Diet ............................................................................144
Nursing Management ..................................................133 Activity .......................................................................144
Myocarditis ............................................................ 133 Health Promotion .......................................................144
Medical–Surgical Management ...................................133 Nursing Management ..................................................145
Pharmacological .......................................................133 Nursing Process ................................................... 145
Activity .......................................................................133 Assessment .................................................................145
Nursing Management ..................................................133 Subjective Data .........................................................145
Pericarditis ............................................................ 133 Objective Data ..........................................................145
Medical–Surgical Management ...................................133 Cor Pulmonale ...................................................... 146
Medical .....................................................................133 Cardiac Transplantation ....................................... 146
Surgical .....................................................................134 Peripheral Vascular Disorders ............................. 146
Pharmacological .......................................................134 Aneurysm .............................................................. 146
Nursing Management ..................................................134 Medical–Surgical Management ...................................147
Valvular Heart Diseases ....................................... 134 Medical .....................................................................147
Stenosis and Insufficiency.................................. 134 Surgical .....................................................................147
Mitral Valve Prolapse ............................................ 134 Pharmacological .......................................................147
Medical–Surgical Management ...................................134 Activity .......................................................................147
Medical .....................................................................134 Health Promotion .......................................................147
Surgical .....................................................................135 Nursing Management ..................................................147
Nursing Management ..................................................136 Nursing Process ................................................... 147
Nursing Process ................................................... 136 Assessment .................................................................147
Assessment .................................................................136 Subjective Data .........................................................147
Subjective Data .........................................................136 Objective Data ..........................................................147
Objective Data ..........................................................136 Hypertension......................................................... 148
Occlusive Disorders ............................................. 137 Medical–Surgical Management ...................................149
Arteriosclerosis .................................................... 137 Medical .....................................................................149
Angina Pectoris .................................................... 137 Pharmacological .......................................................149
Medical–Surgical Management ...................................137 Diet ............................................................................149
Medical .....................................................................137 Activity .......................................................................149
Surgical .....................................................................138 Health Promotion .......................................................150
Pharmacological .......................................................139 Nursing Management ..................................................150
Diet ............................................................................139 Nursing Process ................................................... 150
Activity .......................................................................139 Assessment .................................................................150
Health Promotion .......................................................139 Subjective Data .........................................................150
Nursing Management ..................................................139 Objective Data ..........................................................150
Nursing Process ................................................... 139 Sample Nursing Care Plan: The Client
Assessment .................................................................139 with Hypertension ................................................ 151
Subjective Data .........................................................139 Venous Thrombosis/Thrombophlebitis .............. 152
Objective Data ..........................................................139 Medical–Surgical Management ...................................153
Myocardial Infarction............................................ 140 Medical .....................................................................153
Medical–Surgical Management ...................................141 Surgical .....................................................................153
Medical .....................................................................141 Pharmacological .......................................................153
Surgical .....................................................................141 Diet ............................................................................154
Pharmacological .......................................................141 Activity .......................................................................154
Diet ............................................................................141 Health Promotion .......................................................154
Activity .......................................................................141 Nursing Management ..................................................154
Health Promotion .......................................................141 Nursing Process ................................................... 154
Nursing Management ..................................................142 Assessment .................................................................154
Nursing Process ................................................... 142 Subjective Data .........................................................154
Assessment .................................................................142 Objective Data ..........................................................154
Subjective Data .........................................................142 Varicose Veins ....................................................... 155
Objective Data ..........................................................142 Medical–Surgical Management ...................................155
Heart Failure.......................................................... 143 Medical .....................................................................155

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x CONTENTS

Surgical .....................................................................155 Medical–Surgical Management ...................................170

Pharmacological .......................................................155 Pharmacological .......................................................170
Activity .......................................................................155 Acquired Hemolytic Anemia ................................ 171
Health Promotion .......................................................155 Medical–Surgical Management ...................................171
Nursing Management ..................................................155 Medical .....................................................................171
Buerger’s Disease (Thromboangiitisobliterans) 155 Surgical .....................................................................171
Raynaud’s Disease/Phenomenon ....................... 156 Pharmacological .......................................................171
Medical–Surgical Management ...................................156 Sickle Cell Anemia (Inherited Hemolyticanemia)....171
Medical .....................................................................156 Medical–Surgical Management ...................................172
Surgical .....................................................................156 Medical .....................................................................172
Pharmacological .......................................................156 Pharmacological .......................................................172
Nursing Management ..................................................156 Nursing Management ..................................................173
Medical–Surgical Management ...................................156 Nursing Process ................................................... 173
Medical .....................................................................156 Assessment .................................................................173
Surgical .....................................................................156 Subjective Data .........................................................173
Pharmacological .......................................................156 Objective Data ..........................................................173
Health Promotion .......................................................157 Sample Nursing Care Plan: The Client with
Nursing Management ..................................................157 Sickle Cell Anemia ................................................ 174
Nursing Process ................................................... 157 Polycythemia ......................................................... 176
Assessment .................................................................157 Medical–Surgical Management ...................................176
Subjective Data .........................................................157 Medical .....................................................................176
Objective Data ..........................................................157 Pharmacological .......................................................176
Case Study ............................................................ 158 Diet ............................................................................176
Activity .......................................................................176
Nursing Management ..................................................176
CHAPTER 6: HEMATOLOGIC Nursing Process ................................................... 176
AND LYMPHATIC SYSTEMS / 163 Assessment .................................................................176
Subjective Data .........................................................176
Introduction........................................................... 164 Objective Data ..........................................................176
Anatomy and Physiology Review ........................ 164 WBC Disorders ..................................................... 177
Blood............................................................................164 Leukemia ............................................................... 177
Plasma ......................................................................164 Acute Leukemia .................................................... 177
Red Blood Cells ........................................................164 Medical–Surgical Management ...................................177
White Blood Cells ......................................................165 Medical .....................................................................177
Platelets.....................................................................165 Pharmacological .......................................................178
Blood Types ...............................................................165 Diet ............................................................................178
Rh Factor...................................................................166 Activity .......................................................................178
Blood Transfusions ....................................................166
Chronic Leukemia ............................................... 178
Lymphatic System ........................................................166
Medical–Surgical Management ...................................178
Lymph Fluid and Vessels...........................................166
Medical .....................................................................178
Lymph Nodes ............................................................166
Pharmacological .......................................................179
Lymph Organs ...........................................................167
Diet ............................................................................179
Assessment .......................................................... 167 Activity .......................................................................179
Subjective Data ............................................................167 Nursing Management ..................................................179
Objective Data .............................................................167
Nursing Process ................................................... 179
Common Diagnostic Tests ................................... 168 Assessment .................................................................179
RBC Disorders ...................................................... 168 Subjective Data .........................................................179
Iron Deficiency Anemia ........................................ 168 Objective Data ..........................................................179
Medical–Surgical Management ...................................169 Agranulocytosis.................................................... 180
Pharmacological .......................................................169 Medical–Surgical Management ...................................181
Diet ............................................................................169 Medical .....................................................................181
Activity .......................................................................169 Pharmacological .......................................................181
Aplastic Anemia .................................................... 169 Diet ............................................................................181
Medical–Surgical Management ...................................170 Activity .......................................................................181
Medical .....................................................................170 Nursing Management ..................................................181
Surgical .....................................................................170 Nursing Process ................................................... 181
Pharmacological .......................................................170 Assessment .................................................................181
Pernicious Anemia ............................................... 170 Subjective Data .........................................................181

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 CONTENTS xi

Objective Data ..........................................................181 Nursing Process ................................................... 189

Coagulation Disorders ......................................... 182 Assessment .................................................................189
Disseminated Intravascular Coagulation ........... 182 Subjective Data .........................................................189
Medical–Surgical Management ...................................182 Objective Data ..........................................................189
Medical .....................................................................182 Case Study ............................................................ 190
Pharmacological .......................................................182
Nursing Management ..................................................182
Nursing Process ................................................... 182
Assessment .................................................................182
UNIT 3
Subjective Data .........................................................182
Objective Data ..........................................................182 Nursing Care of the Client:
Hemophilia ............................................................ 183
Medical–Surgical Management ...................................183 Digestion and Elimination / 195
Medical .....................................................................183
Pharmacological .......................................................184 CHAPTER 7: GASTROINTESTINAL
Nursing Management ..................................................184 SYSTEM / 196
Nursing Process ................................................... 184
Assessment .................................................................184 Introduction........................................................... 197
Subjective Data .........................................................184 Anatomy and Physiology Review ........................ 197
Objective Data ..........................................................184 Mouth/Esophagus ........................................................197
Thrombocytopenia ............................................... 185 Stomach.......................................................................197
Medical–Surgical Management ...................................185 Small Intestine .............................................................197
Medical .....................................................................185 Large Intestine .............................................................198
Surgical .....................................................................185 Accessory Organs .......................................................198
Pharmacological .......................................................185 Pancreas ...................................................................198
Diet ............................................................................185 Liver...........................................................................198
Activity .......................................................................185 Gallbladder ...............................................................198
Nursing Management ..................................................185 Effects of Aging ............................................................198
Nursing Process ................................................... 185 Assessment .......................................................... 198
Assessment .................................................................185 Common Diagnostic Tests ................................... 199
Subjective Data .........................................................185 Disorders of the Gastrointestinal Tract .............. 199
Objective Data ..........................................................185 Stomatitis .............................................................. 199
Lymph Disorders .................................................. 185 Medical–Surgical Management ...................................199
Hodgkin’s Disease ................................................ 186 Medical .....................................................................199
Medical–Surgical Management ...................................186 Pharmacological .......................................................199
Medical .....................................................................186 Diet ............................................................................199
Surgical .....................................................................186 Nursing Management ..................................................199
Pharmacological .......................................................186 Nursing Process ...................................................200
Diet ............................................................................186 Assessment ................................................................ 200
Activity .......................................................................186 Subjective Data ........................................................ 200
Non-Hodgkin’s Lymphoma .................................. 187 Objective Data ......................................................... 200
Medical–Surgical Management ...................................188 Esophageal Varices ..............................................202
Medical .....................................................................188 Medical–Surgical Management .................................. 202
Pharmacological .......................................................188 Medical .................................................................... 202
Nursing Management ..................................................188 Surgical .................................................................... 202
Nursing Process ................................................... 188 Pharmacological ...................................................... 202
Assessment .................................................................188 Activity ...................................................................... 202
Subjective Data .........................................................188 Nursing Management ................................................. 202
Objective Data ..........................................................188 Nursing Process ...................................................202
Plasma Cell Disorder............................................ 189 Assessment ................................................................ 202
Multiple Myeloma.................................................. 189 Subjective Data ........................................................ 202
Medical–Surgical Management ...................................189 Objective Data ......................................................... 203
Medical .....................................................................189 Gastroesophageal Reflux Disease ......................204
Surgical .....................................................................189 Medical–Surgical Management .................................. 204
Pharmacological .......................................................189 Medical .................................................................... 204
Diet ............................................................................189 Surgical .................................................................... 204
Activity .......................................................................189 Pharmacological ...................................................... 204
Nursing Management ..................................................189 Diet ........................................................................... 204

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Nursing Management ................................................. 204 Medical–Surgical Management ...................................213

Gastritis .................................................................204 Medical .....................................................................213
Medical–Surgical Management .................................. 204 Surgical .....................................................................213
Medical .................................................................... 204 Pharmacological .......................................................214
Pharmacological ...................................................... 204 Diet ............................................................................214
Diet ........................................................................... 204 Health Promotion .......................................................214
Health Promotion ...................................................... 205 Nursing Management ..................................................214
Nursing Management ................................................. 205 Nursing Process ................................................... 214
Nursing Process ...................................................205 Assessment .................................................................214
Assessment ................................................................ 205 Subjective Data .........................................................214
Subjective Data ........................................................ 205 Objective Data ..........................................................214
Objective Data ......................................................... 205 Irritable Bowel Syndrome..................................... 215
Ulcers.....................................................................206 Medical-Surgical Management ....................................215
Medical–Surgical Management .................................. 206 Medical .....................................................................215
Medical .................................................................... 206 Pharmacological .......................................................215
Surgical .................................................................... 206 Diet ............................................................................215
Pharmacological ...................................................... 206 Activity .......................................................................216
Diet ........................................................................... 206 Nursing Management ..................................................216
Health Promotion ...................................................... 206 Nursing Process ................................................... 216
Nursing Management ................................................. 206 Assessment .................................................................216
Nursing Process ...................................................207 Subjective Data .........................................................216
Assessment ................................................................ 207 Objective Data ..........................................................216
Subjective Data ........................................................ 207 Intestinal Obstruction .......................................... 216
Objective Data ......................................................... 207 Medical–Surgical Management ...................................217
Appendicitis ..........................................................207 Medical .....................................................................217
Medical–Surgical Management .................................. 207 Surgical .....................................................................217
Surgical .................................................................... 207 Pharmacological .......................................................217
Pharmacological ...................................................... 208 Diet ............................................................................217
Diet ........................................................................... 208 Activity .......................................................................217
Activity ...................................................................... 208 Nursing Management ..................................................217
Nursing Management ................................................. 208 Nursing Process ................................................... 217
Nursing Process ...................................................208 Assessment .................................................................217
Assessment ................................................................ 208 Subjective Data .........................................................217
Subjective Data ........................................................ 208 Objective Data ..........................................................217
Objective Data ......................................................... 208 Hernias .................................................................. 218
Diverticulosis and Diverticulitis ..........................208 Medical–Surgical Management ...................................218
Medical–Surgical Management .................................. 209 Medical .....................................................................218
Medical .................................................................... 209 Surgical .....................................................................218
Surgical .................................................................... 209 Diet ............................................................................218
Pharmacological ...................................................... 209 Nursing Management ..................................................218
Diet ........................................................................... 209 Nursing Process ................................................... 218
Activity ...................................................................... 209 Assessment .................................................................218
Stoma/Ostomy Management ...................................... 209 Subjective Data .........................................................218
Assessment .............................................................. 209 Objective Data ..........................................................218
Complications ...........................................................210 Peritonitis .............................................................. 219
Discharge Teaching for the Ostomy Client ...................210 Medical–Surgical Management ...................................219
Assessment ...............................................................210 Surgical .....................................................................219
Appliances ................................................................210 Pharmacological .......................................................219
Irrigation ....................................................................210 Diet ............................................................................219
Support Person .........................................................210 Activity .......................................................................219
Nursing Management ..................................................210 Nursing Management ..................................................219
Nursing Process ................................................... 210 Nursing Process ................................................... 219
Assessment .................................................................210 Assessment .................................................................219
Subjective Data .........................................................210 Subjective Data .........................................................219
Objective Data ..........................................................210 Objective Data ..........................................................219
Sample Nursing Care Plan: The Client with Hemorrhoids .........................................................220
Diverticulitis .......................................................... 211 Medical–Surgical Management .................................. 220
Inflammatory Bowel Disease ............................... 213 Medical .................................................................... 220

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 CONTENTS xiii

Surgical .................................................................... 220 Diet ........................................................................... 229

Pharmacological ...................................................... 220 Activity ...................................................................... 229
Diet ........................................................................... 220 Nursing Management ................................................. 229
Nursing Management ................................................. 220 Nursing Process ...................................................229
Nursing Process ...................................................220 Assessment ................................................................ 229
Assessment ................................................................ 220 Subjective Data ........................................................ 229
Subjective Data ........................................................ 220 Objective Data ......................................................... 229
Objective Data ......................................................... 220 Neoplasms of the Gastrointestinal System ........230
Constipation..........................................................221 Oral Cancer ...........................................................230
Medical–Surgical Management .................................. 221 Medical–Surgical Management .................................. 230
Pharmacological ...................................................... 221 Surgical .................................................................... 230
Diet ........................................................................... 221 Pharmacological ...................................................... 230
Activity ...................................................................... 221 Diet ........................................................................... 230
Nursing Management ................................................. 221 Activity ...................................................................... 230
Nursing Process ...................................................221 Other Therapies ........................................................ 230
Assessment ................................................................ 221 Nursing Management ................................................. 230
Subjective Data ........................................................ 221 Nursing Process ...................................................230
Objective Data ......................................................... 221 Assessment ................................................................ 230
Disorders of the Accessory Organs....................221 Subjective Data ........................................................ 230
Cirrhosis ................................................................221 Objective Data ......................................................... 230
Medical–Surgical Management .................................. 222 Colorectal Cancer .................................................231
Medical .................................................................... 222 Medical–Surgical Management .................................. 231
Surgical .................................................................... 222 Surgical .................................................................... 231
Pharmacological ...................................................... 222 Pharmacological ...................................................... 231
Diet ........................................................................... 223 Diet ........................................................................... 231
Activity ...................................................................... 223 Activity ...................................................................... 231
Nursing Management ................................................. 223 Other Therapies ........................................................ 232
Nursing Process ...................................................223 Nursing Management ................................................. 232
Assessment ................................................................ 223 Nursing Process ...................................................232
Subjective Data ........................................................ 223 Assessment ................................................................ 232
Objective Data ......................................................... 223 Subjective Data ........................................................ 232
Hepatitis ................................................................224 Objective Data ......................................................... 232
Medical–Surgical Management .................................. 224 Liver Cancer ..........................................................232
Pharmacological ...................................................... 224 Obesity ....................................................................... 232
Diet ........................................................................... 224 Medical-Surgical Management ................................... 233
Activity ...................................................................... 224 Nursing Management ................................................. 233
Nursing Management ................................................. 224 Case Study ............................................................234
Nursing Process ...................................................226
Assessment ................................................................ 226 CHAPTER 8: URINARY
Subjective Data ........................................................ 226 SYSTEM / 238
Objective Data ......................................................... 226
Introduction...........................................................239
Pancreatitis ...........................................................227
Medical–Surgical Management .................................. 227 Anatomy and Physiology Review ........................239
Medical .................................................................... 227 Assessment ..........................................................241
Surgical .................................................................... 227 Subjective Data ........................................................... 241
Pharmacological ...................................................... 227 Objective Data ............................................................ 241
Diet ........................................................................... 227 Changes with Aging .................................................... 241
Activity ...................................................................... 227 Common Diagnostic Tests ...................................242
Nursing Management ................................................. 227 Impaired Urinary Elimination ...............................242
Nursing Process ...................................................228 Urinary Retention..................................................242
Assessment ................................................................ 228 Urinary Incontinence ............................................242
Subjective Data ........................................................ 228 Stress Incontinence .................................................... 243
Objective Data ......................................................... 228 Urge Incontinence....................................................... 244
Cholecystitis and Cholelithiasis .........................228 Overflow Incontinence ................................................ 244
Medical–Surgical Management .................................. 228 Total Incontinence ....................................................... 244
Medical .................................................................... 228 Nocturnal Enuresis ..................................................... 244
Surgical .................................................................... 228 Nursing Management ................................................. 244
Pharmacological ...................................................... 229 Infectious Disorders .............................................244

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xiv CONTENTS

Cystitis...................................................................244 Medical–Surgical Management .................................. 255

Medical–Surgical Management .................................. 245 Surgical .................................................................... 255
Medical .................................................................... 245 Pharmacological ...................................................... 255
Diet ........................................................................... 245 Diet ........................................................................... 255
Pharmacological ...................................................... 245 Activity ...................................................................... 255
Activity ...................................................................... 245 Nursing Management ................................................. 256
Nursing Management ................................................. 245 Nursing Process ...................................................256
Nursing Process ...................................................245 Assessment ................................................................ 256
Assessment ................................................................ 245 Subjective Data ........................................................ 256
Subjective Data ........................................................ 245 Objective Data ......................................................... 256
Objective Data ......................................................... 245 Renal Tumors ........................................................257
Pyelonephritis .......................................................246 Medical–Surgical Management .................................. 257
Medical–Surgical Management .................................. 246 Medical .................................................................... 257
Medical .................................................................... 246 Surgical .................................................................... 257
Pharmacological ...................................................... 247 Pharmacological ...................................................... 257
Diet ........................................................................... 247 Diet ........................................................................... 257
Activity ...................................................................... 247 Activity ...................................................................... 258
Nursing Management ................................................. 247 Nursing Management ................................................. 258
Nursing Process ...................................................247 Nursing Process ...................................................258
Assessment ................................................................ 247 Assessment ................................................................ 258
Subjective Data ........................................................ 247 Subjective Data ........................................................ 258
Objective Data ......................................................... 247 Objective Data ......................................................... 258
Acute Glomerulonephritis....................................248 Polycystic Kidney .................................................259
Medical–Surgical Management .................................. 248 Renal Failure .........................................................259
Medical .................................................................... 248 Acute Renal Failure ..............................................259
Pharmacological ...................................................... 248 Postrenal ARF ............................................................. 259
Diet ........................................................................... 248 Prerenal ARF .............................................................. 259
Activity ...................................................................... 249 Intrarenal ARF............................................................. 259
Nursing Management ................................................. 249 Oliguric/Nonoliguric Phase ...................................... 260
Nursing Process ...................................................249 Diuretic Phase .......................................................... 260
Assessment ................................................................ 249 Recovery Phase ....................................................... 260
Subjective Data ........................................................ 249 Medical–Surgical Management .................................. 260
Objective Data ......................................................... 249 Medical .................................................................... 260
Chronic Glomerulonephritis ................................250 Surgical .................................................................... 260
Medical–Surgical Management .................................. 250 Pharmacological ...................................................... 260
Medical .................................................................... 250 Diet ........................................................................... 261
Pharmacological ...................................................... 250 Activity ...................................................................... 261
Diet ........................................................................... 250 Nursing Management ................................................. 261
Activity ...................................................................... 251 Nursing Process ...................................................261
Nursing Management ................................................. 251 Assessment ................................................................ 261
Nursing Process ...................................................251 Subjective Data ........................................................ 261
Assessment ................................................................ 251 Objective Data ......................................................... 261
Subjective Data ........................................................ 251 Sample Nursing Care Plan: The Client with
Objective Data ......................................................... 251 Acute Renal Failure ..............................................262
Obstructive Disorders ..........................................251 Chronic Renal Failure/End-Stage Renal Disease .. 263
Urinary Calculi ......................................................251 Medical–Surgical Management .................................. 264
Medical–Surgical Management .................................. 252 Medical .................................................................... 264
Medical .................................................................... 252 Pharmacological ...................................................... 265
Surgical .................................................................... 253 Diet ........................................................................... 265
Pharmacological ...................................................... 253 Activity ...................................................................... 265
Diet ........................................................................... 253 Nursing Management ................................................. 265
Activity ...................................................................... 253 Nursing Process ...................................................265
Nursing Management ................................................. 253 Assessment ................................................................ 265
Nursing Process ...................................................254 Subjective Data ........................................................ 265
Assessment ................................................................ 254 Objective Data ......................................................... 265
Subjective Data ........................................................ 254 Dialysis ..................................................................266
Objective Data ......................................................... 254 Hemodialysis............................................................... 267
Urinary Bladder Tumors .......................................254 Peritoneal Dialysis....................................................... 268

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 CONTENTS xv

Kidney Transplantation ........................................269 Diet ........................................................................... 291

Organ Rejection .......................................................... 270 Activity ...................................................................... 291
Complications ............................................................. 270 Nursing Management ................................................. 291
Case Study ............................................................270 Nursing Process ...................................................291
Assessment ................................................................ 291
Subjective Data ........................................................ 291
UNIT 4 Objective Data ......................................................... 291
Osteoarthritis (Degenerative Joint Disease) ......292
Nursing Care of the Client: Medical–Surgical Management .................................. 292
Medical .................................................................... 292
Mobility, Coordination, and Surgical .................................................................... 292
Pharmacological ...................................................... 292
Regulation / 275 Nursing Management ................................................. 293
Nursing Process ...................................................293
CHAPTER 9: MUSCULOSKELETAL Assessment ................................................................ 293
SYSTEM / 276 Subjective Data ........................................................ 293
Objective Data ......................................................... 293
Introduction...........................................................277
Total Joint Arthroplasty .......................................293
Anatomy and Physiology Review ........................277
Total Hip Replacement ................................................ 293
Assessment ..........................................................279 Total Knee Replacement ............................................. 294
Common Diagnostic Tests ...................................282 Nursing Management ................................................. 294
Musculoskeletal Trauma.......................................282 Nursing Process ...................................................294
Strain .....................................................................283 Assessment ................................................................ 294
Sprain ....................................................................283 Subjective Data ........................................................ 294
Dislocation ............................................................283 Objective Data ......................................................... 294
Fracture..................................................................283 Musculoskeletal Disorders ..................................295
Medical–Surgical Management .................................. 285 Amputations..........................................................295
Medical .................................................................... 285 Medical–Surgical Management .................................. 295
Surgical .................................................................... 287 Medical .................................................................... 295
Pharmacological ...................................................... 287 Surgical .................................................................... 295
Diet ........................................................................... 287 Pharmacological ...................................................... 296
Activity ...................................................................... 287 Diet ........................................................................... 296
Nursing Management ................................................. 287 Activity ...................................................................... 296
Nursing Process ...................................................287 Nursing Management ................................................. 296
Assessment ................................................................ 287 Nursing Process ...................................................296
Subjective Data ........................................................ 287 Assessment ................................................................ 296
Objective Data ......................................................... 287 Subjective Data ........................................................ 296
Rhabdomyolysis ...................................................288 Objective Data ......................................................... 296
Compartment Syndrome ......................................288 Sample Nursing Care Plan: The Client with a
Inflammatory Disorders .......................................288 Below-the-Knee Amputation................................297
Rheumatoid Arthritis ............................................288 Temporomandibular Joint Disease/Disorder .....299
Bursitis ..................................................................289 Medical–Surgical Management .................................. 300
Osteomyelitis ........................................................289 Medical .................................................................... 300
Medical–Surgical Management .................................. 289 Surgical .................................................................... 300
Medical .................................................................... 289 Diet ........................................................................... 300
Surgical .................................................................... 289 Nursing Management ................................................. 300
Pharmacological ...................................................... 289 Carpal Tunnel Syndrome ......................................300
Diet ........................................................................... 289 Medical–Surgical Management .................................. 300
Activity ...................................................................... 289 Medical .................................................................... 300
Nursing Management ................................................. 289 Surgical .................................................................... 300
Nursing Process ...................................................289 Pharmacological ...................................................... 300
Assessment ................................................................ 289 Nursing Management ................................................. 300
Subjective Data ........................................................ 289 Nursing Process ...................................................300
Objective Data ......................................................... 289 Assessment ................................................................ 300
Degenerative Disorders .......................................290 Subjective Data ........................................................ 300
Osteoporosis ........................................................290 Objective Data ......................................................... 300
Medical–Surgical Management .................................. 290 Systemic Disorders with Musculoskeletal
Pharmacological ...................................................... 291 Manifestations ...................................................... 301

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xvi CONTENTS

Gout ....................................................................... 301 Medical .................................................................... 325

Lyme Disease ........................................................ 301 Surgical .................................................................... 325
Case Study ............................................................302 Pharmacological ...................................................... 325
Diet ........................................................................... 325
CHAPTER 10: NEUROLOGICAL Activity ...................................................................... 325
Nursing Management ................................................. 325
SYSTEM / 305
Nursing Process ...................................................326
Introduction...........................................................306 Assessment ................................................................ 326
Anatomy and Physiology Review ........................306 Subjective Data ........................................................ 326
Central Nervous System ............................................. 306 Objective Data ......................................................... 326
The Brain .................................................................. 306 Epilepsy/Seizure Disorder ...................................327
The Spinal Cord ....................................................... 306 Medical–Surgical Management .................................. 327
Cerebrospinal Fluid .................................................. 306 Surgical .................................................................... 327
Peripheral Nervous System ........................................ 306 Pharmacological ...................................................... 327
Cranial Nerves .......................................................... 307 Diet ........................................................................... 328
Spinal Nerves ........................................................... 307 Activity ...................................................................... 328
Autonomic Nervous System ..................................... 308 Nursing Management ................................................. 328
Assessment ..........................................................308 Nursing Process ...................................................328
Health History ............................................................. 308 Assessment ................................................................ 328
Neurological Assessment ........................................... 308 Subjective Data ........................................................ 328
Cerebral Function..................................................... 308 Objective Data ......................................................... 328
Cranial Nerve Function..............................................313 Herniated Intervertebral Disk...............................329
Motor Function ..........................................................313 Medical–Surgical Management .................................. 329
Sensory Function ......................................................314 Medical .................................................................... 329
Reflexes .....................................................................315 Surgical .................................................................... 330
Common Diagnostic Tests ................................... 317 Pharmacological ...................................................... 330
Head Injury ............................................................ 317 Diet ........................................................................... 330
Scalp ...................................................................... 317 Activity ...................................................................... 330
Skull ....................................................................... 317 Nursing Management ................................................. 330
Brain ...................................................................... 317 Nursing Process ...................................................330
Open Injury ..................................................................317 Assessment ................................................................ 330
Closed Injury ................................................................317 Subjective Data ........................................................ 330
Hemorrhage ..............................................................318 Objective Data ......................................................... 330
Cerebral Edema and Increased Intracranial Spinal Cord Injury.................................................331
Pressure ....................................................................319 Medical–Surgical Management .................................. 332
Medical–Surgical Management ...................................319 Medical .................................................................... 332
Medical .....................................................................319 Surgical .................................................................... 333
Surgical .....................................................................319 Pharmacological ...................................................... 333
Pharmacological .......................................................319 Activity ...................................................................... 334
Activity ...................................................................... 320 Nursing Management ................................................. 334
Nursing Management ................................................. 320 Nursing Process ...................................................334
Nursing Process ...................................................320 Assessment ................................................................ 334
Assessment ................................................................ 320 Subjective Data ........................................................ 334
Subjective Data ........................................................ 320 Objective Data ......................................................... 334
Objective Data ........................................................ 320 Parkinson’s Disease .............................................335
Brain Tumor ...........................................................321 Medical–Surgical Management .................................. 336
Medical–Surgical Management .................................. 321 Medical .................................................................... 336
Medical .................................................................... 321 Surgical .................................................................... 336
Surgical .................................................................... 321 Pharmacological ...................................................... 337
Pharmacological ...................................................... 321 Diet ........................................................................... 337
Nursing Management ................................................. 321 Activity ...................................................................... 338
Nursing Process ...................................................322 Other Therapies ........................................................ 338
Assessment ................................................................ 322 Nursing Management ................................................. 338
Subjective Data ........................................................ 322 Nursing Process ...................................................338
Objective Data ......................................................... 322 Assessment ................................................................ 338
Cerebrovascular Accident/Transient Ischemic Subjective Data ........................................................ 338
Attacks .......................................................................... 322 Objective Data ......................................................... 338
Medical–Surgical Management .................................. 325 Multiple Sclerosis .................................................339

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 CONTENTS xvii

Medical–Surgical Management .................................. 339 Medical–Surgical Management .................................. 352

Pharmacological ...................................................... 339 Surgical .................................................................... 352
Diet ........................................................................... 340 Pharmacological ...................................................... 352
Activity ...................................................................... 340 Nursing Management ................................................. 352
Nursing Management ................................................. 340 Encephalitis, Meningitis .......................................352
Nursing Process ...................................................340 Medical–Surgical Management .................................. 353
Assessment ................................................................ 340 Medical .................................................................... 353
Subjective Data ........................................................ 340 Pharmacological ...................................................... 353
Objective Data ........................................................ 340 Diet ........................................................................... 353
Sample Nursing Care Plan: The Client Activity ...................................................................... 353
with MS ..................................................................341 Nursing Management ................................................. 353
Amyotrophic Lateral Sclerosis (Lou Gehrig’s Huntington’s Disease ...........................................353
Disease) .................................................................344 Medical–Surgical Management .................................. 353
Medical–Surgical Management .................................. 344 Pharmacological ...................................................... 353
Pharmacological ...................................................... 344 Diet ........................................................................... 353
Diet ........................................................................... 344 Activity ...................................................................... 353
Activity ...................................................................... 344 Nursing Management ................................................. 353
Other Therapies ........................................................ 344 Gilles De La Tourette’s Syndrome .......................354
Nursing Management ................................................. 344 Medical–Surgical Management .................................. 354
Nursing Process ...................................................344 Pharmacological ...................................................... 354
Assessment ................................................................ 344 Other Therapies ........................................................ 354
Subjective Data ........................................................ 344 Nursing Management ................................................. 354
Objective Data ......................................................... 344 Case Study ............................................................354
Alzheimer’s Disease .............................................345
Medical–Surgical Management .................................. 347
Pharmacological ...................................................... 347 CHAPTER 11: SENSORY
Diet ........................................................................... 347 SYSTEM / 359
Nursing Management ................................................. 347
Introduction...........................................................360
Nursing Process ...................................................347
Sensation, Perception, and Cognition ................360
Assessment ................................................................ 347
Subjective Data ........................................................ 347
Anatomy and Physiology Review ........................360
Components of Sensation and Perception ................. 360
Objective Data ......................................................... 347
Components of Cognition ........................................... 360
Guillain-Barré Syndrome .....................................348
Consciousness ......................................................... 360
Medical–Surgical Management .................................. 349
Memory .................................................................... 361
Medical .................................................................... 349
Affect ........................................................................ 361
Surgical .................................................................... 349
Judgment ................................................................. 361
Pharmacological ...................................................... 349
Perception ................................................................ 361
Diet ........................................................................... 349
Language ................................................................. 361
Activity ...................................................................... 349
Nursing Management ................................................. 349
Assessment ..........................................................361
The Ear ....................................................................... 362
Nursing Process ...................................................349
Outer Ear .................................................................. 362
Assessment ................................................................ 349
Middle Ear ................................................................ 362
Subjective Data ........................................................ 349
Inner Ear ................................................................... 363
Objective Data ......................................................... 349
The Eye ...................................................................... 363
Headache...............................................................350 Fibrous Tunic ............................................................ 363
Primary Headaches ..............................................350 Vascular Tunic ........................................................... 363
Tension-Type Headache ............................................. 350 Nervous Tunic ........................................................... 363
Migraine Headaches ................................................... 350 External Structures ................................................... 363
Cluster Headaches ..................................................... 350
Common Diagnostic Tests ...................................363
Secondary Headaches .........................................350 Sensory, Perceptual, and Cognitive
Medical–Surgical Management .................................. 351
Alterations .............................................................364
Medical .................................................................... 351
Surgical .................................................................... 351
Sensory Deficit .....................................................365
Pharmacological ...................................................... 351 Sensory Deprivation.............................................365
Diet ........................................................................... 351 Sensory Overload .................................................365
Activity ...................................................................... 351 Disorders of the Ear .............................................365
Nursing Management ................................................. 352 Impaired Hearing ..................................................365
Trigeminal Neuralgia (Tic Douloureux) ...............352 Types of Hearing Loss ................................................ 365

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xviii CONTENTS

Behaviors Indicating Hearing Loss ............................. 366 Assessment ................................................................ 375

Hearing Aids/Assistive Devices .................................. 366 Subjective Data ........................................................ 375
Medical–Surgical Management .................................. 367 Objective Data ......................................................... 375
Medical .................................................................... 367 Glaucoma ..............................................................375
Surgical .................................................................... 367 Medical–Surgical Management ...................................376
Nursing Management ................................................. 367 Medical .....................................................................376
Nursing Process ...................................................367 Surgical .....................................................................376
Assessment ................................................................ 367 Pharmacological .......................................................376
Subjective Data ........................................................ 367 Nursing Management ..................................................376
Objective Data ......................................................... 367 Nursing Process ................................................... 376
Ménière’s Disease.................................................367 Assessment .................................................................376
Medical–Surgical Management ................................. 368 Subjective Data .........................................................376
Medical .................................................................... 368 Objective Data ..........................................................376
Surgical .................................................................... 368 Retinal Detachment ..............................................377
Pharmacological ...................................................... 368 Medical–Surgical Management .................................. 377
Diet .......................................................................... 368 Medical .................................................................... 377
Activity ...................................................................... 368 Surgical .................................................................... 377
Nursing Management ................................................. 368 Pharmacological ...................................................... 377
Nursing Process ...................................................368 Activity ...................................................................... 377
Assessment ................................................................ 368 Nursing Management ................................................. 377
Subjective Data ........................................................ 368 Nursing Process ...................................................378
Objective Data ......................................................... 368 Assessment ................................................................ 378
Otosclerosis ..........................................................369 Subjective Data ........................................................ 378
Medical–Surgical Management .................................. 369 Objective Data ......................................................... 378
Medical .................................................................... 369 Infections...............................................................378
Surgical .................................................................... 370 Keratitis ....................................................................... 378
Nursing Management ................................................. 370 Stye............................................................................. 378
Nursing Process ...................................................370 Chalazion .................................................................... 378
Assessment ................................................................ 370 Conjunctivitis (Pink Eye) ............................................. 379
Subjective Data ........................................................ 370 Refractive Errors ...................................................379
Objective Data ......................................................... 370 Medical–Surgical Management .................................. 380
Acoustic Neuroma ................................................371 Medical .................................................................... 380
Medical–Surgical Management .................................. 371 Surgical .................................................................... 380
Nursing Management ................................................. 371 Nursing Management ................................................. 380
Nursing Process ...................................................371 Nursing Process ...................................................380
Assessment ................................................................ 371 Assessment ................................................................ 380
Subjective Data ........................................................ 371 Subjective Data ........................................................ 380
Objective Data ......................................................... 371 Objective Data ......................................................... 380
Otitis Media ...........................................................372 Injury ......................................................................380
Medical–Surgical Management .................................. 373 Foreign Bodies ............................................................ 380
Medical .................................................................... 373 Chemical Burns .......................................................... 380
Surgical .................................................................... 373 Impaired Vision .....................................................381
Pharmacological ...................................................... 373 Macular Degeneration ..........................................381
Activity ...................................................................... 373 Medical–Surgical Management .................................. 381
Nursing Management ................................................. 373 Medical .................................................................... 381
Nursing Process ...................................................373 Nursing Management ................................................. 381
Assessment ................................................................ 373 Nursing Process ...................................................381
Subjective Data ........................................................ 373 Assessment ................................................................ 381
Objective Data ......................................................... 373 Subjective Data ........................................................ 381
Otitis Externa ........................................................373 Objective Data ......................................................... 381
Mastoiditis .............................................................373 Sample Nursing Care Plan: The Client with
Disorders of the Eye ............................................. 374 Macular Degeneration ..........................................382
Cataracts ............................................................... 374 Other Senses ........................................................384
Medical–Surgical Management ...................................374 Taste ......................................................................384
Surgical .....................................................................374 Smell ......................................................................384
Nursing Management ................................................. 375 Touch .....................................................................384
Nursing Process ...................................................375 Case Study ............................................................384

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CHAPTER 12: ENDOCRINE Subjective Data ........................................................ 406

Objective Data ......................................................... 406
SYSTEM / 388
Syndrome of Inappropriate Antidiuretic
Introduction...........................................................389 Hormone ................................................................406
Anatomy and Physiology Review ........................389 Medical–Surgical Management .................................. 406
Common Diagnostic Tests ...................................391 Medical .................................................................... 406
Diabetes Mellitus ..................................................391 Pharmacological ...................................................... 407
Diagnosis and Classification...............................392 Diet ........................................................................... 407
Diagnosis .................................................................... 392 Nursing Management ................................................. 407
Classification............................................................... 393 Nursing Process ...................................................407
Type 1 Diabetes........................................................ 393 Assessment ................................................................ 407
Type 2 Diabetes........................................................ 393 Subjective Data ........................................................ 407
Other Specific Types ................................................ 393 Objective Data ......................................................... 407
Gestational Diabetes Mellitus................................... 393 Pituitary Tumors ....................................................407
Contributing Factors .................................................... 394 Medical–Surgical Management .................................. 407
Medical–Surgical Management .................................. 394 Medical .................................................................... 407
Medical .................................................................... 394 Surgical .................................................................... 408
Surgical .................................................................... 394 Pharmacological ...................................................... 408
Pharmacological ...................................................... 394 Nursing Management ................................................. 408
Diet ........................................................................... 398 Nursing Process ...................................................408
Activity ...................................................................... 399 Assessment ................................................................ 408
Health Promotion ...................................................... 399 Subjective Data ........................................................ 408
Acute Complications of Diabetes ................................ 399 Objective Data ......................................................... 408
Hypoglycemia (Insulin Reaction) ............................. 399 Hypopituitarism ....................................................408
Diabetic Ketoacidosis .............................................. 400 Simmonds’ Disease ..............................................409
Hyperosmolar Hyperglycemic Nonketotic Diabetes Insipidus ................................................409
Syndrome ..................................................................401 Medical–Surgical Management .................................. 409
Chronic Complications of Diabetes ............................. 402 Pharmacological ...................................................... 409
Infections .................................................................. 402 Nursing Management ................................................. 409
Diabetic Neuropathy ................................................ 402
Nursing Process ...................................................409
Nephropathy (Chronic Renal Failure)....................... 402
Assessment ................................................................ 409
Retinopathy .............................................................. 403
Subjective Data ........................................................ 409
Vascular Changes .................................................... 403
Objective Data ......................................................... 409
Nursing Management ................................................. 403
Thyroid Disorders ................................................. 411
Nursing Process ...................................................403
Hyperthyroidism ................................................... 411
Assessment ................................................................ 403
Medical–Surgical Management ...................................411
Subjective Data ........................................................ 403
Medical .....................................................................411
Objective Data ......................................................... 403
Surgical .....................................................................412
Pituitary Disorders................................................404
Pharmacological .......................................................412
Hyperpituitarism ...................................................404 Diet ............................................................................413
Gigantism ..............................................................404 Nursing Management ..................................................413
Medical–Surgical Management .................................. 405 Nursing Process ................................................... 413
Medical .................................................................... 405 Assessment .................................................................413
Surgical .................................................................... 405 Subjective Data .........................................................413
Pharmacological ...................................................... 405 Objective Data ..........................................................413
Nursing Management ................................................. 405
Sample Nursing Care Plan: The Client with
Nursing Process ...................................................405
Hyperthyroidism ................................................... 414
Assessment ................................................................ 405
Hypothyroidism .................................................... 416
Subjective Data ........................................................ 405
Objective Data ......................................................... 405
Cretinism ............................................................... 416
Acromegaly ...........................................................405 Myxedema ............................................................. 416
Medical–Surgical Management ...................................416
Medical–Surgical Management .................................. 405
Pharmacological .......................................................416
Medical .................................................................... 405
Diet ............................................................................416
Surgical .................................................................... 405
Nursing Management ..................................................417
Pharmacological ...................................................... 406
Nursing Management ................................................. 406 Nursing Process ................................................... 417
Assessment .................................................................417
Nursing Process ...................................................406
Subjective Data .........................................................417
Assessment ................................................................ 406

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xx CONTENTS

Objective Data ..........................................................417 Nursing Management ................................................. 425

Hashimoto’s Thyroiditis ....................................... 417 Case Study ............................................................426
Thyroid Tumors ..................................................... 418
Cancer of the Thyroid ........................................... 418
Medical–Surgical Management ...................................418 UNIT 5
Surgical .....................................................................418
Pharmacological .......................................................418
Nursing Management ..................................................418 Nursing Care of the Client:
Goiter ..................................................................... 418
Parathyroid Disorders .......................................... 419
Reproductive and Sexual
Hyperparathyroidism............................................ 419 Health / 429
Medical–Surgical Management ...................................419
Medical .....................................................................419 CHAPTER 13: REPRODUCTIVE
Surgical .....................................................................419
Pharmacological .......................................................419
SYSTEM / 430
Nursing Management ..................................................419 Introduction...........................................................431
Nursing Process ................................................... 419 Anatomy and Physiology Review ........................431
Assessment .................................................................419 External Female Structures ........................................ 431
Subjective Data .........................................................419 Internal Female Structures ......................................... 431
Objective Data ..........................................................419 Male Reproductive Structures..................................... 432
Hypoparathyroidism .............................................420 Common Diagnostic Tests ...................................433
Medical–Surgical Management .................................. 420 Inflammatory Disorders .......................................433
Pharmacological ...................................................... 420 Pelvic Inflammatory Disease ...............................434
Diet ........................................................................... 421 Medical–Surgical Management .................................. 435
Nursing Management ................................................. 421 Medical .................................................................... 435
Nursing Process ...................................................421 Surgical .................................................................... 435
Assessment ................................................................ 421 Pharmacological ...................................................... 435
Subjective Data ........................................................ 421 Activity ...................................................................... 435
Objective Data ......................................................... 421 Nursing Management ................................................. 435
Adrenal Disorders.................................................422 Nursing Process ...................................................435
Cushing’s Disease Syndrome (Adrenal Assessment ................................................................ 435
Hyperfunction) ......................................................422 Subjective Data ........................................................ 435
Medical–Surgical Management .................................. 422 Objective Data ......................................................... 435
Medical .................................................................... 422 Endometriosis.......................................................436
Surgical .................................................................... 422 Medical–Surgical Management .................................. 436
Pharmacological ...................................................... 423 Medical .................................................................... 436
Diet ........................................................................... 423 Surgical .................................................................... 437
Nursing Management ................................................. 423 Pharmacological ...................................................... 437
Nursing Process ...................................................423 Nursing Process ...................................................437
Assessment ................................................................ 423 Assessment ................................................................ 437
Subjective Data ........................................................ 423 Subjective Data ........................................................ 437
Objective Data ......................................................... 423 Objective Data ......................................................... 438
Addison’s Disease (Adrenal Hypofunction) .......423 Nursing Management ................................................. 438
Medical–Surgical Management .................................. 424 Vaginitis .................................................................438
Medical .................................................................... 424 Nursing Process ...................................................439
Pharmacological ...................................................... 424 Assessment ................................................................ 439
Diet ........................................................................... 424 Subjective Data ........................................................ 439
Nursing Management ................................................. 424 Objective Data ......................................................... 439
Nursing Process ...................................................424 Nursing Management ................................................. 439
Assessment ................................................................ 424 Toxic Shock Syndrome ........................................439
Subjective Data ........................................................ 424 Medical–Surgical Management .................................. 439
Objective Data ......................................................... 424 Medical .................................................................... 439
Pheochromocytoma .............................................425 Pharmacological ...................................................... 439
Medical–Surgical Management .................................. 425 Activity ...................................................................... 439
Surgical .................................................................... 425 Nursing Management ................................................. 439
Pharmacological ...................................................... 425 Nursing Process ...................................................439
Diet ........................................................................... 425 Assessment ................................................................ 439

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 CONTENTS xxi

Subjective Data ........................................................ 439 Cervical Cancer ....................................................455

Objective Data ......................................................... 439 Medical–Surgical Management .................................. 455
Epididymitis/Orchitis/Prostatitis .........................440 Surgical .................................................................... 455
Medical–Surgical Management .................................. 440 Other Therapies ........................................................ 456
Medical .................................................................... 440 Nursing Management ................................................. 456
Pharmacological ...................................................... 440 Nursing Process ...................................................456
Activity ...................................................................... 441 Assessment ................................................................ 456
Nursing Management ................................................. 441 Subjective Data ........................................................ 456
Nursing Process ...................................................441 Objective Data ......................................................... 456
Assessment ................................................................ 441 Endometrial Cancer..............................................457
Subjective Data ........................................................ 441 Medical–Surgical Management .................................. 457
Objective Data ......................................................... 441 Medical .................................................................... 458
Benign Neoplasms ...............................................441 Surgical .................................................................... 458
Fibrocystic Breast Changes ................................441 Pharmacological ...................................................... 458
Medical–Surgical Management .................................. 442 Other Therapies ........................................................ 458
Surgical .................................................................... 442 Nursing Management ................................................. 458
Pharmacological ...................................................... 443 Ovarian Cancer .....................................................458
Diet ........................................................................... 443 Medical–Surgical Management .................................. 458
Nursing Management ................................................. 444 Surgical .................................................................... 458
Nursing Process ...................................................444 Pharmacological ...................................................... 459
Assessment ................................................................ 444 Nursing Management ................................................. 459
Subjective Data ........................................................ 444 Nursing Process ...................................................459
Objective Data ......................................................... 444 Assessment ................................................................ 459
Fibroid Tumors ......................................................444 Subjective Data ........................................................ 459
Medical–Surgical Management .................................. 444 Objective Data ......................................................... 459
Medical .................................................................... 444 Prostate Cancer ....................................................461
Surgical .................................................................... 445 Medical–Surgical Management .................................. 461
Diet ........................................................................... 445 Medical .................................................................... 461
Nursing Management ................................................. 445 Surgical .................................................................... 461
Nursing Process ...................................................445 Pharmacological ...................................................... 461
Assessment ................................................................ 445 Nursing Management ................................................. 461
Subjective Data ........................................................ 445 Nursing Process ...................................................461
Objective Data ......................................................... 445 Assessment ................................................................ 461
Benign Prostatic Hyperplasia ..............................445 Subjective Data ........................................................ 461
Medical–Surgical Management .................................. 446 Objective Data ......................................................... 461
Medical .................................................................... 446 Testicular Cancer..................................................462
Surgical .................................................................... 446 Medical–Surgical Management .................................. 462
Pharmacological ...................................................... 447 Medical .................................................................... 462
Nursing Management ................................................. 447 Surgical .................................................................... 462
Nursing Process ...................................................447 Pharmacological ...................................................... 462
Assessment ................................................................ 447 Nursing Management ................................................. 463
Subjective Data ........................................................ 447 Nursing Process ...................................................463
Objective Data ......................................................... 447 Assessment ................................................................ 463
Malignant Neoplasm.............................................448 Subjective Data ........................................................ 463
Breast Cancer .......................................................448 Objective Data ......................................................... 463
Medical–Surgical Management .................................. 449 Penile Cancer ........................................................464
Medical .................................................................... 449 Medical–Surgical Management .................................. 464
Surgical .................................................................... 449 Medical .................................................................... 464
Pharmacological ...................................................... 451 Surgical .................................................................... 464
Other Therapies ........................................................ 451 Nursing Management ................................................. 464
Nursing Management ................................................. 451 Nursing Process ...................................................464
Nursing Process ...................................................452 Assessment ................................................................ 464
Assessment ................................................................ 452 Subjective Data ........................................................ 464
Subjective Data ........................................................ 452 Objective Data ......................................................... 464
Objective Data ......................................................... 452 Menstrual Disorders .............................................465
Sample Nursing Care Plan: The Client with Dysmenorrhea.......................................................465
Breast Cancer .......................................................453 Amenorrhea ..........................................................465

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Other Disorders ....................................................465 Infertility ................................................................473

Nursing Process ...................................................466 Medical–Surgical Management .................................. 473
Assessment ................................................................ 466 Medical .................................................................... 473
Subjective Data ........................................................ 466 Surgical .................................................................... 473
Objective Data ......................................................... 466 Pharmacological ...................................................... 473
Nursing Management ................................................. 466 Health Promotion .......................................................474
Premenstrual Syndrome ......................................466 Contraception ....................................................... 474
Medical–Surgical Management .................................. 466 Natural Method...................................................... 474
Pharmacological ...................................................... 466 Hormonal Methods ...............................................475
Diet ........................................................................... 466 Oral Contraceptives .................................................... 475
Activity ...................................................................... 467 Depo-Provera ...............................................................476
Nursing Management ................................................. 467 Lunelle .........................................................................476
Nursing Process ...................................................467 Mirena ..........................................................................476
Assessment ................................................................ 467 Transdermal Patch .......................................................476
Subjective Data ........................................................ 467 Vaginal Ring.................................................................476
Objective Data ......................................................... 467 Nonhormonal Methods ........................................ 476
Menopause ............................................................467 Intrauterine Device .......................................................476
Medical–Surgical Management .................................. 468 Barriers ........................................................................476
Pharmacological ...................................................... 468 Spermicides .................................................................476
Diet ........................................................................... 468 Sterilization Method ............................................. 476
Activity ...................................................................... 468 Case Study ............................................................477
Nursing Management ................................................. 468
Nursing Process ...................................................468
Assessment ................................................................ 468 CHAPTER 14: SEXUALLY
Subjective Data ........................................................ 468
TRANSMITTED INFECTIONS / 481
Objective Data ......................................................... 468
Structural Disorders .............................................469 Introduction...........................................................482
Cystocele, Urethrocele, Rectocele, Prolapsed Anatomy and Physiology Review ........................482
Uterus ....................................................................469 Common Diagnostic Tests ...................................482
Medical–Surgical Management .................................. 469 Chlamydia..............................................................482
Medical .................................................................... 469 Medical–Surgical Management .................................. 484
Surgical .................................................................... 469 Pharmacological ...................................................... 484
Activity ...................................................................... 469 Health Promotion ...................................................... 484
Nursing Management ................................................. 470 Gonorrhea .............................................................484
Nursing Process ...................................................470 Medical–Surgical Management .................................. 486
Assessment ................................................................ 470 Pharmacological ...................................................... 486
Subjective Data ........................................................ 470 Syphilis ..................................................................486
Objective Data ......................................................... 470 Medical–Surgical Management .................................. 487
Hydrocele, Spermatocele, Varicocele, Torsion Pharmacological ...................................................... 487
of the Spermatic Cord ..........................................470 Genital Herpes ......................................................487
Medical–Surgical Management ................................. 471 Medical–Surgical Management .................................. 488
Nursing Management ................................................. 471 Pharmacological ...................................................... 488
Nursing Process ...................................................471 Cytomegalovirus...................................................488
Assessment ................................................................ 471 Human Papillomavirus/Genital Warts .................488
Subjective Data ........................................................ 471 Medical–Surgical Management .................................. 489
Objective Data ........................................................ 471 Surgical .................................................................... 489
Functional Disorders and Concerns ...................471 Pharmacological ...................................................... 489
Impotence..............................................................471 Health Promotion ...................................................... 489
Medical–Surgical Management .................................. 472 AIDS .......................................................................489
Medical .................................................................... 472 Trichomoniasis .....................................................490
Surgical .................................................................... 472 Medical–Surgical Management .................................. 490
Pharmacological ...................................................... 472 Pharmacological ...................................................... 490
Nursing Process ...................................................472 Hepatitis B .............................................................490
Assessment ................................................................ 472 Medical–Surgical Management .................................. 490
Subjective Data ........................................................ 472 Medical .................................................................... 490
Objective Data ......................................................... 472 Health Promotion ...................................................... 490
Nursing Management ................................................. 472 Nursing Management ................................................. 490

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 CONTENTS xxiii

Nursing Process ...................................................490 Nursing Diagnoses ......................................................510

Assessment ................................................................ 490 Planning/Outcome Identification ..................................511
Subjective Data ........................................................ 490 Implementation ............................................................511
Objective Data ......................................................... 491 Emergency Measures ...............................................511
Sample Nursing Care Plan: The Client with Cleansing the Wound...................................................511
Genital Herpes ......................................................492 Dressing the Wound ..................................................511
Case Study ............................................................494 Monitoring Drainage of Wounds................................511
Other Therapies .........................................................511
Evaluation ....................................................................511
UNIT 6 Burns ..................................................................... 512
Major Causes...............................................................512
Severity ........................................................................512
Nursing Care of the Client: Complications ..............................................................514
Body Defenses / 499 Smoke Inhalation and Carbon Monoxide
Poisoning ..................................................................514
CHAPTER 15: INTEGUMENTARY Shock ........................................................................514
Infection.....................................................................514
SYSTEM / 500 Medical–Surgical Management ...................................514
Introduction........................................................... 501 Medical .....................................................................514
Anatomy and Physiology Review ........................ 501 Surgical .....................................................................514
Structure of the Skin ....................................................501 Pharmacological .......................................................515
Epidermis ..................................................................501 Diet ............................................................................515
Dermis .......................................................................501 Activity .......................................................................515
Subcutaneous Tissue ................................................501 Nursing Management ..................................................516
Functions of the Skin ...................................................501 Nursing Process ................................................... 516
Protection ..................................................................501 Assessment .................................................................516
Temperature Regulation ........................................... 502 Subjective Data .........................................................516
Sensory Perception .................................................. 502 Objective Data ..........................................................516
Fluid and Electrolyte Balance .................................. 502 Neoplasms: Malignant.......................................... 519
Structure and Function of Hair .................................... 502 Basal Cell Carcinoma ........................................... 519
Structure and Function of Nails................................... 503 Squamous Cell Carcinoma .................................. 519
Structure and Function of Mucous Membranes .......... 503 Malignant Melanoma ............................................520
Effects of Aging ........................................................... 503 Cutaneous T-Cell Lymphoma ...............................520
Assessment ..........................................................503 Medical–Surgical Management .................................. 521
Assessment of Skin .................................................... 503 Surgical .................................................................... 521
Assessment of Hair, Nails, and Mucous Nursing Management ................................................. 521
Membranes ................................................................. 506 Neoplasms: Nonmalignant ..................................521
Common Diagnostic Tests ...................................507 Infectious Disorders of the Skin..........................521
Wounds..................................................................507 Nursing Management ................................................. 523
Physiology of Wound Healing ..................................... 507 Nursing Process ...................................................523
Defensive (Inflammatory) Phase .............................. 507 Assessment ................................................................ 523
Reconstructive (Proliferative) Phase ........................ 508 Subjective Data ........................................................ 523
Maturation Phase ..................................................... 508 Objective Data ......................................................... 523
Types of Healing ....................................................... 509 Sample Nursing Care Plan: The Client
Kinds of Wound Drainage ........................................ 509
with Scabies ..........................................................524
Factors Affecting Wound Healing ................................ 509
Inflammatory Disorders of the Skin ....................528
Hemorrhage ............................................................. 509
Infection.................................................................... 509
Dermatitis ..............................................................528
Wound Classification .................................................. 509 Eczema ..................................................................528
Cause of Wound ....................................................... 509 Nursing Management ................................................. 529
Cleanliness of Wound................................................510 Contact Dermatitis................................................529
Depth of Wound ........................................................510 Nursing Management ................................................. 529
Assessment .................................................................510 Dermatitis Venenata and Medicamentosa ..........529
Location.....................................................................510 Nursing Management ................................................. 529
Size ...........................................................................510 Exfoliative Dermatitis ...........................................529
General Appearance and Drainage ..........................510 Nursing Management ................................................. 530
Pain ...........................................................................510 Psoriasis................................................................530
Laboratory Data.........................................................510 Medical–Surgical Management .................................. 530

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xxiv CONTENTS

Medical .................................................................... 530 Anaphylactic Reaction .........................................550

Pharmacological ...................................................... 530 Case Study ............................................................550
Nursing Management ................................................. 531 Medical–Surgical Management .................................. 550
Nursing Process ...................................................531 Medical .................................................................... 550
Assessment ................................................................ 531 Pharmacological ...................................................... 550
Subjective Data ........................................................ 531 Diet ........................................................................... 551
Objective Data ......................................................... 531 Activity ...................................................................... 551
Ulcers.....................................................................531 Nursing Management ................................................. 551
Venous Ulcers .......................................................531 Nursing Process ...................................................551
Medical–Surgical Management .................................. 531 Assessment ................................................................ 551
Medical .................................................................... 531 Subjective Data ........................................................ 551
Pharmacological ...................................................... 532 Objective Data ......................................................... 551
Diet ........................................................................... 532 Transfusion Reactions .........................................551
Nursing Management ................................................. 532 Medical–Surgical Management .................................. 552
Nursing Process ...................................................532 Medical .................................................................... 552
Assessment ................................................................ 532 Pharmacological ...................................................... 552
Subjective Data ........................................................ 532 Diet ........................................................................... 552
Objective Data ......................................................... 532 Activity ...................................................................... 552
Pressure Ulcers ....................................................533 Nursing Management ................................................. 552
Physiology of Pressure Ulcers .................................... 533 Nursing Process ...................................................552
Risk Factors for Pressure Ulcers .............................. 534 Assessment ................................................................ 552
Medical–Surgical Management .................................. 537 Subjective Data ........................................................ 552
Medical .................................................................... 537 Objective Data ......................................................... 552
Surgical .................................................................... 537 Transplant Rejection ............................................553
Pharmacological ...................................................... 538 Medical–Surgical Management .................................. 553
Diet ........................................................................... 538 Medical .................................................................... 553
Activity ...................................................................... 538 Pharmacological ...................................................... 553
Nursing Management ................................................. 538 Activity ...................................................................... 553
Nursing Process ...................................................538 Nursing Management ................................................. 553
Assessment ................................................................ 538 Nursing Process ...................................................553
Subjective Data ........................................................ 538 Assessment ................................................................ 553
Objective Data ......................................................... 538 Subjective Data ........................................................ 553
Alopecia.................................................................539 Objective Data ......................................................... 553
Case Study ............................................................539 Latex Allergy .........................................................554
Autoimmune Diseases .........................................554
CHAPTER 16: IMMUNE Rheumatoid Arthritis ............................................554
SYSTEM / 543 Medical–Surgical Management .................................. 555
Medical .................................................................... 555
Introduction...........................................................544 Surgical .................................................................... 555
Anatomy and Physiology Review ........................544 Pharmacological ...................................................... 555
Organs of the Immune System ................................... 544 Diet ........................................................................... 557
Cells of the Immune System ....................................... 544 Activity ...................................................................... 557
Types of Immunity ....................................................... 546 Nursing Management ................................................. 557
Factors Influencing Immunity ...................................... 546 Nursing Process ...................................................557
Assessment ..........................................................546 Assessment ................................................................ 557
Common Diagnostic Tests ...................................547 Subjective Data ........................................................ 557
Hypersensitive Immune Response .....................547 Objective Data ......................................................... 557
Allergies ................................................................547 Systemic Lupus Erythematosus .........................558
Medical–Surgical Management .................................. 548 Medical–Surgical Management .................................. 558
Medical .................................................................... 548 Medical .................................................................... 558
Pharmacological ...................................................... 548 Pharmacological ...................................................... 559
Diet ........................................................................... 548 Diet ........................................................................... 559
Activity ...................................................................... 548 Activity ...................................................................... 559
Nursing Management ................................................. 548 Nursing Management .............................................. 559
Nursing Process ...................................................548 Nursing Process ...................................................559
Assessment ................................................................ 548 Assessment ................................................................ 559
Subjective Data ........................................................ 548 Subjective Data ........................................................ 559
Objective Data ......................................................... 548 Objective Data ......................................................... 559

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 CONTENTS xxv

Myasthenia Gravis ................................................560 Assessment ................................................................ 573

Medical–Surgical Management .................................. 561 Subjective Data ........................................................ 573
Medical .................................................................... 561 Objective Data ......................................................... 573
Surgical .................................................................... 561 Central Nervous System Opportunistic
Pharmacological ...................................................... 561 Infections...............................................................573
Diet ........................................................................... 561 AIDS Dementia Complex......................................573
Activity ...................................................................... 561 Toxoplasmosis ......................................................573
Nursing Management ................................................. 561 Cryptococcosis..................................................... 574
Nursing Process ...................................................561 Nursing Management ..................................................574
Assessment ................................................................ 561 Nursing Process ................................................... 574
Subjective Data ........................................................ 561 Assessment .................................................................574
Objective Data ......................................................... 561 Subjective Data .........................................................574
Sample Nursing Care Plan: The Client with Objective Data ..........................................................574
Myasthenia Gravis ................................................562 Opportunistic Malignancies ................................ 574
Inadequate Immunological Response ................564 Kaposi’s Sarcoma ................................................. 574
HIV/AIDS ................................................................564 Non-Hodgkin’s Lymphoma ..................................575
Demographics of AIDS in the United States ............... 565 Nursing Management ................................................. 575
Age ........................................................................... 565 Nursing Process ...................................................575
Gender ..................................................................... 565 Assessment ................................................................ 575
Modes of Transmission ............................................... 565 Subjective Data ........................................................ 575
Medical–Surgical Management .................................. 566 Objective Data ......................................................... 575
Medical .................................................................... 566
Case Study ............................................................ 576
Pharmacological ...................................................... 566
Health Promotion ...................................................... 567
Pulmonary Opportunistic Infections ..................567
Pneumocystis Carinii Pneumonia .......................567
Histoplasmosis .....................................................568 UNIT 7
Tuberculosis..........................................................568
Nursing Management ................................................. 568 Nursing Care of the Client:
Nursing Process ...................................................568
Assessment ................................................................ 568 Physical and Mental
Subjective Data ........................................................ 568
Objective Data ......................................................... 568
Integrity / 581
Gastrointestinal Opportunistic Infections ..........569
Mycobacterium Avium Complex..........................569
CHAPTER 17: MENTAL ILLNESS / 582
Cytomegalovirus...................................................569 Introduction...........................................................583
Cryptosporidiosis .................................................569 Mental Health and Illness.....................................583
Hepatitis ................................................................570 Relationship Development...................................584
HIV-Wasting Syndrome ........................................570 Trust ............................................................................ 584
Nursing Management ................................................. 570 Rapport ....................................................................... 584
Nursing Process ...................................................570 Respect....................................................................... 584
Assessment ................................................................ 570 Genuineness............................................................... 584
Subjective Data ........................................................ 570 Empathy ...................................................................... 584
Objective Data ......................................................... 570 The Client Experiencing a Crisis .........................584
Oral Opportunistic Infections ..............................571 Anxiety...................................................................585
Oral and Esophageal Candidiasis.......................571 Mild Anxiety...........................................................585
Oral Hairy Leukoplakia.........................................571 Moderate Anxiety ..................................................585
Nursing Management ................................................. 572 Severe Anxiety ......................................................585
Nursing Process ...................................................572 Panic ......................................................................585
Assessment ................................................................ 572 Anxiety Disorders .................................................585
Subjective Data ........................................................ 572 Generalized Anxiety Disorder ..............................585
Objective Data ......................................................... 572 Panic Disorder ......................................................585
Gynecological Opportunistic Infections ............572 Obsessive-Compulsive Disorder ........................586
Vaginal Candidiasis ..............................................572 Post-Traumatic Stress Disorder ..........................586
Cervical Intraepithelial Neoplasia .......................572 Medical–Surgical Management .................................. 586
Nursing Management ................................................. 573 Medical .................................................................... 586
Nursing Process ...................................................573 Pharmacological ...................................................... 586

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xxvi CONTENTS

Activity ...................................................................... 587 Activity ...................................................................... 606

Nursing Management ................................................. 587 Nursing Management ................................................. 606
Nursing Process ...................................................587 Case Study ............................................................606
Assessment ................................................................ 587 Nursing Process ...................................................607
Subjective Data ........................................................ 587 Assessment ................................................................ 607
Objective Data ......................................................... 587 Subjective Data ........................................................ 607
Depression ............................................................588 Objective Data ......................................................... 607
Mild Depression ....................................................589 The Client Requiring Special Consideration ......607
Moderate Depression ...........................................589 Attention-Deficit/Hyperactivity Disorder ............607
Severe Depression ...............................................589 Predominantly Hyperactive-Impulsive Type .......608
Depression Disorders ..........................................589 Predominantly Inattentive Type ...........................608
Major Depressive Disorder ..................................589 Combined Type .....................................................608
Dysthymic Disorder ..............................................590 Medical–Surgical Management .................................. 608
Medical–Surgical Management .................................. 590 Medical .................................................................... 608
Medical .................................................................... 590 Pharmacological ...................................................... 608
Pharmacological ..................................................... 590 Diet ........................................................................... 609
Diet ........................................................................... 590 Activity ...................................................................... 609
Activity ...................................................................... 592 Nursing Management ................................................. 609
Nursing Management ................................................. 593 Nursing Process ...................................................609
Nursing Process ...................................................594 Assessment ................................................................ 609
Assessment ................................................................ 594 Subjective Data ........................................................ 609
Subjective Data ........................................................ 594 Objective Data ......................................................... 609
Objective Data ......................................................... 594 Neglect and/or Abuse ........................................... 610
The Client Who Is Potentially Violent ..................594 Elder Abuse and Neglect ..................................... 610
Homicidal Intent....................................................594 Domestic Violence ................................................ 611
Suicidal Intent .......................................................594 Rape ....................................................................... 612
Suicidal Ideations .................................................595 Medical–Surgical Management ...................................612
Actively Suicidal ...................................................595 Medical .....................................................................612
Medical–Surgical Management .................................. 596 Health Promotion .......................................................612
Medical .................................................................... 596 Nursing Management ..................................................612
Pharmacological ...................................................... 596 Nursing Process ................................................... 612
Diet ........................................................................... 596 Assessment .................................................................612
Activity ...................................................................... 596 Subjective Data .........................................................612
Nursing Management ................................................. 596 Objective Data ..........................................................613
Nursing Process ...................................................596 Eating Disorders ................................................... 613
Assessment ................................................................ 596 Medical–Surgical Management ...................................613
Subjective Data ........................................................ 596 Diet ............................................................................613
Objective Data ......................................................... 597 Other Therapies .........................................................613
Sample Nursing Care Plan: The Suicidal Nursing Management ..................................................613
Client with Major Depression ..............................598 Nursing Process ................................................... 614
The Client Who Is Psychotic ................................ 601 Assessment .................................................................614
Schizophrenia ....................................................... 601 Subjective Data .........................................................614
Medical–Surgical Management ...................................601 Objective Data ..........................................................614
Medical .....................................................................601
Pharmacological .......................................................601 CHAPTER 18: SUBSTANCE
Diet ........................................................................... 602 ABUSE / 617
Activity ...................................................................... 604
Nursing Management ................................................. 604 Introduction........................................................... 618
Nursing Process ...................................................604 Historical Perspectives ........................................ 618
Assessment ................................................................ 604 Factors Related to Substance Abuse.................. 618
Subjective Data ........................................................ 604 Individual Factors .........................................................618
Objective Data ......................................................... 604 Family Patterns ............................................................618
Bipolar Disorder ...................................................604 Lifestyle....................................................................... 620
Medical–Surgical Management .................................. 605 Environmental Factors ................................................ 620
Medical .................................................................... 605 Developmental Factors ............................................... 620
Pharmacological ..................................................... 605 Prevention .............................................................620
Diet ........................................................................... 605 Diagnostic Testing ................................................620

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 CONTENTS xxvii

Treatment/Recovery .............................................621 Treatment/Rehabilitation ............................................. 629

Substance Use Patterns .......................................621 Nicotine .................................................................629
CNS Depressants .................................................621 Incidence .................................................................... 629
Alcohol ..................................................................621 Signs and Symptoms .................................................. 629
Incidence .................................................................... 621 Potential for Addiction ................................................. 631
Signs and Symptoms .................................................. 622 Associated Problems/Disorders .................................. 631
Potential for Addiction ................................................. 622 Respiratory ............................................................... 631
Associated Problems/Disorders .................................. 622 Cardiovascular ......................................................... 631
Liver Deterioration .................................................... 622 Cancer...................................................................... 631
Gastrointestinal Disturbances .................................. 622 Withdrawal .................................................................. 631
Pancreatitis............................................................... 622 Treatment/Rehabilitation ............................................. 631
Wernicke’s Encephalopathy ..................................... 622 Methylphenidate Hydrochloride (Ritalin) ............631
Korsakoff’s Psychosis ............................................... 622 Hallucinogens .......................................................631
Cardiovascular Disturbances ................................... 622 Lysergic Acid Diethylamide .................................631
Fetal Alcohol Syndrome ........................................... 622 Incidence .................................................................... 632
Withdrawal .................................................................. 623 Signs and Symptoms .................................................. 632
Treatment/Rehabilitation ............................................. 623 Potential for Addiction ................................................. 632
Detoxification ............................................................ 623 Associated Problems/Disorders .................................. 632
Psychological Intervention ....................................... 623 Withdrawal .................................................................. 632
Education ................................................................. 624 Treatment/Rehabilitation ............................................. 632
Self-Help Groups ..................................................... 624 Phencyclidine........................................................632
Disulfiram ................................................................. 624 Incidence .................................................................... 632
Benzodiazepines and Other Signs and Symptoms .................................................. 632
Sedative-Hypnotics ..............................................626 Potential for Addiction ................................................. 632
Incidence .................................................................... 626 Associated Problems/Disorders .................................. 632
Signs and Symptoms .................................................. 626 Withdrawal .................................................................. 633
Potential for Addiction ................................................. 626 Treatment/Rehabilitation ............................................. 633
Withdrawal .................................................................. 626 Opioids ..................................................................633
Treatment/Rehabilitation ............................................. 626 Incidence .................................................................... 633
Marijuana (Cannabis) ...........................................626 Signs and Symptoms .................................................. 633
Incidence .................................................................... 626 Potential for Addiction ................................................. 633
Signs and Symptoms .................................................. 627 Associated Problems/Disorders .................................. 634
Potential for Addiction ................................................. 627 Withdrawal .................................................................. 634
Associated Problems/Disorders .................................. 627 Treatment/Rehabilitation ............................................. 634
Withdrawal .................................................................. 627 Detoxification ............................................................ 634
Treatment/Rehabilitation ............................................. 627 Counseling/Self-Help Groups .................................. 634
CNS Stimulants.....................................................627 Behavioral Therapy ................................................... 634
Cocaine..................................................................627 Inhalants ................................................................634
Incidence .................................................................... 627 Incidence .................................................................... 634
Signs and Symptoms .................................................. 627 Signs and Symptoms .................................................. 635
Potential for Addiction ................................................. 627 Potential for Addiction ................................................. 635
Associated Problems/Disorders .................................. 628 Associated Problems/Disorders .................................. 635
Withdrawal .................................................................. 628 Withdrawal .................................................................. 635
Treatment/Rehabilitation ............................................. 628 Treatment/Rehabilitation ............................................. 635
Medications.............................................................. 628 Ecstasy ..................................................................635
Education ................................................................. 628 Incidence .................................................................... 635
Amphetamines ......................................................628 Signs and Symptoms .................................................. 635
Incidence .................................................................... 628 Potential for Addiction ................................................. 635
Signs and Symptoms .................................................. 628 Associated Problems/Disorders .................................. 635
Potential for Addiction ................................................. 628 Anabolic Steroids .................................................635
Associated Problems/Disorders .................................. 628 Incidence .................................................................... 635
Withdrawal .................................................................. 629 Signs and Symptoms .................................................. 636
Treatment/Rehabilitation ............................................. 629 Potential for Addiction ................................................. 636
Caffeine..................................................................629 Associated Problems/Disorders .................................. 636
Incidence .................................................................... 629 Withdrawal .................................................................. 636
Signs and Symptoms .................................................. 629 Treatment/Rehabilitation ............................................. 636
Potential for Addiction ................................................. 629 Nursing Process ...................................................636
Withdrawal .................................................................. 629 Assessment ................................................................ 636

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xxviii CONTENTS

Subjective Data ........................................................ 636 Nursing Management: Dehydration ......................... 658

Objective Data ......................................................... 636 Nursing Management: Dental Disorders .................. 658
Nursing Diagnoses ..................................................... 637 Urinary System ........................................................... 659
Planning/Outcome Identification ................................. 637 Nursing Management: Incontinence ........................ 659
Nursing Interventions .................................................. 637 Nursing Management: Urinary Tract Infections ........ 660
Evaluation ................................................................... 638 Musculoskeletal System.............................................. 660
Codependency ......................................................638 Nursing Management: Osteoporosis ....................... 661
Characteristics ............................................................ 638 Nursing Management: Osteoarthritis ....................... 661
Treatment .................................................................... 638 Nursing Management: Fractured Hip....................... 661
The Impaired Nurse ..............................................638 Neurological System ................................................... 661
Case Study ............................................................639 Nursing Management: Alzheimer’s Disease ............ 662
Sample Nursing Care Plan: The Client with Nursing Management: Depression .......................... 663
Nursing Management: Transient Ischemic Attack .... 663
Pain Medication Tolerance ...................................639
Sensory Changes ....................................................... 663
Vision .......................................................................... 663
UNIT 8 Nursing Management: Visual Impairment ................ 664
Hearing ....................................................................... 664
Nursing Management: Hearing Impairment ............. 664
Nursing Care of the Client: Sample Nursing Care Plan: The Client with
Older Adult / 645 Alzheimer’s Disease (AD) ....................................665
Endocrine System ....................................................... 667
CHAPTER 19: THE OLDER Nursing Management: Diabetes Mellitus Type 2 ...... 667
Reproductive System: Female .................................... 667
ADULT / 646 Nursing Management: Female Reproductive
Introduction...........................................................647 System Disorders ..................................................... 668
Gerontological Nursing ........................................647 Reproductive System: Male ........................................ 668
Theories of Aging .................................................648 Nursing Management: Male Reproductive
Myths and Realities of Aging ...............................648 System Disorders ..................................................... 668
Integumentary System ................................................ 668
Health and Aging ..................................................650
Nursing Management: Alteration in Skin Integrity ........669
Activities of Daily Living .............................................. 650
Nursing Management: Herpes Zoster ...................... 670
Mobility ..................................................................... 650
Nursing Management: Skin Cancer ......................... 671
Bathing ..................................................................... 650
Hygiene .................................................................... 651 Financing Older Adult Care .................................671
Grooming ................................................................. 651 Medicare ..................................................................... 671
Dressing ................................................................... 651 Medicaid ..................................................................... 671
Eating ....................................................................... 651 Omnibus Budget Reconciliation Act ............................ 672
Toileting .................................................................... 651 Balanced Budget Act of 1997...................................... 672
Exercise ...................................................................... 652 Case Study ............................................................672
Nutrition ...................................................................... 652
Psychosocial Considerations ...................................... 652
Strengths .................................................................... 653 UNIT 9
Health Promotion and Disease Prevention.................. 653
Physiologic Changes Associated with Aging ....653
Respiratory System ..................................................... 654
Nursing Care of the
Nursing Management: Respiratory Client: Health Care in the
Tract Infections ......................................................... 654
Nursing Management: Chronic Obstructive Community / 677
Pulmonary Disease .................................................. 655
Nursing Management: Pulmonary Tuberculosis ....... 656 CHAPTER 20: AMBULATORY,
Cardiovascular System ............................................... 656 RESTORATIVE, AND PALLIATIVE CARE
Nursing Management: Peripheral Vascular
Disease .................................................................... 657
IN COMMUNITY SETTINGS / 678
Nursing Management: Hypertension ....................... 657 Introduction...........................................................679
Nursing Management: Chronic Congestive Ambulatory and Urgent Care Settings ...............679
Heart Failure ............................................................. 657 Ambulatory Care Settings ........................................... 679
Gastrointestinal System .............................................. 657 Care Provided in Ambulatory/Urgent Care Centers ..... 679
Nursing Management: Over-/Undernutrition ............ 658 Ambulatory Care Nurses............................................. 679
Nursing Management: Constipation ........................ 658 Legal Issues ..........................................................680

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 CONTENTS xxix

Confidentiality ............................................................. 680 Hospital Triage ............................................................ 699

Consent to Treat .......................................................... 681 Disaster Triage and Mass Casualty Incidents ............. 700
Treatment of a Minor ................................................... 681 Emergency Medical Services ...................................701
Reportable Conditions ................................................ 681 Shock ..................................................................... 701
Rehabilitation/Restorative Care...........................681 Medical–Surgical Management .................................. 702
Minimum Data Set ...................................................... 681 Medical .................................................................... 702
Interdisciplinary Health Care Team ............................. 682 Pharmacological ...................................................... 702
Roles of the Interdisciplinary Health Care Team...........682 Nursing Management ................................................. 702
Role of the LPN/VN .................................................... 683 Nursing Process ...................................................703
Functional Assessment and Evaluation for Assessment ................................................................ 703
Rehabilitation/Restoration ........................................... 683 Subjective Data ........................................................ 703
Assessment of Abilities ............................................... 684 Objective Data ......................................................... 703
Functional Independence Measure and Cardiopulmonary Emergencies ..........................703
Functional Assessment Measure ............................. 685 Medical–Surgical Management .................................. 704
Barthel Index ............................................................ 685 Medical .................................................................... 704
Rehabilitation/Restorative Care Settings ..................... 685 Pharmacological ...................................................... 704
Special Beds............................................................ 685 Activity ...................................................................... 704
Urinary Devices ........................................................ 685 Nursing Management ................................................. 704
Home Health Care.................................................686 Nursing Process ...................................................704
Types of Home-Based Care ........................................ 686 Assessment ................................................................ 704
Professional .............................................................. 687 Subjective Data ........................................................ 704
Technical .................................................................. 687 Objective Data ......................................................... 704
Home Visit Outcomes ................................................. 687 Neurological/Neurosurgical Emergencies .........705
Trends in Home Care ................................................. 687 Medical–Surgical Management .................................. 705
Telehealth ................................................................... 687 Medical .................................................................... 705
Role of the Home Health Nurse .................................. 687 Pharmacological ...................................................... 705
Role of the LPN/VN .................................................... 687 Activity ...................................................................... 705
Future of Home Health Care ....................................... 688 Nursing Management ................................................. 705
Assisted Living .....................................................688 Nursing Process ...................................................706
Adult Day Care ......................................................688 Assessment ................................................................ 706
Respite Care ..........................................................688 Subjective Data ........................................................ 706
Long-Term Care ....................................................688 Objective Data ......................................................... 706
Long-Term Care Facilities ........................................... 688 Abdominal Emergencies......................................706
Reimbursement ........................................................ 689 Medical–Surgical Management .................................. 706
Discharge.................................................................... 689 Medical .................................................................... 706
Extended Care Facilities ......................................689 Pharmacological ...................................................... 706
Holistic Nursing in Extended Care .............................. 689 Nursing Management ................................................. 706
Routines and Treatments ............................................ 689 Nursing Process ...................................................707
Activities...................................................................... 689 Assessment ................................................................ 707
Dietary ........................................................................ 690 Subjective Data ........................................................ 707
Financial Issues .......................................................... 690 Objective Data ......................................................... 707
Palliative Care and Hospice .................................690 Genitourinary Emergencies .................................707
Sample Nursing Care Plan: The Stroke Medical–Surgical Management .................................. 707
Client......................................................................691 Medical .................................................................... 707
Case Study ............................................................693 Surgical .................................................................... 707
Pharmacological ...................................................... 707
Diet ........................................................................... 708
Activity ...................................................................... 708
UNIT 10
Nursing Management ................................................. 708
Nursing Process ...................................................708
Applications / 697 Assessment ................................................................ 708
Subjective Data ........................................................ 708
CHAPTER 21: RESPONDING TO Objective Data ......................................................... 708
EMERGENCIES / 698 Ocular Emergencies .............................................708
Medical–Surgical Management .................................. 709
Introduction...........................................................699 Medical .................................................................... 709
Emergency/Disaster Preparedness ....................699 Surgical .................................................................... 709
Approaches To Emergency Care .........................699 Pharmacological ...................................................... 709

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xxx CONTENTS

Diet ........................................................................... 709 Nursing Process ................................................... 718

Activity ...................................................................... 709 Assessment .................................................................718
Nursing Management ................................................. 709 Subjective Data .........................................................718
Nursing Process ...................................................709 Objective Data ..........................................................718
Assessment ................................................................ 709 Terrorism ............................................................... 718
Subjective Data ........................................................ 709 Nuclear Terrorism ................................................. 718
Objective Data ......................................................... 709 Chemical Terrorism............................................... 719
Musculoskeletal Emergencies ............................709 Nerve Agents ...............................................................719
Medical–Surgical Management ...................................710 Pulmonary Agents........................................................719
Medical .....................................................................710 Cyanide Agents ............................................................719
Surgical .....................................................................710 Vesicant Agents ...........................................................719
Pharmacological .......................................................710 Incapacitating Agents...................................................719
Diet ............................................................................710 Bioterrorism .......................................................... 719
Activity .......................................................................710 Anthrax ........................................................................719
Nursing Management ..................................................710 Smallpox ..................................................................... 720
Nursing Process ................................................... 710 Plague......................................................................... 720
Assessment .................................................................710 Botulism ...................................................................... 720
Subjective Data .........................................................710 Viral Hemorrhagic Fevers ........................................... 720
Objective Data ..........................................................710 Tularemia .................................................................... 720
Soft-Tissue Emergencies ..................................... 711 Legal Issues ..........................................................720
Medical–Surgical Management ...................................711 Death in the Emergency Department..................720
Medical .....................................................................711 Case Study ............................................................722
Pharmacological .......................................................711
Activity .......................................................................711
Nursing Management ..................................................711 CHAPTER 22: INTEGRATION / 725
Nursing Process ................................................... 711 Introduction...........................................................725
Assessment .................................................................711 Systems Reviewed in Diabetes Mellitus
Subjective Data .........................................................711 Multisystem Case Study.......................................726
Objective Data ..........................................................711 Diabetes Mellitus Case Study ..............................726
Sample Nursing Care Plan: The Client with Systems Reviewed in Cirrhosis Multisystem
a Soft-Tissue Injury .............................................. 712 Case Study ............................................................727
Poisoning and Drug Overdoses ......................... 714 Cirrhosis Case Study ...........................................727
Medical–Surgical Management ...................................715
Systems Reviewed in Hypertension,
Medical .....................................................................715
Congestive Heart Failure, and Chronic
Pharmacological .......................................................715
Renal Failure Multisystem Case Study ...............727
Diet ............................................................................715
Nursing Management ..................................................715 Hypertension, Congestive Heart Failure, and
Nursing Process ................................................... 715 Chronic Renal Failure Case Study ......................728
Assessment .................................................................715 Systems Reviewed in Parkinson Disease
Subjective Data .........................................................715 Case Study ............................................................728
Objective Data ..........................................................715 Parkinson Disease Case Study ...........................728
Environmental/Temperature Emergencies ......... 716 Systems Reviewed in Hematologic
Medical–Surgical Management ...................................717 Disorder Multisystem Case Study .......................729
Medical .....................................................................717 Hematologic Disorder Case Study ......................729
Pharmacological .......................................................717
Diet ............................................................................717
Appendix A: NANDA–I Nursing Diagnoses
Nursing Management ..................................................717
2009–2011. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1
Nursing Process ................................................... 717
Assessment .................................................................717 Appendix B: Functional Assessments. . . . . . . . . . . . . B-1
Subjective Data .........................................................717 Appendix C: Abbreviations,
Objective Data ..........................................................717 Acronyms, and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1
Multiple-System Trauma ....................................... 718 Appendix D: English/Spanish
Medical–Surgical Management ...................................718 Words and Phrases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1
Medical .....................................................................718 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-1
Nursing Management ..................................................718 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-1

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 CONTRIBUTORS xxxi

CONTRIBUTORS

Carol A. Fetters Andersen, Mary Elias, RNC, BSN, CCE Margaret L. Griffin, RN,
RN, MSN Instructor BSN, MS
Director of Mental Health Services Practical Nursing Program Instructor
St. Anthony Regional Hospital and Ivy Tech State College Luthern College of Health
Nursing Home Fort Wayne, IN Professions
Carroll, IA Chapter 13, Reproductive System Fort Wayne, IN
Chapter 19, The Older Adult Chapter 15, Integumentary System
Michael A. Fiedler, CRNA, MS
Carma Andrus, RN, MN,CNS Assistant Professor Beverly F. Hidebrand, RN,
Dauterive Primary Care Clinic Applied Health Sciences BSN, MS
St. Martinville, LA University of Alabama at Birmingham Former Health Occupations
Chapter 11, Sensory System Birmingham, AL Coordinator
Chapter 1, Anesthesia Washington, Saratoga, Warren,
Hamilton, & Essex Counties BOCES
Diane R. Behrens, RNCS, Nancy Fieldhouse, RNBC, MSN Saratoga, NY
MA, MSEd Ivy Tech Community College Northeast Chapter 8, Urinary System
Instructor Fort Wayne, IN
University of Saint Francis Chapter 20, Ambulatory, Restorative, and Janet Leah Joost, RN, BSN
Fort Wayne, IN Palliative Care in Community Settings Instructor
Chaptere 16, Immune System Front Range Community College
Lynn Franck, MS, RN Boulder, CO
Gyl A. Burkhard, RN, BSN, MS Assistant Professor Chapter 4, Respiratory System
Instructor Rhodes State College
OCM BOCES Lima, OH Janet E. Keith, RN, MSEd
Syracuse, NY Chapter 12: Endocrine System Instructor Practical Nursing Program
Chapter 8, Urinary System Ivy Tech State College
Norma Fujise, RN, C, MS Fort Wayne, IN
School of Nursing Chapter 9, Musculoskeletal System
Diana L. Case, RN, MA, FNP University of Hawaii
Neighborhood Health Clinic Honoloulu, HI Vicki L. Khouli, RN, BSN, MA,
Fort Wayne, IN Chapter 15, Integumentary System IBCLC
Chapter 2, Surgery Instructor
Cathy Greer, RN, MS Practical Nursing Program
Janice Eilerman, MSN, RN Instructor Ivy Tech State College
Rhodes State College Lutheran College of Health Professions Fort Wayne, IN
Lima, OH Fort Wayne, IN Chapter 14, Sexually Transmitted
Chapter 15: Integumentary System Chapter 2, Surgery Infections

xxxi
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xxxii CONTRIBUTORS

Celinda Kay Leach, RN, BS, MPH Joan Fritsch Needham, Mary Kay Schultz, RN,
Program Chair RNC, MS MSN, ANP
Practical Nursing Program Director of Education Instructor
Ivy Tech State College DeKalb County Nursing Home Department of Nursing
Bloomington, IN DeKalb, IL Regis University
Chapter 3, Oncology Chapter 19, The Older Adult Denver, CO
Chapter 12, Endocrine System
Sandra Liming, RN, MN Raymond Phillips, RN,
Nursing Instructor MS, CCRN Leslee R. Sinn, RN, BSN
North Seattle Community College Clinical Nurse Specialist Instructor
North Seattle, WA Staff Development Coordinator Front Range Community College
Chapter 13, Reproductive System U.S. Naval Hospital Boulder, CO
Rota, Spain Chapter 7, Gastrointestinal System
Patricia Lokken, MSN, FNP-C Chapter 11, Sensory System
Family Nurse Practitioner Russlyn A. St. John, RN, MSN
Blearwater Health Services Susan Reinhart, RN, MS Associate Professor & Coordinator
Bagley, MN Assistant Professor Practical Nursing
Chapter 20, Ambulatory, Restorative, Department of Registered Nurse St. Charles Community College
and Palliative Care in Community Education St. Peters, MO
Settings Del Mar College Chapter 12, Endocrine System
Corpus Christi, TX
Cheryl McGaffic, RN, PhD Chapter 17, Mental Illness Patricia Tutor, PhD
Clinical Instructor Riverside Community College
College of Nursing Kathy Rockwell, RN, BSN, MA, Riverside, CA
The University of Arizona MSN, PNP Chapter 7: Gastrointestinal System
Tucson, AZ Professor
Chapter 16, Immune System Department of RN Education Donna Jean White, RN, MS
Del Mar College Corpus Christi, TX Rhodes State College
Robin Theresa McKenzie, RN, and Lima, OH
MSN, CCRN Supervisor, Surgical Services Chapter 19: The Older Adult
Assistant Chairman 94th General Hospital
Navy Medical Center Seagoville, TX Lorrie Wong, RN, MS
San Diego, CA Chapter 21, Responding to Emergencies School of Nursing
Chapter 11, Sensory System University of Hawaii
Martha Ann Rust, RN, Honolulu HI
David K. Miller, RNC, BSN, MSEd BSN, MSN Chapter 15, Integumentary System
ICU/Medical-Surgical Manager Instructor
W. S. Major Hospital Lutheran College of Health Professions
Shelbyville, IN Fort Wayne, IN
Chapter 16, Immune System Chapter 10, Neurological System

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 REVIEWERS

Charlene Bell, RN, MSN, NCSN Helena L. Jermalovic, RN, MSN Cheryl Pratt, RN, MA, CNAA
Instructor Assistant Professor Regional Dean of Nursing
Associate Degree Nursing Program University of Alaska Rasmussen College
Southwest Texas Junior College Anchorage, AK Mankato, MN
Uvalde, TX
Sharon Knarr, RN Cherie R. Rebar, RN, MSN,
Donna Burleson, RN, MS Clinical Instructor MBA, FNP
Chair of Nursing Department LPN Program Chair, Associate Professor, Nursing
Cisco Junior College Northcoast Medical Training Program
Abilene, TX Academy Kettering College of Medical Arts
Kent, OH Kettering, OH
Dotty Cales, RN
Instructor Timm Reed, RRT, RN, BS,
Christine Levandowski, RN,
North Coast Medical Training Academy MSN, MBA
BSN, MSN
Kent, OH Assistant Professor
Director of Nursing
University of Saint Francis
Baker College
Carolyn Du, BSN, MSN, NP, CDe Fort Wayne, IN
Auburn Hills, MI
Director of Education
Patricia Schrull, RN, MSN, MBA,
Pacific College
Wendy Maleki, RN, MS MEd, CNE
Costa Mesa, CA
Director Director, Practical Nursing Program
Vocational Nursing Program Lorain County Community College
Jennifer Einhorn, RN, MS
American Career College Elyria, OH
Nursing Instructor
Ontario, CA
Chamberlain College of Nursing Laura Spinelli
Addison, IL Keiser Career College
Katherine C. Pellerin, RN,
Miami Lakes, FL
Patricia Fennessy, RN, MSN BS, MS
Education Consultant Department Head, LPN Program Frances S. Stoner, RN, BSN, PHN
Connecticut Technical High School Norwich Technical High School Instructor, NCLEX Coordinator
System Norwich, CT American Career College
Middletown, CT Anaheim, CA
Jennifer Ponto, RN, BSN
Carol Greulich, CS, RN, MSN Faculty Tina Terpening
Assistant Professor Vocational Nursing Program Associate Nursing Faculty
University of Saint Francis South Plains College University of Phoenix, Southern
Fort Wayne, IN Levelland, TX California Campus
xxxiii

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xxxiv REVIEWERS

Lori Theodore, RN, BSN Sarah Elizabeth Youth Griffin Technical College
Orlando Tech Whitaker, DNS, RN Griffin, GA
Orlando, FL Nursing Program Director
Computer Career Center Christina R. Wilson, RN, BAN,
Kimberly Valich, RN, MSN El Paso, TX PHN
Nursing Faculty, Department Faculty, Practical Nursing Program
Chairperson Shawn White, RN, BSN Anoka Technical College
South Suburban College Clinical Coordinator, Nursing Anoka, MN
South Holland, IL Instructor

MARKET REVIEWERS AND CLASS TEST PARTICIPANTS

Deborah Ain Scott Coward, RN Edith Gerdes, RN, MSN, BHCA
Nursing Professor Campus Director Associate Professor of Nursing
College of Southern Nevada Angeles Institute Ivy Tech Community College
Las Vegas, NV Lakewood, CA South Bend, IN

Mary Ann Ambrose, MSN, FNP Jennifer Decker Juanita Hamilton-Gonzalez

Program Director Clinical Instructor Professor
Cuesta Community College Vocational College of Eastern Utah Coordinator – Practical Nursing Program
Nursing Program Price, UT City University of New York – Medgar
Paso Robles, CA Evers
C. Kay Devereux Brooklyn, NY
Jennie Applegate, RN, BSN
Professor
Practical Nursing Instructor Jane Harper
Department Chair, Vocational
Keiser Career College Assistant Professor
Nurse Education
Greenacres, FL Southeast Kentucky Community &
Tyler Junior College
Tyler, TX Technical College
Charlotte A. Armstrong, RN, BSN Pineville, KY
Instructor
Northcoast Medical Training Academy Carolyn Du, BSN, MSN, NP, CDe
Director of Education Angie Headley
Kent, OH
Pacific College Nursing Instructor
Costa Mesa, CA Swainsboro Technical College
Camille Baldwin
Swainsboro, GA
High Tech Central
Fort Myers, FL Laura R. Durbin, RN, BSN, CHPN
Instructor Lillie Hill
Priscilla Burks, RN, BSN West Kentucky Community and Clinical Coordinator/Instructor
Practical Nursing Instructor Technical College Practical Nursing
Hinds Community College Paducah, KY Durham Technical Community College
Pearl, MS Durham, NC
Robin Ellis, BSN, MS
Virginia Chacon Michelle Hopper
Nursing Faculty
Colorado Technical University Sanford-Brown College
Provo College
Pueblo, CO St. Peters, MO
Provo, UT
Sherri Comfort, RN Karla Huntsman, RN, MSN
Practical Nursing Instructor Department Suzanne D. Fox, RN Instructor
Chair Practical Nursing Instructor Nursing Program
Holmes Community College Arkansas State University Technical Center AmeriTech College
Goodman, MS Marked Tree, AR Draper, UT

Brandy Coward, BNS, MA Judie Fritz, RN, MSN Connie M. Hyde, RN, BSN
Director of Nursing Instructor Practical Nursing Instructor
Angeles Institute Keiser Career College Louisiana Technical College
Lakewood, CA Miami Lakes, FL Lafayette, LA

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 REVIEWERS xxxv

Denise Isackila Kristie Oles, RN, MSN Laura Spinelli

Instructor Practical Nursing Chair Keiser Career College
North Coast Medical Training Academy Brown Mackie College Miami Lakes, FL
Kent, OH North Canton, OH
Jennifer Teerlink, RN, MSN
Kimball Johnson, RN, MS Beverly Pacas Nursing Faculty
Nursing Professor Department Head/Instructor Provo College
College of Eastern Utah Practical Nursing Provo, UT
Price, UT Louisiana Technical College
Baton Rouge, LA Dana L. Trowell, RN, BSN
Sandy Kamhoot, BSN
LPN Program Director
Faculty
Debra Perry, RN, MSN Dalton State College
Santa Fe College
Instructor Dalton, GA
Gainesville, FL
Lorain County Community College
Juanita Kaness, MSN, RN, CRNP Elyria, OH Racheal Vargas, LVN
Nursing Program Coordinator Clinical Liaison
Lehigh Carbon Community College Cheryl Pratt, RN, MA, CNAA Medical Assisting/Vocational Nursing
Schnecksville, PA Regional Dean of Nursing Lake College
Rasmussen College Reading, CA
Mary E. Kilbourn-Huey, MSN Mankato, MN
Assistant Professor Sarah Elizabeth Youth Whitaker,
Maysville Community and Technical Charlotte Prewitt, RN, BSN DNS, RN
College Practical Nursing Instructor Nursing Program Director
Maysville, KY Meridian Technology Center Computer Career Center
Stillwater, OK El Paso, TX
Gloria D. Kline, RN
Practical Nursing Instructor Stephanie Price Shawn White, RN, BSN
Hinds Community College Faculty, Practical Nursing Clinical Coordinator, Nursing Instructor
Vicksburg, MS Holmes Community College Griffin Technical College
Goodman, MS Griffin, GA
Christine Levandowski, RN,
BSN, MSN
Patricia Schrull, RN, MSN, MBA, Sharon Wilson
Director of Nursing
MEd, CNE Program Director/Instructor, Practical
Baker College
Director, Practical Nursing Program Nursing
Auburn Hills, MI
Lorain County Community College Durham Technical Community College
Mary Luckett, RN, MS Elyria, OH Durham, NC
Professor Vocational Nursing
Level 1 Coordinator Margi J. Schutlz, RN, MSN, PhD Vladmir Yarosh, LVN, BS
Houston Community College Director, Nursing Division Program Coordinator —Vocational Nurse
Coleman College for Health Sciences GateWay Community College Program
Houston, TX Phoenix, AZ Gurnick Academy of Medical Arts
San Mateo, CA
Wendy Maleki, RN, MS Sherie A. Shupe, RN, MSN
Director Director of Nursing DiAnn Zimmerman
Vocational Nursing Program Computer Career Center Director, Instructor
American Career College Las Cruces, NM Dakota County Technical College
Ontario, CA Rosemount, MN
Sherri Smith, RN
Luzviminda A. Malihan Chairwoman
Assistant Professor Arkansas State University Technical
Hostos Community College Center
Bronx, NY Jonesboro, AR
Vanessa Norwood McGregor,
Cheryl Smith, RN, BSN
RN, BSN, MBA
Practical Nursing Instructor
Practical Nursing Instructor
Colorado Technical University
West Kentucky Community and
North Kansas City, MO
Technical College
Paducah, KY

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 PREFACE

F oundations of Adult Health Nursing, third edition, cov-

ers the common medical/surgical conditions generally
encountered by Practical/Vocational nurses. An anatomy and
ORGANIZATION
Foundations of Adult Health Nursing, third edition, consists of
physiology review is provided at the beginning of each body 22 chapters grouped into 10 units.
system chapter. Each condition is presented and is followed
by medical-surgical management topics—including pharma- • Unit 1: ESSENTIAL CONCEPTS—discusses the various
cological, dietary, activity aspects, and nursing management. types of anesthesia and the nursing care required for each.
The nursing process is presented in great detail and incor- Surgery describes the perioperative care of clients. The
porates the current NANDA-I diagnoses and NIC/NOC Oncology chapter covers the various types of cancer, the
references. As well, it identifies subjective and objective data usual treatments, and the nursing care required.
with health history questions, possible nursing diagnoses, • Unit 2: NURSING CARE OF THE CLIENT:
goals/outcomes, interventions, and evaluation. Each chapter OXYGENATION AND PERFUSION— includes the
contains a sample care plan. The student is provided with respiratory system, cardiovascular system, and hematologi-
opportunities to demonstrate knowledge and develop criti- cal and lymphatic systems.
cal thinking skills by completing the Case Studies included • Unit 3: NURSING CARE OF THE CLIENT:
in many of the chapters. New client case studies have been DIGESTION AND ELIMINATION— discusses the gas-
added throughout. The student has the opportunity to assess trointestinal system and urinary system.
knowledge and critical thinking of essential nursing concepts • Unit 4: NURSING CARE OF THE CLIENT: MOBILITY,
by answering NCLEX®-style review questions at the end of COORDINATION, AND REGULATION—covers the
each chapter. musculoskeletal system, neurological system, sensory sys-
Although a systems approach is presented, the concept of tem, and endocrine system.
holistic care is fundamental to this text. Throughout the book, • Unit 5: NURSING CARE OF THE CLIENT: REPRO-
boxes highlight special topics regarding critical thinking ques- DUCTIVE AND SEXUAL HEALTH—includes the male
tions, memory tricks, life span development, client teaching, and female reproductive systems and sexually transmitted
cultural considerations, professional tips, community/home infections.
health care, safety, and infection control. • Unit 6: NURSING CARE OF THE CLIENT: BODY
Health care settings are changing, multifaceted, chal- DEFENSES—discusses the integumentary system and the
lenging, and rewarding. Critical thinking and sound nursing immune system.
judgments are essential in the present health care environ-
ment. Practical/Vocational nursing students confront and • Unit 7: NURSING CARE OF THE CLIENT: PHYSICAL
adapt to changes in technology, information, and resources AND MENTAL INTEGRITY— addresses substance
by building a solid foundation of accurate, essential infor- abuse and the care of clients with common mental illnesses.
mation. A firm knowledge base also allows nurses to meet Substance Abuse describes substances which are commonly
the changing needs of clients. This text was written to abused, the signs and symptoms of abuse, and treatments
equip the LPN/VN with current knowledge, basic problem- available.
solving and critical thinking skills to successfully pass the • Unit 8: NURSING CARE OF THE CLIENT: OLDER
NCLEX®-PN exam and meet the demanding challenges of ADULT—explains nursing care for the older adult. Physio-
today’s health care. logical changes of aging are presented for each body system.

xxxvii

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xxxviii PREFACE

• Unit 9: NURSING CARE OF THE CLIENT: HEALTH • Professional Tip: offers tips and technical hints for the
CARE IN THE COMMUNITY— defines the role of the nurse to ensure quality care.
nurse in ambulatory, restorative, and palliative care in com- • Safety: emphasizes the importance of and ways to main-
munity settings. Discusses appropriate client assessments tain safe care.
and nursing interventions in each health care setting. • Community/Home Health Care: describes factors to
• Unit 10: APPLICATIONS—describes how nursing consider when providing care in the community or in a cli-
knowledge is applied in emergencies. Specific information ent’s home, and adaptation in care that may be necessary.
is provided for common emergencies. A number of sce- • Drug Icon: highlights pharmacological treatments and
narios describing clients with multisystem problems assist interventions that may be appropriate for certain condi-
students to see the integration of the body. tions and disorders.
• Collaborative Care: mentions members of the care team
FEATURES and their roles in providing comprehensive care to clients.
• Infection Control: indicates reminders of methods to
Each chapter includes a variety of learning aids designed to prevent the spread of infections.
help the reader further a basic understanding of key concepts. The back matter includes a Glossary of Terms. The appendi-
Each chapter opens with a Making the Connection box that ces include NANDA-I Nursing Diagnoses; Recommended
guides the reader to other key chapters related to the current Childhood, Adolescent, and Adult Immunization Sched-
chapter. This highlights the integration of the text material. ules; Abbreviations, Acronyms and Symbols; and English/
Procedures used for the care of clients with medical/surgical Spanish Words and Phrases. Standard Precautions are
disorders are identified as appropriate. Learning Objectives found on the inside back cover.
are presented at the beginning of each chapter as well. These
help students focus their study and use their time efficiently.
A listing of Key Terms is provided to identify the terms the
student should know or learn for a better understanding of the NEW TO THIS EDITION
subject matter. These are typeset in color and defined at first Added one new chapter:
use in the chapter. Each medical/surgical chapter has a brief
review of anatomy and physiology to review the organs and • Chapter 20, Ambulatory, Restorative, and Palliative Care in
functions of the system being discussed. Community Settings defines the role of the nurse, explains
The content of each chapter is presented in nursing the legal issues when providing nursing care, and discusses
process format. Where appropriate, a Sample Nursing Care appropriate client assessments and nursing interventions
Plan is provided in the chapter. These serve as models for in each health care setting.
students to refer to as they create their own care plans based Extensively updated chapters:
on case studies. Case Studies are presented at the conclu- • Chapter 2, Surgery, now contains additional robotic and
sion of most chapters. These call for students to draw upon minimally invasive surgeries.
their knowledge base and synthesize information to develop • Chapter 5, Cardiovascular System, has improved anatomy
their own solutions to realistic cases. Nursing Diagnoses, and physiology and assessment sections, explanations of
Planning/Outcomes, and Interventions are presented in a cutting-edge diagnostic tests, and extensively updated con-
convenient table format for quick reference. tent on implantable cardioverter-defibrillator, pacemaker,
A bulleted Summary list and multiple-choice NCLEX -
style Review Questions at the end of each chapter assist the
® cardiac valve management, angina, minimally invasive sur-
gery, ventricular assist device, and pharmacological care.
student in remembering and using the material presented.
References/Suggested Readings allow the student to find • Chapter 22, Integration, includes more in-depth case
the source of the material presented and also to find addi- studies to use as appropriate throughout the educational
tional information concerning topics covered. Resources are experience.
also listed and provide names and internet addresses of orga- Updated content within chapters:
nizations specializing in a specific area of health care. • Updates to Chapter 3, Oncology, include sections on pho-
Boxes used throughout the text emphasize key points and todynamic therapy, hormone therapy, and targeted cancer
provide specific types of information. The boxes are: therapy, and a table on cancer screening guidelines.
• Critical Thinking: encourages the student to use the • Updates to Chapter 6, Hematologic and Lymphatic Sys-
knowledge gained to think critically about a situation. tems, include a critical thinking activity for students to
• Memory Trick: provides an easy-to-remember saying or visually compare the different anemias, pertinent drugs
mnemonic to assist the student in remembering important used in system disease conditions, and a section on Hodg-
information presented. kin’s disease and nodular lymphocyte predominance
• Life Span Considerations: provides information related Hodgkin’s disease.
to the care of specific age groups during the life span. • A new section to help the student understand issues in car-
• Client Teaching: identifies specific items that the client ing for clients with obesity.
should know related to the various disorders. • Content added to Chapter 9, Musculoskeletal System,
• Cultural Considerations: shares beliefs, manners, and include guidelines for assessing muscle strength, external
ways of providing care, communication, and relationships fixation, and an explanation of the bone mineral density
of various cultural and ethnic groups as a way to provide test and medications for osteoporosis. The sections on
holistic care.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 PREFACE xxxix

cast care, traction, and total hip replacement have also Instructor Resources
received extensive updates.
• Updates to Chapter 10, Neurological System, include Foundations of Adult Health Nursing
intrathecal chemotherapy, chemotherapy disk-shaped Instructor’s Resource, third edition
wafers, Stroke Risk Scorecard, diet therapy, positron
emission tomography scanning and ablation procedures ISBN-10: 1-428-31780-5
for Parkinson’s disease; sniff test to diagnose Alzheimer’s ISBN-13: 978-1-428-31780-2
disease, Parkinson’s disease, and other neurodegenerative The Instructor’s Resource has four components to assist the
disorders. instructor and enhance classroom activities and discussion.
• New sections in Chapter 21, Responding to Emergencies,
discuss disaster triage, mass casualty incidents, and poison- Instructor’s Guide
ing and drug overdoses. • Instructional Approaches: Ideas and concepts to help
Other additions: educators manage different presentation methods. Sug-
gestions for approaching topics with rich discussion topics
• Added case studies to all chapters as offering a mixture of and lecture ideas are provided.
critical thinking and nursing process questions. • Student Learning Activities: Ideas for activities such as
• Added Concept Maps to several chapters so the student classroom discussions, role play, and individual assign-
can link facts with real life clinical practice. ments designed to encourage critical thinking as students
• Added Concept Care Maps to chapters as appropriate for engage with the concepts presented in the text.
visual picture of the nursing process. • Resources: Additional books, videos, and resources for
• Increased number of challenging and applicable critical use in developing and implementing your curriculum.
thinking questions. • Web Activities: Suggestions for student learning experi-
• Updated cultural considerations and cultural content ences online, including specific websites and accompany-
included throughout the text. ing activities.
• Added Adult Immunization Schedule along with Child- • Suggested Responses to the Case Study: Case studies
hood and Adolescent Immunization Schedules. located throughout the book challenge student critical
• Added objective and subjective assessment guidelines thinking with questions about nursing care. Suggested
to medical-surgical chapters for student use in clinical responses are included.
settings. • Answers to Review Questions: Answers and rationales for
• Cited research articles in understandable manner for easy
application of evidence-based practice. ®
all end-of-chapter NCLEX -style questions are provided.

• Added current NANDA-I diagnoses according to North Computerized Testbank

American Nursing Diagnosis Association International
(2010) NANDA-I Nursing Diagnoses: Definitions and Classifi- • Includes a rich bank of questions that test students on
cation (NANDA Nursing Diagnosis). retention and application of material in the text.
®
• Added new NCLEX -style review questions at the end of • Many questions are now presented in NCLEX style, ®
with each question providing the answer and rationale, as
chapters to help students challenge their understanding of
content while gaining practice with this important ques- well as cognitive levels.
tion style. • Allows the instructor to mix questions from each of the
• Added memory tricks for ease of student recall of perti- didactic chapters to customize tests.
nent information.
• Numerous new photos and illustrations for improved pre- Instructor Slides Created in PowerPoint
sentation of concepts. • A robust offering of instructor slides created in Power-
™
• New, free, StudyWARE CD-ROM provides interactive
games, animations, videos, heart and lung sounds, and
Point outlines the concepts from text in order to assist the
instructor with lectures.
much more to augment the learning experience and sup- • Ideas presented stimulate discussion and critical thinking.
port mastery of concepts.
Image Library
A searchable Image Library provides more than 800 illustra-
EXTENSIVE TEACHING/ tions and photographs that can be incorporated into lectures,
LEARNING PACKAGE class materials, or electronic presentations.

The complete supplements package for Foundations of Adult Student Resources

Health Nursing, third edition, was developed to achieve two
goals: Foundations of Adult Health Nursing
1. To assist students in learning the information and pro- Study Guide, third edition
cedures presented in the text. ISBN-10: 1-4283-1785-6
2. To assist instructors in planning and implementing ISBN-13: 978-1-4283-1785-7
their programs for the most efficient use of time and A valuable companion to the core book, this student resource
other resources. provides additional review of all 22 chapters of Foundations of

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
xl PREFACE

Adult Health Nursing, third edition, with Key Terms match- Foundations of Nursing WebTutor
ing review questions, Abbreviation Review Exercises, Self-
Assessment Questions, and other Review Exercises and Advantage on Blackboard
Activities. Answers to questions are provided at the back of ISBN-10: 1-4283-1781-3
the book making this an excellent resource for self-study and ISBN-13: 978-1-4283-1781-9
review.
Foundations of Nursing WebTutor
Foundations of Nursing Online Advantage on WebCT
Companion
ISBN-10: 1-4283-1782-1
ISBN-10: 1-4283-1779-1
ISBN-13: 978-1-4283-1782-6
ISBN-13: 978-1-4283-1779-6
The Online Companion gives online access to all the compo- • A complete online environment that supplements the
nents in the Instructor’s Resource as well as additional tools course provided in both Blackboard and WebCT format.
to reinforce the content in each chapter and enhance class- • Includes chapter overviews, chapter outlines, and
room teaching. Multimedia animations, Concept Care Map competencies.
Model, and Physical Assessment Guide are just some of the • Useful classroom management tools include chats and
many resources found on this robust site. To access the site calendars, as well as instructor resources such as the
for Foundations of Nursing, third edition, simply point your instructor slides created in PowerPoint.
browser to http://www.delmar.cengage.com/companions. • Multimedia offering includes video clips and 3D
Select the nursing discipline and then select Foundations of animation.
Nursing, third edition. • Comprehensive Audio Glossary with all terms and defini-
tions from this text in downloadable audio format.
CL eBook to Accompany Foundations of
Adult Health Nursing, third edition
Printed access code ISBN-10: 1-4354-8788-5
Printed access code ISBN-13: 978-1-4354-8788-8
Instant access code ISBN-10: 1-4354-8787-7
Instant access code ISBN-13: 978-1-4354-8787-1

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
ABOUT THE AUTHORS

L ois Elain Wacker White earned a diploma in nursing

from Memorial Hospital School of Nursing, Springfield,
Illinois; an Associate degree in Science from Del Mar Col-
an LPN program, and director of an Associate degree nursing
program. She has taught LPN, ADN, BSN, and MSN nurs-
ing students. As a faculty member, she taught many nursing
lege, Corpus Christi, Texas; a Bachelor of Science in Nurs- courses and served on a statewide curriculum committee for
ing from Texas A & I University—Corpus Christi, Corpus a state college. As director of an Associate degree nursing
Christi, Texas; a Master of Science in Education from Corpus program, she was instrumental in starting and obtaining state
Christi State University, Corpus Christi, Texas; and a Doc- board approval of an LPN-RN nursing program.
tor of Philosophy degree in Education Administration— Her master’s research thesis was entitled “An Inves-
Community College from the University of Texas, Austin, tigation of Learning Styles of Practical and Baccalaureate
Texas. Students.” The results of the study are published in the Jour-
She has taught at Del Mar College, Corpus Christi, nal of Nursing Education. She has coauthored two textbooks,
Texas, in both the Associate Degree Nursing program and the a medical-surgical textbook and a transitions text for LPN
Vocational Nursing program. For 14 years, she was also chair- to RN students. She has been an active member of Sigma
person of the Department of Vocational Nurse Education. Theta Tau.

W
Dr. White has taught fundamentals of nursing, mental health/
mental illness, medical-surgical nursing, and maternal/pediat- endy Baumle is currently a nursing instructor at James
ric nursing. Her professional career has also included 15 years A. Rhodes State College in Ohio. She has spent 19
of clinical practice. years as a clinician, educator, school district health coordina-
Dr. White has served on the Nursing Education Advi- tor, and academician. Mrs. Baumle has taught fundamentals of
sory Committee of the Board of Nurse Examiners for the nursing, medical-surgical nursing, pediatrics, obstetrics, phar-
State of Texas and the Board of Vocational Nurse Examin- macology, anatomy and physiology, and ethics in health care
ers, which developed competencies expected of graduates in practical nursing and associate nursing degree programs.
for each level of nursing. She has previously taught at Lutheran College, Fort Wayne,

G
Indiana, at Northwest State Community College, Archbold,
ena Duncan has worked as an RN for 36 years in the Ohio, and at James. A. Rhodes State College in Lima, Ohio.
clinical, community health, and educational arenas. This Mrs. Baumle earned her Bachelor of Science degree in Nurs-
has equipped Mrs. Duncan with a wide range of nursing ing from The University of Toledo, Toledo, Ohio, and her
experiences and varied skills to meet the educational needs of Master’s degree in Nursing from The Medical College of
today’s students. She has an MSEd and MSN. Ohio, Toledo, Ohio. Mrs. Baumle is a member of a number
During her professional career, Mrs. Duncan served as a of professional nursing organizations, including Sigma Theta
staff nurse, an assistant head nurse of a medical-surgical unit, Tau, the American Nurses Association, the National League
a continuing education instructor, an associate professor in for Nursing, and the Ohio Nurses Association.

xli

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 TITLE
ACKNOWLEDGMENTS

M any people must work together to produce any text-

book, but a comprehensive book such as this requires
even more people with various areas of expertise. We would
We would like to acknowledge and sincerely thank the
entire team at Delmar Cengage Learning who has worked
to make this textbook a reality. Juliet Steiner, senior product
like to thank the contributors for their time and effort to share manager, receives a special thank you. She has kept us on track
their knowledge gained through years of experience in both and provided guidance with humor, enthusiasm, sensitivity,
the clinical and academic settings. Debra Thorson, RN, MS, and expertise. We extend a special thank you to Steve Helba,
nursing instructor at Northwest Technical College at Bemidji, executive editor, for his vision for this text, calm demeanor,
Minnesota, contributed content to Chapter 21, Responding and patience. Other members on the team—Marah Belle-
to Emergencies. garde, managing editor; James Zayicek, senior content prod-
To the reviewers, we thank you for your time spent uct manager; Jack Pendleton, senior art director; and Meghan
critically reading the manuscript, and for your expertise and Orvis, editorial assistant, have all worked diligently for the
valuable suggestions that have added to this text. completion of this textbook. Thank you to all.

xlii

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 HOW TO USE
THISTITLE
TEXT

This text is designed with you, the reader, in mind. Special elements and feature boxes appear throughout the text to guide you in
reading and to assist you in learning the material. Following are suggestions for how you can use these features to increase your
understanding and mastery of the content.

MAKING THE CONNECTION

CHAPTER 3
Oncology Read these boxes before beginning a chapter to
link material across the holistic care continuum and
to tie new content to the material you have already
MAKING THE CONNECTION
Refer to the following chapters to increase your understanding of oncology nursing: encountered.
Adult Health Nursing • Reproductive System
• Surgery • Integumentary System
• Hematologic and Lymphatic Systems • Immune System
• Gastrointestinal System • The Older Adult
• Neurological System
• Endocrine System
LEARNING OBJECTIVES
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
Read the chapter objectives before reading the
•
•
Define key terms.
Explain how the behavior of cancer cells differs from that of normal cells.
chapter to set the stage for learning. Revisit the
•
•
Describe the role of the nurse in cancer detection.
Discuss three medical treatments for cancer. objectives when preparing for an exam to see
• Describe four complications that can occur in advanced cancer.
• Discuss ways the licensed practical/vocational nurse can aid the client in
coping with cancer.
which entries you can respond to with “Yes, I can
KEY TERMS do that.”
alopecia carcinogen neoplasm
anorexia carcinoma oncology
antineoplastic chemotherapy palliative surgery
benign curative surgery photodynamic therapy (PDT)
biologic response modifier
(BRM)
differentiation
extravasation
radiotherapy
reconstructive surgery KEY TERMS
bone marrow transplantation leukemia sarcoma
(BMT) lymphoma stomatitis CHAPTER 5 Cardiovascular System 143
cachexia malignant tumor marker
cancer Q HEART
metastasis FAILUREvesicant Medical–Surgical Management Review this list before reading the chapter to famil-
H
Medical
F is often the final stage of many other heart conditions.

iarize yourself with the new terms and to revisit

A weakened muscle wall from a myocardial infarction Goals for treating HF are to improve circulation to the coro-
44 or a heart that has been stressed over a period of time to meet nary arteries and decrease the workload of the left ventricle.
metabolic needs of the body can cause HF. HF develops when To meet these goals, cardiac efficiency is increased with medi-
cation; oxygen requirements of the body are decreased by bed
the heart is no longer capable of meeting the oxygen needs
of the body. The muscles of the left ventricle hypertrophy
(increases in muscle mass), and often the ventricular chamber
rest with the head elevated 45 degrees; edema and pulmonary
congestion are treated with medications, diet, and restricted
fluid intake; and fluid retention is monitored by weighing the
those terms you already know to link them to the
enlarges in an attempt to meet the oxygen needs of the body.
Both the right and left ventricles act as pumps for the heart.
Each of these pumps can fail separately, resulting in two types of
HF: right-sided HF and left-sided HF. HF usually begins on the
client daily. A chest x-ray directly visualizes the ventricles and
evidence of lung congestion. An ECG is done and arterial
blood gases are evaluated. The client’s oxygen saturation level
content in the new chapter.
left side. Some of the causes of right-sided failure are untreated is monitored by pulse oximetry. Depending on the seriousness
left ventricular failure, right ventricular myocardial infarction, of the client’s condition, a pulmonary artery catheter (Swan-
chronic obstructive coronary disease, cor pulmonale, and pul- Ganz catheter) may be inserted to determine left ventricular
monic valve stenosis. Left-sided failure is caused by left ventricu- function.
lar myocardial infarction, aortic valve stenosis, prolapsed valve In right-sided failure, the symptoms of edema, hepatomeg-
complications, and hypertension. Notice that right- and left-sided aly, and neck vein distention are significant diagnostic evidence.
failure are caused by a defect of the ventricle or an increased
resistance in the path of the blood pumped by the ventricles. This Surgical
causes an increased workload for the involved ventricle. Two mechanical devices are available: an intra-aortic balloon
When left-sided HF occurs, the left ventricle is not able pump and a ventricular assist device (VAD). An intra-aortic
to completely empty of blood or effectively pump blood out
through the aorta to the body systems. Usually the right ventri-
cle continues to pump adequate quantities of blood. This causes
balloon is threaded through the femoral artery to the descend-
ing aorta (Figure 5-21). The pump is synchronized with the
contractions of the left ventricle so the balloon inflates during
CRITICAL THINKING
blood to back up in the left ventricle, left atrium, and pulmonary diastole and deflates during systole. Inflation of the balloon
veins. The lungs become congested with fluid as fluid leaks increases the blood flow to the coronary arteries, thus increas-
through the capillaries and fills air spaces in the lungs. The client ing oxygenation of the myocardium. Deflation of the balloon
becomes cyanotic, dyspneic, restless, and coughs up blood-
tinged sputum. The breath sounds have moist crackles. Often
the client has tachycardia with low blood pressure because the
allows the left ventricle to pump blood to the body tissues
with less peripheral resistance.
The ventricular assist device (VAD) does not replace the
Visit these boxes after reading the entire chap-
heart is not able to pump sufficient blood to meet the body’s heart, but it assists a weakened heart to pump sufficient blood
demands. The client may have decreased urinary output because
enough blood is not pumped through the kidneys. As the blood
oxygen level decreases, the client becomes confused.
throughout the body. It is referred to as “a bridge to transplant”
because a client uses the VAD while waiting for a heart transplant.
Some clients who are not transplant candidates may use the VAD
ter to check your understanding of the concepts
As the right side of the heart fails, blood becomes congested
in the inferior vena cava, causing edema first in the extremities
and then in the trunk of the body. As the condition progresses,
until death. A left VAD takes blood from the left ventricle and
delivers it to the aorta (see Figure 5-22); a right VAD takes blood
from the right ventricle and delivers it to the pulmonary artery.
presented.
the client experiences edema of the ankles, lower legs, thighs, Potential complications are bleeding, blood clots, respiratory
and finally in the abdomen. The excess abdominal fluid causes failure, renal failure, infection, stroke, and device failure.
the client to be anorectic. Hepatomegaly (enlargement of the
liver) and splenomegaly (enlargement of the spleen) develop. Pharmacological
The jugular veins in the neck become distended when the cli- Medications to reduce the heart’s workload in moderate HF
ent is sitting or standing, and pitting edema occurs in the lower are angiotensin converting enzymes (ACE) inhibitors, angio-
extremities. Refer to Figure 5-6. Oliguria occurs as decreased tensin receptor blockers, vasodilators, nitrates, beta blockers,
amounts of blood are pumped through the kidneys. diuretics, digitalis, and aspirin (Table 5-4). The client with HF
In the early stages of HF, the client experiences fatigue, will receive diuretics such as furosemide (Lasix) to decrease
dyspnea with slight exertion, pedal edema, and a slight cough fluid retention. ACE inhibitors, such as captopril (Capoten)
with a small amount of expectoration. The client may also or enalopril (Vasotec), are given to reduce blood pressure and
have paroxysmal nocturnal dyspnea. peripheral arterial resistance and improve CO. Beta blockers
carvedilol (Coreg) and metoprolol succinate (Toprol XL),
CRITICAL THINKING the only beta-blockers approved for HF in the United States,
are then added (Ammon, 2001). A digitalis preparation may
Lifestyle Changes for MI be required to increase the strength and contractility of the
heart muscle. Vasodilators such as nitroglycerin (Cardabid)
are given to dilate the veins so the blood will stay in the periph-
What would you teach a client to assist him in
eral vessels and decrease blood return to the right side of the
decreasing risk factors for an MI? heart, thereby decreasing the workload on the heart. Clients
What lifestyle changes could you take to decrease in severe HF who are already taking an ACE inhibitor may be
the risk factors for an MI? given spironolactone (Aldactone) (Ahmed, 2008). Morphine
sulfate is given in the acute phase to control pain and decrease
anxiety.

xliii

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HOW TO USE THIS TEXT (Continued)
52 UNIT 1 Essential Concepts

PROFESSIONALTIP

Chemotherapy and Protective

Equipment
• Because many chemotherapy drugs are carcino-
genic, the nurse preparing and administering
the chemotherapy wears protective equipment.
• All personnel involved in any aspect of handling
PROFESSIONAL TIP
chemotherapeutic agents receive instructions
about the known risks of the drugs, the proper
use of protective equipment, the applicable skill
3 feet 9 feet procedures, and the policies regarding pregnant
personnel.
Use these boxes to increase your professional competence and confidence,
Figure 3-2 Radiation dose decreases with distance.
(Courtesy of the U.S. Nuclear Regulatory Commission) and to expand your knowledge base.
precautions to avoid exposure. Agency policies and proce- drug at the tumor site, including intrathecal injection and
dures as well as Standard Precautions are followed closely. intracavity instillation. Table 3-5 lists some commonly used
Unsealed sources are not usually radioactive as long as the drugs.
sealed sources. Careful attention is given to intravenous administration.

Chemotherapy
Leakage of fluid from the vein into the surrounding tissues
during infusion is called extravasation. Because most che- COMMUNITY/HOME HEALTH CARE
motherapeutic drugs are irritating to the tissues, extravasa-
Chemotherapy is used to cure, prevent, or relieve cancer tion is a potentially serious problem, especially if the drugs
symptoms. Drugs used in chemotherapy are called anti- administered are vesicants. These agents are so irritating
neoplastics because they inhibit the growth and repro-
duction of malignant cells. To understand how anticancer
drugs work, one must have a basic understanding of the cell
that they can cause blistering and even necrosis. All sites
must be monitored carefully. Pain, swelling, redness, and the
presence of vesicles are all signs of extravasation. Additional
Read these boxes before making a home visit to a client with a given disorder.
cycle. signs include the following:
Almost all anticancer drugs kill cancer cells by affecting
DNA synthesis or function, but they vary in how they exert
their activity within the cell cycle. Most chemotherapeutic
drugs are classified as cell-cycle specific (CCS) or cell-cycle
nonspecific (CCNS).
CCS drugs attack cancer cells when the cells enter a cer-
tain phase of reproduction. These agents are most effective Home Care After Chemotherapy
against rapidly growing tumors. Many of the drugs are “sched- Teach clients receiving chemotherapy to monitor
ule dependent” because they produce a greater cell kill when
the side effects of therapy at home.
given in multiple, repeated doses.
CCNS drugs can destroy cancer cells in any phase • Inspect the skin daily for any signs of rash or
of the cell cycle and are used for large tumors that have dermatitis, which indicates hypersensitivity to a
fewer actively dividing cells. These drugs are not schedule drug.
dependent but, rather, dose dependent. This means that the • Report taste loss and tingling in the face,
number of cells destroyed is determined by the amount of fingers, or toes, which may signal peripheral
drug given. 20 UNIT 1 Essential neuropathy.
Concepts
Anticancer agents are cytotoxic (toxic to cells) and
• Report signs of dizziness, headache, confusion,
destroy both normal and abnormal cells. They are most effec-
tive against cells that reproduce rapidly, such as those Chronic slurred speech,
in bonealcohol use increases surgicalorrisk
convulsions,
because it which
is are signs
Most hospitals use a standard preprinted form. The infor-
often
marrow, gastrointestinal lining, hair follicles, and the accompanied
ova and by impaired nutrition
of central nervous andsystem
liver disease. mation written by the health care personnel is specific to the
(CNS) toxicity.
sperm. Because cells multiply at their most rapid Postoperatively,
rate at the the client may exhibit
• Report delirium
signs of unusual tremens
bleedingor or bruising;
individual client. The client’s signature on the consent form
acutecancer
beginning of the disease, the drugs work best against withdrawal
in syndrome. Furthermore,
fever; sore throat;pain medication
or mouth indicates
sores, which may the information has been read and is correct. The
its earliest stages. may be less effective.
Many of these drugs are given in combination with or
signal developing myelosuppression.
client has the right to refuse treatment even after signing the
consent. When this occurs, the nurse informs the physician
• Report signs of jaundice; yellowing of immediately
the eyes; of the client’s decision.
CULTURAL CONSIDERATIONS
Psychosocial Health
after radiation or surgery to achieve maximum effect. They
clay-colored stools; or dark urine, which signals
are usually given intermittently over an extended period. Drug
resistance can occur. Assessment developing hepatic dysfunction.
Preoperative Teaching
The most common routes of administration are oral
and intravenous. A few drugs are given topically, The psychosocial
neously, or intramuscularly. Recently, other methods
subcuta-
The nursehave
• Report a continued cough or shortness of
health status of the client is also assessed.
breath, which indicates developing pulmonary
elicits the client’s perceptions of surgery and the
fibrosis.
The client about to have surgery is at risk for knowledge deficit
related to preoperative procedures and protocols and postop-
Test your sensitivity to cultural and ethnic diversity by scan-
expectedofoutcome. The nurse also ascertains the client’s cop- erative expectations. The potential benefits of preoperative
been introduced to increase the local concentration the
ing mechanisms and the client’s knowledge level and ability to
understand. The data collected are incorporated into nursing
teaching include reduced anxiety and more rapid recovery with
fewer complications and shorter hospitalization. Reduction in ning these boxes and using the guidelines and suggestions
care throughout the perioperative experience. anxiety has a secondary benefit: The client usually requires less
Cultural beliefs can influence a client’s perception of
surgery. For example, some cultures believe that surgery is a
medication for pain. The purposes of preoperative teaching are
to (1) answer questions and concerns about surgery, (2) ascer- in your practice. You may also want to ask yourself what
“final effort” performed only when all other possible treat- tain the client’s knowledge of the intended surgery, (3) ascertain
ments have been of no avail. Furthermore, surgeries that cause
changes in the appearance of the body can alter body image
the need or desire for additional information, and (4) provide
information in a manner most conducive to learning. biases or preconceptions you have about different cultural
and self-esteem; the client may worry about being sexually One-on-one sessions constitute the most personal
attractive or active after surgery.
The nurse provides an opportunity for the client to
express his spiritual values and beliefs. Many clients wish to
method of instruction, but try to include the family or sig-
nificant other when possible. The level of learning increases
when more than one teaching medium is used. For example,
practices before reading a chapter and then read these
see a member of the clergy before having surgery. using materials such as videotapes, charts, tours, anatomic
models, pictures, and brochures reinforces both visual and boxes for information that may help you be more sensitive
Surgical Consent auditory learning. Demonstration followed by return demon-
An informed consent is a legal form signed by the client
and witnessed by another person that grants permission to
stration is helpful. Written instructions serve as a reference for
later use. Make instructions simple, using terms the client can
understand. Any unfamiliar words or concepts are thoroughly
in your nursing care and approach to clients.
the client’s physician to perform the procedure described by explained.
the physician. An informed consent is needed whenever these Clients are often interested in any information that
situations occur: describes the sights, sounds, tastes, feelings, odors, and tem-
• Anesthesia is used. perature of what they are about to experience. For example, the
• The procedure is considered invasive. feeling of relaxation from preoperative medications; the sounds
• The procedure is nonsurgical but has more than a slight of instruments or equipment in the operating room (OR); the
risk of complications (such as with an arteriogram). pressure from the automatic blood pressure cuff; the warmth or
coolness of skin-preparation solutions; or the brightness of the
• Radiation or cobalt therapy is used. OR lights are all sensations the client may experience. Analogies
Informed consent protects both the client (against or stories of real or fictitious situations of sensory experiences
unauthorized procedures) and the physician and the health help the client understand. The teaching methods used strongly
care facility and its employees (against claims that an unau- influence the client’s learning and retention of information.
thorized procedure was performed). Although the ultimate Preoperative teaching begins as soon as surgery is agreed
responsibility for obtaining the informed consent lies with the upon. Instructions given over the phone and/or mailed to
physician, the nurse often obtains and witnesses the client’s the client during the time leading up to surgery are beneficial.
signature and ensures that the client signs the consent form Just before surgery, a brief review with additional information
voluntarily and is alert and comprehending of the action. tailored to the needs of the client are given. Give the client an
opportunity to ask questions.
Information always is targeted to the client’s needs and
according to the client’s level of knowledge and anxiety.
Mild-to-moderate anxiety actually heightens a person’s alert-
ness and motivates learning. Mildly anxious clients receive
CULTURAL CONSIDERATIONS the most complete instructions. Moderately anxious clients
receive less information but more attention to specific areas of
concern. Severely anxious clients receive only basic informa-
Impending Surgery tion but are encouraged to verbalize their concerns. Clients in
• Some clients desire special religious rites before a state of panic are unable to learn; in such cases, no instruc-
surgery.
tion is given, and the surgeon is notified.
• Some clients may not want to receive blood
transfusions or other treatments. Physical Preparation
• All client beliefs are respected. Extremely close attention is given to identifying the proper
client both verbally and by reading the identification name
CHAPTER 5 Cardiovascular System 123

To heart To heart To heart contributing factors for women include menopause, use of
birth control pills, and high triglyceride level.
Blood Advancing age, male gender, diabetes, heredity, and family
flow history of chest pain or myocardial infarctions are risk factors
that cannot be altered. Alterable risk factors are physical inac-
COURTESY OF DELMAR CENGAGE LEARNING

Contracted
skeletal tivity, smoking, contraceptive method, dyslipidemia, overweight,
muscles Back
flow
obesity, and triglyceride level. A change in diet may alter the
last four factors.
Relaxed
skeletal
There are two objectives in assisting the client toward a
muscles healthier lifestyle: (1) to educate the client about the risk fac-
tors; and (2) to determine what risk factors the client would
A B C
like to modify. Once this is determined, assist the client to
establish goals and determine actions to achieve the goals.
Figure 5-5 Valves in the veins hold the blood at a certain
level in the vein. A, Contracted skeletal muscles apply pressure to
veins and assist with the circulation of blood. B, Valves prevent
the backflow of blood. C, Incompetent valves allow a backflow ASSESSMENT
of blood. Assessment includes clients’ self-report of symptoms as well as
physical findings and confirming lab data.
thinner. The outer layer is reduced to a very thin layer of
connective tissue.
Subjective Data
Capillaries The typical concerns expressed by a client with a cardiac dis-
order are chest pain, dyspnea (difficulty breathing), edema,
Capillaries are very tiny thin vessels that connect the smallest fainting, palpitations, diaphoresis, and fatigue. When a client
arterioles with the smallest venules. They have only one layer talks about having chest pain, ascertain the time of onset, situ-
of endothelial cells whose cell membranes are the semiperme- ation occurring at the onset of pain, location and radiation of
able membrane that allows the exchange of oxygen, nutrients, pain, severity of chest pain, duration, past episodes of chest
carbon dioxide, and waste products between the tissues of the pain, and methods used to alleviate pain. Using the Memory
body and the blood. Trick: Pain Assessment PQRST is an ideal way for a nurse to
assess a client’s pain. This method is described in the Memory
Venules and Veins Trick: Pain Assessment PQRST. Women are more likely to
experience shortness of breath, fatigue, back or jaw pain, and
MEMORY TRICK
Venules are small vessels that emerge from the capillaries and atypical discomfort such as a feeling of indigestion or nausea
gradually increase in size to eventually form veins. Veins have and vomiting (Nagle & Nee, 2002; AHA, 2007b).
three layers or tunics like the arteries, but the middle layer of a The client may be experiencing several types of dyspnea.
vein is thinner with less smooth muscle and elastic tissue. The
elasticity of the smooth muscles allow the walls of the veins
Exertional dyspnea occurs when a person participates in
moderate activity and becomes short of breath. This occurs
Use the mnemonic devices provided in the new Memory
to dilate more easily. Endothelial flaps, called valves, are on in the early stages of HF and indicates that the heart is not
the inside lining of veins. The valves open and close with each
contraction of the surrounding skeletal muscles. The valves
able to meet the demands of the body during moderate activ-
ity. Orthopnea is when a client has difficulty breathing
Trick feature to help you remember the correct steps or
assist the blood in returning to the heart. Blood is held by
the valves until skeletal muscle contractions move the blood
toward the heart against gravity (Figure 5-5).
while lying down and must sit upright or stand to relieve the
proper order of information when working with clients.
MEMORYTRICK
HEALTH HISTORY Pain Assessment PQRST
There are three goals when obtaining a health history from
a client: (1) identify present and potential health problems, P = what provokes the pain (aggravating factors)
(2) identify possible familial and lifestyle risk factors, and and palliative measures (alleviating factors)
(3) involve the client in planning long-term health care. Q = quality of pain (gnawing, pounding, burning,
Ascertain the onset of the symptoms, the predisposing stabbing, pinching, aching, throbbing, and
factors that cause the symptoms, and the client’s treatment crushing)
of the symptoms. Ask about the client’s activity level or
limitations in activity. Determine if appetite has increased or R = region (location) and radiation to other body
decreased. Evaluate the client’s ability to sleep, the need for the sites
trunk of the body to be supported with pillows when sleeping, S = severity (quantity of pain on 0–10 scale, 0 =
or the need to sleep in a chair. no pain and 10 = worst pain experienced) and
Major risk factors associated with cardiovascular diseases
setting (what causes the pain)
are age, gender, heredity (including race), smoking, dyslipidemia
(presence of increased total serum cholesterol and low-density T = timing (onset, duration, and frequency)
lipoprotein [LDL]), high blood pressure, physical inactivity,
overweight, obesity, and diabetes mellitus. An individual’s (Adapted from Estes, 2010)
response to stress may be a contributing factor. Additional

xliv

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HOW TO USE THIS TEXT (Continued)

80 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Medical–Surgical
CLIENTTEACHING Management
Pneumonia Medical
• Discuss pertinent information about medications Clearing the airways of exudate and maintaining adequate
being taken. oxygenation are the goals of treatment for clients with pneu-
• Instruct in measures to prevent spread of infec- monia. Postural drainage and percussion may be ordered to
tion (covering the mouth and nose with a tissue
aid the client in mobilizing secretions. Aerosol or nebulization
treatments may also be utilized, often with added medications.
when coughing or sneezing).
• Encourage disposal of tissues in a closed paper
sack.
The client is encouraged to cough and deep breathe, particu-
larly following respiratory treatments. Incentive spirometry,
which measures the amount of air inspired in one inhalation,
DRUG ICONS
• Outline individual’s specific risk factors (age, is ordered to aid the client when coughing and deep breathing
chronic respiratory condition, cardiac condition). are inadequate (e.g., after surgery) (Figure 4-6). If the client
• Instruct in methods to prevent future infection
(avoiding crowds and obtaining vaccine).
is unable to mobilize secretions, suctioning of the respiratory
tract is indicated. When secretions are overwhelming, the These symbols draw attention to information relating to the pharmacologi-
physician may perform a bronchoscopy in order to remove
• Encourage increase in oral fluid intake, if appro-
priate for client.
them. Intravenous fluids are utilized to maintain adequate
hydration, especially in the presence of fever. Adequate hydra- cal management available for certain disorders. Review these sections to
tion promotes liquefaction of respiratory secretions and thus
aids in their removal. Pulse oximetry or ABGs are done to
assess the level of oxygenation. Supplemental oxygen is used
understand the pharmacological treatments appropriate for your clients’
when oxygenation is inadequate.
or those infected with human immunodeficiency virus (HIV).
Pneumocystis carinii pneumonia can also occur in the immu- Pharmacological
conditions.
nosuppressed client. The invading organism associated with
The treatment of choice for bacterial pneumonia is specific
Pneumocystis carinii pneumonia is thought to be a protozoan.
based on a sputum specimen for culture and sensitivity. It
The infecting microorganisms that cause pneumonia are
should be obtained before initiating antibiotic therapy. After a
spread by airborne droplets or direct contact with infected
specimen has been obtained, the physician may start therapy
individuals or carriers.
with a broad-spectrum antibiotic. If laboratory data indicate
Chemical pneumonia is caused by entry of irritating sub-
stances into the pulmonary passageways. A common source of
chemical pneumonia is the aspiration of gastric contents. Inhala-
tion of irritating substances can also result in a chemical pneu-
monia. Pneumonia is now classified according to the causative
factor rather than the area of the lung affected (e.g., aspiration
COLLABORATIVE CARE
pneumonia). The right middle and lower lobes are affected by
pneumonia more frequently than the right upper and left lobes
These boxes explain which other health care
COURTESY OF DELMAR CENGAGE LEARNING

because of the anatomy of the right bronchus and the effects of

gravity.
A high fever of sudden onset is often the presenting
complaint of the client. The elderly client, however, may be
seriously ill and have only a low-grade fever. A productive professionals may be involved in the compre-
cough yielding abnormally thick and discolored sputum
may be present. Associated respiratory symptoms include
dyspnea, coarse crackles, and diminished breath sounds.
hensive care offered to clients. Review these
Most clients complain of pleuritic chest pain, which is stab-
bing in nature and increases on inspiration. Pain occurs
as a result of irritation of the pleura lying adjacent to the
Figure 4-6 An Incentive Spirometer boxes and ask yourself if you understand how
affected alveoli.
In the case of bacterial pneumonia, white blood cell
count increases and may go as high as 40,000/mm3. Pneu-
your role as a nurse will complement the care
COLLABORATIVECARE
monia caused by viruses or mycoplasms may produce a
normal or a lowered white blood cell count. Chest x-ray provided by others on the health care team.
reveals consolidation in the affected areas. Bacterial pneu- Postural Drainage, Medications
monia is likely to produce isolated areas of consolidation on
a chest x-ray, whereas viral and chemical pneumonia appear Respiratory therapists work together with nurses
as more diffuse areas of consolidation. Arterial blood gases in providing postural drainage for clients with
(ABGs) may reveal a decrease in PaO2 or oxygen saturation
caused by interference with gas exchange. Pulmonary func-
tion tests (PFTs) are usually within normal limits unless
568
pneumonia

also collaborate
UNIT
or other

on Primary
6 Nursing
respiratory

administering
problems
Care ofwhen
exudate drainage from the lungs is desired. They
aerosol
the Client: Body Defenses

or to therapy for those

INFECTION CONTROL
200 or less. prophylaxis refers
the client has an underlying pulmonary disorder such as nebulized medications.
considered at risk for PCP based on the CD4 count to prevent
emphysema. infection with PCP. Secondary prophylaxis refers to therapy INFECTION CONTROL
to prevent recurrences in clients who have already had PCP.
Current guidelines recommend either oral sulfamethoxazole-
When reading a chapter, stop and pay atten-
trimethoprim or aerosolized pentamidine for prophylaxis. TB
For those allergic to sulfamethoxazole-trimethoprim, pent-
amidine diluted in sterile water administered by a Respigard II
A densely woven, snug-fitting mask (N95 partic-
ulate respirator) should be worn by all persons
tion to these features and ask yourself, “Had
nebulizer can be used. in contact with the person who has TB until the
person has received treatment for 2 to 3 weeks.
I thought of that? Do I practice these precau-
HISTOPLASMOSIS Persons with TB should also be taught to cover

Histoplasmosis is an infection caused by the fungus His-

their mouths while coughing and should wear
a particulate respirator when they are out of
tions?”
toplasma capsulatum. The fungus has been isolated in bird
their room for tests.
droppings, dirt from chicken coops, and caves. The spores
from the fungus are introduced into the body by inhalation.
Histoplasmosis is not specific to the lung. In most clients with
HIV disease, histoplasmosis is disseminated (spread out).
Histoplasmosis should be suspected if the person presents The most common test for exposure to TB is the Mantoux
with fever of uncertain origin, cough, and malaise. skin test, which consists of injecting 0.1 mL of (PPD) intrad-
The diagnosis is confirmed by culture or biopsy of the ermally. A negative reaction does not rule out infection. HIV-
bone marrow, blood, lymph nodes, lungs, or skin. Initial treat- positive clients with a CD4 count lower than 200/mm3 may no
ment of histoplasmosis is usually IV amphotericin B. Oral longer have an immune response to the PPD. The chest x-ray
ketoconazole (Nizoral) can be used for maintenance therapy. may reveal middle and lower lobe infiltrates. A sputum specimen
Prophylaxis against recurrence of histoplasmosis is provided is smeared and stained with an acid-fast stain, then examined
by itraconazole (Sporanox). under the microscope for acid-fast bacillus (AFB). Other body
fluids such as urine, blood, and stool may also be tested for AFB.
The risk of transmission of TB to health care workers
TUBERCULOSIS is highest during and immediately after procedures that
induce coughing. In the home and health care setting, cough-
Mycobacterium tuberculosis, an acid-fast aerobic bacterium, is inducing procedures should be performed only in well-
the cause of tuberculosis (TB). It is spread through airborne ventilated areas.
particles and enters the body by inhalation. The particles Because of the upsurge of multidrug-resistant TB
402 UNIT 4 Nursing Care of the Client: Mobility, Coordination,usually
and Regulation
lodge in the apex of the lungs; however, one-half to (MDR-TB), the CDC recommends treating with multiple
two-thirds of cases of HIV-associated or AIDS-associated TB medications. Treatment is provided in two phases. In the
Clinical manifestations of HHNS reflect dehydration involve organs outside the lungs as well. initial treatment phase, the client receives isoniazid (Lani-
and shock. Hyperosmolality eventually results in lethargy, sei- Clinical manifestations include fever, night sweats, cough, azid), rifampin (Rifadin), pyrazinamide, and ethambutol Hcl
zures, and coma (Table 12-6). Blood glucose level ranges from
CLIENTTEACHING
and weight loss. People with AIDS will commonly present (Myambutol) or streptomycin sulfate for 2 to 6 months,
600 mg/dL to 2,000 mg/dL and serum osmolality greater with a productive
Guidelines to Healthy coughFeet
and pleuritic pain. Diagnosis is made depending on whether Mycobacterium tuberculosis is identified
than 350 mOsm/L. by a combination of tests: skin testing with purified protein outside the lungs. In the continuation phase, treatment with
Medical management of DKA and HHNS involves fluid • Washderivative
feet daily and dry
(PPD); them carefully,
examination and culture of sputum, urine, two to four of the medications used in the initial phase is indi-
and electrolyte replacement (particularly potassium), insulin, especially between
and other fluids;the toes.
x-rays; and other tests such as IVP. cated for 4 to 6 months longer.
and treatment of any precipitating factors. DKA and HHNS • Inspect feet and between toes for blisters, cuts,
are associated with significant mortality rates, and the client and infections. Use a mirror to see the bottoms
is usually acutely ill. Treatment will occur in the intensive care of the feet. If your vision is impaired, have a
setting until the client is stabilized. family Nursing
member diagnoses
examine your forfeet.
the HIV-positive
Remember, client with pulmonary disorders

Chronic Complications include

because the following:
of decreased feeling in your feet, you

of Diabetes
may have an infection
NURSING and not know
DIAGNOSES it.
PLANNING/OUTCOMES NURSING INTERVENTIONS
• Avoid Ineffective
activities that restrict blood flow
Airway to thewill mobilize
The client Administer 2.5–3 L of fluid per day (oral or IV) to decrease
Long-term complications of diabetes occur 5 to 10 years feet, especially
Clearance,smoking and sittingsecretions
related to with legs effectively. thick secretions and medications as ordered to suppress
after diagnosis in both type 1 and type 2 diabetes. The exact crossed.
chronic, unrelieved cough, cough and decrease pain.
pathophysiology is not completely understood but is known
to be related to the effects of elevated blood glucose level.
Recent studies have shown that intensive insulin therapy and
• Wear shoes that
pain, or are comfortable,
viscous secretions well-fitting,
and closed toed. Wear new shoes for short
Reposition client every 2 hours and PRN. CLIENT TEACHING
tight glycemic control can reduce or delay the occurrence of intervals until broken
Impaired in. Do not walk
Gas Exchange Thebarefoot.
client will maintain an Administer oxygen as ordered. Encourage use of incentive
many long-term complications associated with diabetes. • Prevent cuts and
related irritations. AlwaysSaO
to inadequate wear
2
> 90% spirometer, if not contraindicated.

Infections
stockings. Look inside shoes for rough edges,
ventilation/oxygenation
nail points, foreign objects. Read these boxes to gain insight into client
Diabetics, particularly clients who are poorly controlled, • Avoid Ineffective
temperature Breathing The client
extremes. Test bath waterwill pace activities Plan care to allow rest periods.
appear to be more prone to developing certain infections.
Infections of particular concern to diabetics include diabetic
Pattern,
with hands related
before to fatigue
getting to minimize
in. Do not
bottles or heating pads on feet.
use waterfatigue. learning needs related to the specific disorder
foot infections, boils, cellulitis, necrotizing fasciitis, urinary Evaluation: Evaluate each outcome to determine how it has been met by the client.
tract infections, and yeast infections. Small cuts on the feet can
become gangrenous (Figure 12-8) and require amputation.
• See your physician regularly and make sure that
your feet are examined each visit.
or condition. You may want to make your own
Infections increase the need for insulin and can result in
ketoacidosis. Infections, once they occur, can often be difficult
to treat and heal slowly because of impaired circulation.
• When toenails are trimmed, cut them straight
across. When corns or calluses are present, see a
physician or podiatrist. Do not cut them yourself.
index cards or electronic notes listing these
Diabetic Neuropathy teaching guidelines to use when you are work-
Neuropathy is the most common chronic complication asso-
ciated with diabetes. The incidence of neuropathy increases
with age and duration of disease and is related to elevated
peripheral circulation place the client at risk for undetected
foot injury.
ing with clients.
blood glucose level. Neuropathy can affect all types of nerves, Autonomic neuropathy can affect almost any organ system,
but the two most common types of diabetic neuropathy are including gastrointestinal (delayed gastric emptying, constipa-
peripheral neuropathy and autonomic neuropathy. tion, diarrhea), urinary (retention, neurogenic bladder), and
Peripheral neuropathy causes paresthesias and burning reproductive (male impotence).
sensations, primarily in the lower extremities. Decreased
sensations of pain and temperature coupled with decreased
Nephropathy (Chronic Renal Failure)
LIFE SPAN CONSIDERATIONS
Diabetic nephropathy develops slowly over many years, pro-
gressing eventually to kidney failure. Elevated blood glucose
level causes a decrease in the glomerular filtration rate result-
ing in fluid retention. Prolonged injury to the nephron may
Use these boxes to increase your awareness of
eventually lead to renal failure. Controlling hypertension and
blood glucose level is the key to delaying renal damage. Good
hydration before and diuresis following any dye study is valu-
variations in care based on client age; this will
able in preventing renal damage. Diligent monitoring of a
help you deliver more effective and appropriate
COURTESY OF DELMAR CENGAGE LEARNING

LIFE SPAN CONSIDERATIONS care.

Diabetic Neuropathy
Advancing age is the strongest risk factor regardless
of disease duration and blood sugar control.
Figure 12-8 Gangrene of the toes and foot as a result of an
infection often means eventual amputation.

xlv

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HOW TO USE THIS TEXT (Continued)
CHAPTER 10 Neurological System 327

Pharmacological
QEPILEPSY/SEIZURE
DISORDER The primary method of controlling seizure activity is phar- SAFETY
macological. Seizure activity is controlled with an anticon-

E pilepsy is a disorder of cerebral function in which the

client experiences sudden attacks of altered consciousness,
motor activity, or sensory phenomenon. Convulsive seizures
vulsant agent or a combination of anticonvulsants in 75%
of clients (Hickey, 2008). Phenytoin (Dilantin), phenobar-
bital (Phenobarbital), carbamazepine (Tegretol), valproic
Pause while reading to consider these elements and
are the most common type. Most recurrent seizure patterns are acid (Depakene), and primidone (Mysoline) are often used.
Anticonvulsant agents are started one at a time in gradually
caused by epilepsy. Most clinicians and authors use the term
“seizure disorder” for epilepsy or seizures (Hickey, 2008).
A seizure is initiated by an electrical disturbance in the
increasing doses. The client’s blood level is monitored for
therapeutic range, and the client is assessed for side effects of
quiz yourself: “Do I take steps such as these to ensure
the drug and signs of drug toxicity, such as drowsiness, dizzi-
neurons, which, in turn, causes an aberrant discharge of elec-
trical activity from any part of the cerebral cortex and possibly ness, gastric distress, rash, blood dyscrasias, and ataxia.
The goal is to obtain seizure control with minimal side
my own and the client’s safety? Do I follow these guide-
from other areas of the brain (Samuels, 2004). This electrical
discharge may cause involuntary episodes of loss of conscious-
ness, excessive muscular movement or loss of muscle tone,
effects. Any anticonvulsant is gradually discontinued. Abrupt
lines in every practice encounter?”
and changes in behavior, mood, sensation, and/or perception
(Smeltzer, Bare, Hinkle, & Cheever, 2008).
The etiology of the electrical disturbance may be birth SAFETY
trauma, hypoxia, infection, tumor, alcohol toxicity, drugs, drug
withdrawal, carbon monoxide or lead poisoning, vascular Precautions During a Seizure
abnormalities such as CVA, hypoglycemia electrolyte imbal- If the client is in bed:
ance, or fever. Often, the cause is idiopathic, or unknown. • Be sure the side rails are up.
Seizures are classified as generalized or partial. In general-
ized seizures, the entire brain is affected simultaneously, caus- • Put padding (blankets) on the side rails to
ing bilateral, symmetrical reactions. Generalized seizures are prevent injury.
classified as tonic and/or clonic (grand mal), absence (petit If the client is out of bed:
mal), or myoclonic. • Carefully ease the client to the floor.
Tonic–clonic seizures involve rigid tonic contractions of mus- • Move nearby objects so that the client will not
cles and loss of postural control followed by a clonic stage of inter-
be injured.
mittent contraction and relaxation. Incontinence of stool or urine
is common. Absence seizures involve loss of conscious activity • Place a soft item beneath the client’s head.
without the muscular involvement of tonic–clonic seizures. Myo- Whether the client is in or out of bed:
clonic seizures are very mild, sudden, involuntary contractions of a • Never leave the client alone.
muscle group or rapid, forceful movements. They usually occur in • Do not restrain the client. CHAPTER 6 Hematologic and Lymphatic Systems 175
the trunk or extremities and involve no loss of consciousness.
Partial seizures initiate in a focal point in the brain and • Do not attempt to put anything in the client’s
involve the function of those specific neurons. Partial seizures mouth after the seizure has begun.
are either simple or complex. In simple partial seizures, the •
SAMPLE NURSING CARE PLAN (Continued)
Loosen any restrictive clothing around the
area affected may be a hand, a finger, the ability to talk, or a client’s neck.
• TurnEVALUATION
sense such as smell. Consciousness is not lost. the client’s head to the side.
Complex partial seizures generally involve loss of conscious- Circulation in lower extremities has improved as manifested by prompt capillary refill and strong pedal
ness and produce cognitive, affective, psychosensory, or psycho- • Monitor seizure activity carefully, noting
and popliteal
the exact time that pulses. Extremities
the seizure began andare warm to touch.
motor symptoms. The client performs inappropriate purposive
behaviors, called automatisms, or mechanical, repetitive motor ended.
NURSING DIAGNOSIS 3 Deficient Knowledge related to prescribed treatment regimen as evidenced
behaviors performed unconsciously, such as lip-smacking. Auras, After the
by seizure:
a lack of rest and working long hours
peculiar sensations that precede a seizure, may take the form of a • Call the client by name and ask to perform a
taste, smell, sight, or sound; dizziness; or a “funny” feeling. After Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
the seizure, the client typically cannot remember the episode.
Diagnostic testing to determine the type of seizure activity
simple command.
Knowledge: Energy Conservation
• Test the client’s memory by asking to remember
Knowledge: Treatment Regimen
Self-Modification Assistance
Teaching: Individual
SAMPLE NURSING CARE PLAN
includes an EEG to identify abnormal electrical activity and/or two words.
the focal point of the seizure. Sleep and video EEGs document • Ask the client whether an aura was experienced
PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
changes in electrical activity of the brain. CT scans identify or before the seizure.
rule out lesions, degenerative changes, or vascular abnormalities. R.T.the
• Check
ment
willoral
relate the prescribedthe
cavity—especially treat- Teach R.T. the pathophysiology
related to sickle cell disease.
Improves compliance with the
medical regimen.
Use this feature to test your understanding and
tongue—for injury.
Medical–Surgical Management regimen
• Offer comfortbefore discharge. as the clientEncourage
and reassurance, is R.T. to take medica- Improves circulation and post-
application of the content presented. Ask yourself:
Surgical frightened and embarrassed. tions as ordered. pones sickle cell crisis situations.
Surgical intervention is indicated for a very small percentage
of clients; those for whom pharmacological treatment has not
• Document everything observed. Explain the importance of avoid-
• Keep the client in a side-lying position if theing stressful situations and the
These situations increase oxygen
demands. “Would I have come up with the same nursing
been effective and when the focal points are identified. Micro- client remains lethargic. symptoms of infection.
surgery is used to irradiate focal points of abnormal electrical
discharge caused by tumor, vascular abnormality, or abscess.
Explain the importance of ad-
equate rest on a routine basis.
Allows adequate oxygenation and
reduces stress.
diagnoses? Are these the interventions that I
EVALUATION
would have proposed? What other interventions
R.T. states his RBCs have Hgb S rather than Hgb A, and a lack of oxygen causes his RBCs to sickle. Sickling
is caused by fatigue, lack of oral fluids, emotional and physical stress, infection, exposure to cold and an- would be appropriate?”
esthesia. He knows the purpose and side effects of each medication and the times he is to take them.
R.T. states he is to avoid high altitudes. R.T. states that he will try to routinely have enough rest.

NURSING DIAGNOSIS 4
Activity intolerance related to imbalance between oxygen supply and demand, as evidenced by
weakness, fatigue, dyspnea, tingling, and numbness
CONCEPT CARE MAPS
NOC: Activity Intolerance

Review these graphical tools to help incorporate

NIC: Exercise Therapy, Prescribed Activity/Exercise

CLIENT GOAL
the interrelatedness of nursing concepts in prepa-
ration for clinical practice.
R.T. will tolerate minimal activity.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Assist R.T. as needed with activities of 1. Conserves energy resources.
daily living.
2. Teach R.T. the importance of alternating 2. Conserves energy.
periods of rest with activity.

234 UNIT 3 Nursing Care of the Client: Digestion and Elimination

EVALUATION
continue using it in the hospital. The nurse assesses pain Postoperative complications
Is R.T. are nausea
conserving and dumping
his energy by alternating periods
of rest with activity?
regularly, monitors PCA use, and obtains appropriate orders syndrome. The nurse assesses for abdominal distension,
to manage pain (Sammons, 2002). If an NG tube is in place, diarrhea, cramping, hypotension, flushing, and tachycardia
the nurse does not reposition the NG tube as the movement Concept
indicating CareofMap
symptoms 6-1 syndrome that last 20 to
dumping
may damage the suture line. The client takes sips of water and, 30 minutes. Dumping syndrome is a common side effect
if tolerated, slowly progresses to eating very small portions of caused by eating simple sugars. It is a benign problem that
pureed food or juices. The nurse teaches diet modifications possibly can be modified by decreasing the ingestion of
and exercise to assist the client in controlling weight. Weight simple sugar.
loss is a lifetime challenge.

CASE STUDY
CASE STUDY
R.J. is a 52-year-old woman admitted to the hospital with acute abdominal pain. R.J. complains of right upper
quadrant pain radiating to the back. She has had previous episodes, usually occurring about 2 hours after eat-
ing. This episode, however, is not resolving. R.J. also complains of nausea. Her vital signs are BP 152/88 mm Hg,
Read over these boxes within the text. Draw on
pulse 92 beats/min, and respirations 24 breaths/min and shallow. R.J. is a slightly obese female who states she has
recently been dieting to lose weight. Laboratory analysis includes a CBC with slightly elevated WBCs, elevated the knowledge you have gained and synthe-
bilirubin, and elevated alkaline phosphatase. An IV is started, and R.J. is given meperidine (Demerol) IM for pain.
R.J. has been made NPO. An ultrasound of the gallbladder is ordered. size information to develop your own educated
The following questions will guide your development of a nursing care plan for this case study.
1. List subjective and objective data a nurse would want to obtain about R.J.
2. List risk factors other than those R.J. has that would put a client at risk for developing cholecystitis.
responses to the case study challenges.
3. List two nursing diagnoses and goals for R.J.
4. The ERCP is successful in removing the CBD stone. The decision is made to perform a laparoscopic cholecystectomy.
What teaching will R.J. need?
5. Why is meperidine (Demerol) the medication of choice for pain control? SUMMARY
6. List at least three successful outcomes for R.J.

SUMMARY
Carefully read the bulleted list to review key con-
• The gastrointestinal system is a complex system composed • Inflammatory bowel disease includes both Crohn’s cepts discussed. This is an excellent resource
of the digestive tract as well as accessory organs. disease and ulcerative colitis. IBD can lead to
• Disorders of the GI tract affect the breakdown and
absorption of nutrients, breakdown of wastes and
nutritional imbalances, bowel obstructions,
alterations in the structure of the intestine, and
when studying or preparing for exams.
by-products, and the lifestyle of the individual. affected lifestyle.
• Because the liver is responsible for so many functions in • Bowel obstructions have multiple causes and can lead
the body, disorders of the liver can affect other systems to electrolyte imbalances, dehydration, and possibly
significantly.
• Peptic ulcers may be either gastric or duodenal. H. pylori is
sepsis.
• Viral hepatitis is a concern for health care professionals at REVIEW QUESTIONS
a common cause of ulcers and can be treated with risk for exposure. Standard precautions must be used to
antibiotics. prevent the transmission of the virus.
• Diverticulosis is a commonly occurring disorder in the • Colorectal cancer is one of the most preventable forms of
United States and is believed to be caused by a low-fiber diet. cancer if routine screenings are performed. Test your knowledge and understanding by
REVIEW QUESTIONS ®
answering the NCLEX -style review questions
with each chapter. These are an excellent way
1. A client with a bleeding esophageal varix: 4. will not need follow-up once the bleeding has
1. should be encouraged to vomit the blood to
decrease abdominal distention and pressure.
stopped.
2. A client with a perforated duodenal ulcer:
to test your mastery of the concepts covered in
2. should have an NG tube placed to suction blood
from the stomach
1. requires an EGD to repair the perforation.
2 may need diet modification after surgery
the chapter, and a good opportunity to become
®
familiar with answering NCLEX -style review
questions.

xlvi

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HOW TO USE STUDYWARE™ TO
ACCOMPANY FOUNDATIONS
OF ADULT HEALTH NURSING,
THIRD EDITION

Minimum System Requirements

• Operating systems: Microsoft Windows XP w/SP 2,
StudyWARE ™ is a trademark used herein under license.
Windows Vista w/ SP 1, Windows 7
• Processor: Minimum required by Operating System
® ®
Microsoft and Windows are registered trademarks of the
Microsoft Corporation.
• Memory: Minimum required by Operating System
• Hard Drive Space: 500 MB ®
Pentium is a registered trademark of the Intel Corporation.
• Screen resolution: 1024 ⫻ 768 pixels
• CD-ROM drive Getting Started
• Sound card and listening device required for audio ™
The StudyWARE software helps you learn terms and con-
cepts in Foundations of Adult Health Nursing, third edition.
features
As you study each chapter in the text, be sure to explore the
• Flash Player 10. The Adobe Flash Player is free, activities in the corresponding chapter in the software. Use
and can be downloaded from http://www.adobe
.com/products/flashplayer/ ™
StudyWARE as your own private tutor to help you learn
the material in your Foundations of Adult Health Nursing, third
edition textbook.
Set-Up Instructions Getting started is easy! Install the software by following
the installation instructions provided above. When you open
1. Insert disc into CD-ROM drive. The StudyWARE
installation program should start automatically. If it
™ the software, enter your first and last name so the software can
does not, go to step 2. store your quiz results. Then choose a chapter or section from
the menu to take a quiz or explore media and activities.
2. From My Computer, double-click the icon for the CD
drive.
3. Double-click the setup.exe file to start the program.

Technical Support
Telephone: 1-800-648-7450
8:30 A.M.-6:30 P.M. Eastern Time
E-mail: delmar.help@cengage.com

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HOW TO USE STUDYWARE™ (Continued)

MENU

You can access the menu from wherever you are in the program. The
menu includes Animations, Video, Heart & Lung Sounds, Chapter Activi-
®
ties for all didactic chapters, and NCLEX -style Quizzes for each major
unit. You can also access your scores from the button to the right of the
main menu button.

ANIMATION

This section on your StudyWARE™ CD-ROM provides 35

multimedia animations of biological, anatomical, and phar-
macological processes. These animations visually explain
some of the more difficult concepts and are an engaging
resource to support your understanding.

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HOW TO USE STUDYWARE™ (Continued)
VIDEO

A selection of 20 high quality video clips on topics

ranging from infection control to the cardiovascular
and respiratory systems has been provided. Click on
the clip you would like to view, then click on the play
button on the media viewer in the center of the screen.
These video clips, many of which were developed by
Concept Media, are a wonderful resource to help visu-
alize difficult processes and skills.

HEART & LUNG SOUNDS

This searchable multimedia program provides a com-

prehensive library of audio files for different heart
and lung sounds that will be encountered by nurses.
Sounds can be viewed according to category or spe-
cific sounds can be found by using the alphabetical
term search function. In addition to hearing the sounds,
related information about etiology and auscultation is
provided.

CHAPTER ACTIVITIES

For each chapter from Foundations

of Adult Health Nursing, third edition,
games and activities are provided to
help you master the glossary terms in
a fun and interesting way. Concentra-
tion is a memory game that asks you to
flip cards to match definitions with their
terms. Flash Cards allow you to test
your knowledge of a term by reading the
term, thinking about the definition, then
checking the actual definition. Hangman
follows the traditional hangman game
format and can be played by one or
two players, challenging you to fill in the
blanks for a term before the puzzle is
completed. Crossword Puzzles provide
definitions of key terms as clues so you
can fill in the appropriate term and clear
the board.

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HOW TO USE STUDYWARE™ (Continued)

QUIZZES

For each unit in Foundations of Adult Health

Nursing, third edition, both practice and live
quizzes are provided to test your understanding
of critical concepts. The quiz program keeps
track of your answers and a report can be gen-
erated at the end of the quiz outlining the ques-
tions, your answers, and the correct answers.
Once the quiz has been completed, click on the
Scores button for these details. Use the ques-
tions you missed as topic areas for additional
study.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
UNIT 1 Essential Concepts
Chapter 1 Anesthesia / 2

Chapter 2 Surgery / 15

Chapter 3 Oncology / 44

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 CHAPTER 1
Anesthesia

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of anesthesia:
Adult Health Nursing
• Surgery

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe the difference between regional and general anesthesia.
• Identify the purposes of sedation.
• Describe the effects of sedation or general anesthesia on memory and
cognitive function.
• Discuss the types of monitoring necessary to ensure client safety during
sedation.
• Describe the signs and symptoms and risks of oversedation.
• Discuss the dangers involved in aspiration of gastric contents and how
gastric aspiration is prevented during anesthesia.
• List the medications that are typically given on the day of surgery.
• List and describe the different types of regional anesthesia.
• Describe the risks involved with regional and general anesthesia.
• Discuss the residual effects of anesthesia on the client.
• List three methods of postoperative pain management and explain briefly
how each is administered.

KEY TERMS
amnesia anesthetist regional anesthesia
analgesia capnography sedation
anesthesia general anesthesia synergism
anesthesiologist orthostatic hypotension

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 CHAPTER 1 Anesthesia 3

INTRODUCTION
Anesthesia refers to the absence of normal sensation. Anal-
gesia refers to pain relief without producing anesthesia. The
delivery of general anesthesia to prevent pain during surgery
began in the United States in the 1800s. When surgeons began

COURTESY OF DELMAR CENGAGE LEARNING

using anesthesia routinely, they soon realized the need for
someone trained in its administration and turned to the nurses
with whom they worked daily. Early nurse anesthetists were
trained on the job by the surgeons with whom they worked.
Anesthesia is now a specialty of both nursing and medicine.
Experienced registered nurses (RNs) with a baccalaureate degree
can become certified registered nurse anesthetists (CRNAs) after
completing two or more years of graduate education in nurse anes-
thesia. In November 2001, the Centers for Medicare and Medicaid
Services (CMS) published an anesthesia care rule stating a gover-
Figure 1-1 A nurse prepares a client for anesthesia and
surgery.
nor could notify CMS of the desire to opt out of the federal physi-
cian supervision requirement for nurse anesthetists administering nursing staff who cares for the client both before and after
anesthesia to Medicare clients (AANA, 2000). Since then, 13 surgery (Figure 1-1). The client may undergo general (total
states have opted out of the supervision rule (AANA, 2005). body) anesthesia, where the control of body functions is tem-
Today there are more than 37,000 CRNAs who adminis- porarily lost; regional anesthesia, where a region of the body
ter more than 30 million anesthetics in the United States each is made insensible to pain; or local anesthesia, where only a
year and are the only anesthesia providers in two-thirds of all small area of the body is made insensible to pain.
the U.S. rural hospitals (AANA, 2009). CRNAs often work in
Oral Intake
groups with anesthesiologists.
An anesthesiologist is a licensed physician educated
and skilled in the delivery of anesthesia who also adds to the Normally, only air should enter the trachea and lungs. The
knowledge of anesthesia through research or other scholarly body prevents foreign material from entering the trachea by
pursuits. An anesthetist is a qualified RN, dentist, or physi- coughing forcefully when something other than air enters
cian who administers anesthetics. or by tightly closing the vocal cords to prevent entry of the
Before administering an anesthetic, the anesthesia pro- foreign substance. Anyone who has ever drank something and
vider assesses the client’s health status, discusses the risks and had it go down the trachea knows how uncomfortable it is and
benefits of anesthesia with the client, and plans an anesthetic how hard the body works to cough up the foreign substance.
appropriate for the client and the surgical procedure. Surgical General anesthesia removes a person’s ability to guard
nurses prepare clients to talk with their anesthesia providers the airway by coughing or closing the vocal cords. Passive
by encouraging them to ask any questions they have about regurgitation of stomach contents into the back of the throat
anesthesia and the care they will receive. can occur at any time during the delivery of general anesthesia.
The use of anesthesia is essential to the health and well- Aspiration of gastric contents into the lungs can cause signifi-
being of clients undergoing surgery. Although anesthesia pre- cant illness or death. An important step in preventing aspira-
vents any sensation of pain, it also temporarily eliminates or tion of gastric contents is ensuring that the stomach is as empty
diminishes the client’s ability to control many essential physi- as possible. In the past, adults have been instructed not to eat
ologic functions such as respiration, heart rate, and temperature or drink anything for at least 8 hours before surgery and usually
regulation. In addition to ensuring adequate levels of anesthesia nothing past midnight the night before surgery. More recent
throughout a surgical procedure, the anesthesia provider moni- information, however, strongly indicates that adults need not
tors and, when necessary, controls physiologic functions such go without clear liquids for 8 or more hours before surgery;
as respiratory rate and blood pressure. Before the end of the 2 hours are sufficient (ASA, 1999; ASA, 2007). In fact, the
surgery, the anesthesia provider administers appropriate medi- amount of liquid in a person’s stomach at the time of surgery
cations to ensure that the client is comfortable when emerging may actually be decreased if water is taken a couple of hours
from the anesthetic. Pain may be relieved with local anesthetic
infiltration, opioid analgesics, or nonopioid analgesics.
LIFE SPAN CONSIDERATIONS
PREANESTHETIC PREPARATION Anesthesia for Pediatric Clients
Preparing a client for anesthesia and surgery is a cooperative • Have a parent present when the anesthesiologist
effort involving the surgeon, the anesthesia provider, and the
examines the child and performs the preopera-
CRITICAL THINKING tive assessment.
• Explain the procedure at the child’s level of
Physical Assessment and Anesthesia understanding, such as “This mask will help you
What is the relevance of physical assessment and go to sleep for a while.”
anesthesia? • Allow the child to play with a mask.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
4 UNIT 1 Essential Concepts

CLIENTTEACHING PROFESSIONALTIP
Oral Intake Before Surgery Preanesthetic Care
• Clearly explain to clients those things that • Health care providers explain the risks and ben-
they will or will not be allowed to eat or drink efits of anesthesia and the surgical procedure
before surgery. and have the client sign consent forms before
• Emphasize the need to exactly follow the they administer any preoperative medications.
instructions related to the time at which eating The client must be alert to sign consent forms.
or drinking must cease before surgery. • Complete the preoperative checklist.
• Discuss taking usual medications with doctor • Make sure all preoperative orders are executed,
before surgery. especially those for blood tests, preoperative
medications, and blood from the blood bank.
• Check, verify, and document the presence or
before surgery. Some anesthesia providers still prefer that their absence of drug allergies for each client.
clients not have anything to eat or drink for at least 8 hours • Administer regular daily oral medications with a
before surgery; others may allow water up to 2 hours before. small sip of water as ordered.

Preoperative Medication • Remind the client of the importance of follow-

ing instructions regarding any eating or drink-
Most scheduled medications that a person receives while in ing restrictions.
the hospital or takes at home every day are continued until • Administer preoperative medications at the
the time of surgery. Give oral medications with just enough ordered time. Timing can be crucial to achieving
water to swallow them, even when a client is having surgery
the desired effect at the correct time.
first thing in the morning. The anesthesia provider usually
writes orders specifying how the morning medication should • If the client responds abnormally to the pre-
be managed. Diabetic drugs and cardiovascular medications operative medication, notify the anesthesia
such as antihypertensives and heart medications are especially department immediately.
important for the client to receive. • Be sure the client’s chart is complete when it
Exceptions to the practice of continuing scheduled medi- goes to the operating room with the client.
cations before surgery include administration of drugs such Recent diagnostic test results are especially
as insulin and oral antihyperglycemics, nonsteroidal anti-
important to include; otherwise, surgery may be
inflammatory drugs (NSAIDs) such as aspirin, and anticoagu-
lants such as heparin or warfarin (Coumadin). Because food delayed while these results are sought.
is withheld, giving insulin or oral antihyperglycemic drugs • Make sure the client’s consents are in order and
is likely to result in a dangerously low blood sugar level. The included in the chart when the client is trans-
way insulin and glucose administration is handled depends ported to surgery.
on the severity of the client’s disease and the preference of
the physician and anesthesia provider. Anticoagulants and
NSAIDs affect clotting. With some types of surgery, the bleed- the INR or PT for Coumadin and APTT or PTT levels for
ing caused by aspirin-like drugs or low-dose heparin is more heparin.
likely. In some cases, no NSAIDs are allowed for 10 days to Additional medications may be ordered to prepare the cli-
2 weeks before surgery. In other circumstances, they are taken ent for surgery or anesthesia. Surgeons often order prophylac-
right up until surgery. Low-dose heparin or heparinoids may tic antibiotics. The anesthesia provider may order a sedative
be given preoperatively to prevent postoperative thromboem- to help the client sleep the night before surgery or to ease the
bolism, but higher doses of heparin and any dose of Coumadin client’s anxiety while waiting for surgery. Opioids like mor-
is stopped before surgery to allow coagulation times to return phine or meperidine (Demerol) also are used for pain relief
to within normal ranges. Coumadin is usually stopped a week or to ease the induction of anesthesia. Atropine may be given
to 10 days before surgery and heparin within a few hours of to decrease oral secretions and prevent aspiration. Some anes-
surgery. Health care providers may order laboratory work the thesia providers prefer to give preoperative medications in the
morning of surgery if the client takes anticoagulants to check operating room to precisely control the medication’s effect on
the client. This is especially true for very sick clients.

LIFE SPAN CONSIDERATIONS Consent

Consent for anesthesia is usually obtained on the same form
Fasting: Infants and Small Children as is surgical consent, or a separate anesthesia consent form
Infants and small children have a high metabolic
may be used instead of or in addition to the combined con-
sent. In either case, for informed consent to be obtained, the
need and tolerate only short periods of fasting,
anesthetic must be discussed with the client by someone with
4 hours or less. expert knowledge of anesthesia, usually an anesthesia provider
or the surgeon.

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 CHAPTER 1 Anesthesia 5

The Joint Commission standards for monitoring clients

SEDATION undergoing procedural sedation require that the BP be mea-
Sedation refers to a reduction of stress, excitement, or irri- sured at frequent and regular intervals and the heart rate and
tability and involves some degree of central nervous system oxygenation be continually monitored by pulse oximetry. They
(CNS) depression. Sedation is used to decrease awareness of also require the continual monitoring of respiratory rate and
events, relieve anxiety, control the physiologic changes that pulmonary ventilation. Cardiac rhythm for clients with signifi-
often accompany anxiety, and ease the induction of general cant cardiovascular disease or predisposition to dysrhythmias
anesthesia. This is welcome news to many clients who fear local is monitored with an EKG ( Joint Commission, 2009).
or regional anesthesia because they do not want to be awake and One method of monitoring pulmonary ventilation is
see and hear anything during surgery or a diagnostic procedure. capnography that measures a client’s carbon dioxide concen-
Different sedatives given in combination have a greater tration. The capnogram displays the CO2 level as a waveform
effect on the client than does any one of the sedatives given (Srinivasa & Kodali, 2008). The individual monitoring the
alone. This phenomenon is called synergism. The synergistic client’s breathing and vital signs is devoted to that task to the
effect that occurs when different sedative drugs are admin- exclusion of any other duties.
istered together makes respiratory depression and uncon-
sciousness more likely. In general, benzodiazepines (diazepam
[Valium] and midazolam hydrochloride [Versed]) are better
Residual Effects of Sedation
Sedation usually persists beyond the duration of the surgical
sedatives than are opioids (morphine and fentanyl citrate procedure. The length of time it takes to recover from sedation
[Sublimaze]). If a client’s anxiety is caused by pain, an opioid depends on the health of the client, the properties of the drugs
is a better choice of sedative because the opioid relieves the used, other drugs the client may be taking, and the amount of
pain that caused the anxiety. sedative drugs administered.
Sedative medications are administered based on the cli- Amnesia (the inability to remember things) produced
ent’s physical condition, weight, mental state, and the proce- by sedatives is commonly found even in clients who appear
dure being performed, with close observation of the effects of to be completely recovered. Such clients will probably not
the drugs on the client. remember any instructions given to them during or soon after
The amount of sedation required by a client for comfort is the procedure. Given that minor procedures and surgery are
always balanced with the amount of stimulation experienced commonly performed on an outpatient basis, some clients
as a result of pain or anxiety. Sedation and general anesthesia may be discharged before regaining the ability to remember
both involve CNS depression; thus sedation and anesthesia verbal instructions. All instructions should thus be given in
exist on a continuum. As sedation becomes deeper and deeper, writing and explained to the person responsible for taking the
it eventually becomes general anesthesia. Sometimes, the line client home. Some facilities put the discharge instructions on a
between sedation and general anesthesia is very difficult to CD-ROM, DVD, or video for the client to take home and review.
distinguish. When sedation becomes general anesthesia, all If heavy sedation was used or the procedure ends sud-
of the risks of general anesthesia are present, including airway denly, the client may remain significantly sedated after the pro-
obstruction, respiratory arrest, and aspiration of gastric con- cedure is over because the CNS stimulation ended while the
tents. For this reason, all but the lightest sedation should be CNS depressant effect of the sedative remains. The client is
administered by an anesthetist or another provider skilled and closely monitored until the effects of the sedative medications
experienced in airway assessment, protection, and manage- wear off enough for the client to wake and become oriented.
ment, as well as assessment of oxygenation and ventilation.

Sedation and Monitoring REGIONAL ANESTHESIA

Sedation is often used to alleviate client anxiety and discom-
fort during procedures performed under local anesthesia. In regional anesthesia a region of the body is temporarily
Properly administered, local anesthetic injection blocks the rendered insensible to pain by injection of a local anesthetic.
painful stimulus of small incisions and minor surgical pro- Local anesthetics are a class of drugs that temporarily block
cedures; however, local anesthetic administration can cause the transmission of small electrical impulses through nerves
significant discomfort because of edema and tissue irritation (Table 1-1). The duration of anesthesia produced by a local
caused by the acidity of the local anesthetic solution. Most cli- anesthetic depends on the drug used, the amount injected,
ents are uncomfortable knowing they are undergoing surgery and into which part of the body the drug is injected. The
and prefer to be less alert during the procedure. Procedural amount of insulation surrounding a nerve fiber, the anatomic
sedation (also known as moderate sedation and conscious location of the fiber, and the diameter of the fiber all influ-
sedation), decreases the client’s perception of these physical ence the ease with which nerve impulses are blocked by local
and mental discomforts. anesthetics.
During local anesthesia and sedation, the client must
remain conscious and in control of his own airway and
breathing reflexes. Oversedation is likely to result in airway
Types of Regional Anesthesia
obstruction and places the client at risk for aspiration of There are three types of regional anesthesia: local anesthesia,
gastric contents. Because sedatives are CNS depressants and, nerve blocks, and spinal and epidural blocks.
thus, respiratory depressants, give supplemental oxygen to
clients during sedation. Monitoring during sedation is done Local Anesthesia
through observation by an individual knowledgeable and Clinically, the use of local anesthetics to block nerves is
experienced in the assessment of respiratory volume and identified by different names depending on the amount of
airway patency. local anesthetic used and where it is injected. When a small

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6 UNIT 1 Essential Concepts

Table 1-1 Drugs Used For

Sedation And Anesthesia SAFETY
Local anesthetics chloroprocaine (Nesacaine) Preventing Choking and Aspiration
procaine (Novocain)
tetracaine (Pontocaine) To prevent choking and aspiration after the use of
bupi vacaine (Marcaine) an oral anesthetic solution (e.g., viscous lidocaine)
dibucaine (Nupercaine, Nupercainal) or spray, fluids and foods must be withheld until
lidocaine (Xylocaine) the gag reflex returns.
prilocaine (Citanest)

General enflurane (Ethrane)

anesthetics halothane (Fluothane) plastic surgery, this type of anesthesia is used over a large area
isoflurane (Forane) of the body. In this case, longer-acting local anesthetics are
used. Because very small amounts of local anesthetics are gen-
Intravenous methohexital sodium (Brevital) erally used, the risk of local anesthetic toxicity is also small.
anesthetics thiopental sodium (Pentothal) Topical anesthesia, achieved with direct application of a
diazepam (Valium) local anesthetic to tissue, is desired in some situations (e.g.,
midazolam hydrochloride (Versed) before insertion of an IV). The anesthetic takes the form of an
fentanyl citrate (Sublimaze) ointment, lotion, solution, or spray.

Adjuncts to succinylcholine chloride (Anectine, Nerve Blocks

anesthesia Quelicin, Sucostrin) When a local anesthetic is injected more deeply into the body
tubocurarine chloride (Tubocurarin) and/or is directed at a specific nerve or nerves, it is called
a nerve block. Nerve blocks are often called by the name of
Adapted from Pharmacology for Nurses: A Pathophysiologic the specific nerve or nerves they block. Examples include an
Approach, by M. Adams, L. Holland, and P. Bostwick, 2008,
Upper Saddle River, NJ: Pearson Prentice Hall.
ulnar nerve block in the arm or a brachial plexus block of all
the nerves in the arm. Nerve blocks are often performed using
lidocaine (Xylocaine), mepivacaine (Carbocaine), or bupiva-
amount of local anesthetic drug is injected either into the
caine (Marcaine) and may last from 1 to 12 hours.
skin and subcutaneous tissues around a cut or at the site of a
needle puncture for a central line placement, it is called local
anesthesia. The anesthetic is not aimed at a specific nerve; Spinal and Epidural Blocks
rather it anesthetizes all small superficial nerves in the target Blocks also are identified according to where the local anes-
area. Local anesthesia is most commonly performed using thetic is injected. One example is an epidural block, for which
lidocaine (Xylocaine) and lasts approximately 1 hour. Serious local anesthetic is injected into the epidural space near the
side effects of lidocaine (Xylocaine) are convulsions, respira- spinal cord to anesthetize several spinal nerves at once. With
tory depression, and dysrhythmias leading to cardiac arrest. spinal blocks (also called subarachnoid blocks), the local anes-
Lidocaine with preservatives or epinephrine are used only for thetic is injected into the cerebrospinal fluid (CSF), where it
local anesthesia and never given for dysrhythmias (Adams, can bathe uninsulated spinal nerves as they exit the spinal cord
Holland, & Bostwick, 2008). Occasionally, for some types of to the periphery of the body (Figure 1-2).

A B C
Anterior Spinous process
Dura mater Vertebral Spinal cord
Subdural space body Supraspinous
Arachnoid ligament
Subarachnoid Intervertebral Interspinous ligament
space foramen Ligamentum flavum
Ventral Epidural catheter
ramus in epidural space
Posterior Epidural space
Dura arachnoid
COURTESY OF DELMAR CENGAGE LEARNING

Transverse Pia Dorsal Subdural space

Spinal ramus
process mater ganglion Cerebrospinal
fluid space
Posterior Epidural space
Vertebral body
Anterior
Spinous process

Figure 1-2 A, Cross-Sectional Anatomy of the Spine; B, Side View of Spinal Anatomy with the Tip of an Epidural Needle Placed in
the Epidural Space; C, Side View of Spinal Anatomy with the Tip of an Epidural Catheter Placed in the Epidural Space

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 CHAPTER 1 Anesthesia 7

down and returns when the individual sits up or stands. Pain

commonly occurs in both the front and the back of the head
and is sometimes accompanied by neck and shoulder stiffness.
Photophobia or double vision may be present with severe head-
ache. The onset of the headache is usually not immediate and
may take 1 to 2 days to become bothersome. Treatment involves
adequate hydration to allow the normal production of CSF;
analgesics; and bed rest in a supine position. One treatment for
significant or persistent PDPH is a procedure called an epidural
blood patch, which involves injecting 15 to 20 mL of the cli-
ent’s own blood into the epidural space. Once the blood clots,
it plugs the hole in the dural membrane. Another treatment
involves connecting an IV infusion to the epidural catheter to
replace the lost CSF and treat the headache.

Sacrum Residual Effects of Regional

Anesthesia

COURTESY OF DELMAR CENGAGE LEARNING

All anesthetics wear off as the drug responsible for causing
the anesthesia is removed, metabolized, and eliminated. Some
effects wear off faster than others. The client may be wide
awake and able to carry on a conversation but have residual
Pelvis Spinous Transverse Vertebra effects that are not detected by casual observation. Motor,
process process sensory and sympathetic residual block effects are common.
Figure 1-3 Correct positions for performing a spinal
block or inserting an epidural catheter into the lumbar area. Residual Motor Block
The assistance of trained personnel is crucial to the proper A motor block is a temporary condition caused when local
positioning, reassurance, and safety of the client. anesthetic blocks nerves that carry instructions to skeletal
muscles telling them to contract. Motor block results in the
Spinal and epidural blocks are generally used to anesthe- inability to move a body part and is usually the last effect
tize a significant area of the body. They are capable of safely to develop and the first to wear off. It results only when the
producing anesthesia sufficient for surgery in the abdomen, regional block is very dense and complete.
pelvis, perineum, or lower extremities. When an epidural A complete motor block results in a temporary paralysis,
block is performed, a catheter is usually inserted into the with the client being incapable of moving the blocked part
epidural space, making it possible to inject additional doses of despite tremendous effort. With a complete motor block,
drug. The client must either be sitting in a bent-over position there is usually no function in any other type of nerve in the
or lying on the side with head and knees as close together as same area. A client with a complete motor block of any part
possible (Figure 1-3). Either position separates the vertebra, of the body would not likely be released from the recovery
making insertion of the needle or catheter possible. Epidural area. Clients experiencing residual (incomplete) motor block
blocks have an added advantage in that by varying the way the may be released from recovery. A client who has had any type
anesthetic is used, the block can produce analgesia (pain relief of block involving the legs is not allowed to get out of bed
without producing anesthesia), complete anesthesia, and even without assistance until it is demonstrated that a complete
profound muscular relaxation (needed for some types of sur- recovery of motor strength in the legs is regained. Even a small
gery). This allows epidural anesthesia to be used not only for amount of residual motor block greatly increases the possibil-
surgical procedures, but also for analgesia during labor and for ity that a client will fall.
postoperative pain relief. As a regional block begins to wear off, motor function
Spinal blocks are most often performed using lidocaine begins to return first, sensation begins to return next, and
(Xylocaine) or bupivacaine (Marcaine) and last from 1 to 3 sympathetic nervous function returns last. Motor function
hours. Epidural blocks are most commonly performed using and sensation is detected easily by asking the client to move
bupivacaine (Marcaine), and the block can be continued as the blocked part or by touching the skin and asking the client
long as local anesthetic is injected through the catheter into whether it feels normal. The return of sympathetic function is
the epidural space. more difficult to detect. Orthostatic hypotension may occur
Opioids such as morphine and fentanyl citrate (Subli- even after motor and sensory functions have completely
maze) may be added to the local anesthetic in either of these returned and the regional block appears to have worn off. To
blocks to intensify the analgesic or anesthetic effect, or to pro- prevent fainting, the nurse assists the client in getting out of
vide postoperative pain relief after the block has worn off. bed until she is able to do so without any dizziness or signifi-
One type of complication is peculiar to spinal and epidural cant decrease in blood pressure.
regional anesthetics. When CSF leaks out through a hole made
in the dural membrane during performance of a subarachnoid
block or an accidental dural puncture during the attempted Residual Sensory Block
performance of an epidural block, a postdural puncture head- Normal sensation may not have returned completely upon client
ache (PDPH) may result. The headache is caused by the loss of discharge from the recovery area. As the regional block wears
CSF from around the brain. The headache is relieved by lying off, sensation returns gradually. As sensation begins to return,

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8 UNIT 1 Essential Concepts

the client experiences a “pins-and-needles” feeling in an arm or Stylet

leg that has been blocked and may feel touch or pressure before Endotracheal tube Laryngoscope
recovering complete sensation. Until complete recovery of
normal sensation, any blocked areas are frequently checked and Esophagus
carefully protected, as the client may be unaware that a finger or
Trachea
hand, for example, is being pinched or denied blood supply.
Nasopharynx
Residual Sympathetic Block
The last nerve fibers to recover as a local anesthetic wears off
are those responsible for carrying instructions to the muscles
that surround blood vessels. When these sympathetic nerves are
blocked, veins and arteries dilate, lowering the blood pressure.
The venous system has a large capacity, and venous dilation

COURTESY OF DELMAR CENGAGE LEARNING

results in the pooling of a large amount of blood. This decreases
the amount of blood that returns to the heart, and the blood
pressure falls. The amount of blood that pools is greatest in parts
of the body that are farthest below the level of the heart. Even in a
client who has had a spinal or epidural block and is lying supine,
a significant amount of venous pooling occurs, resulting in low- 10 cm
er-than-normal blood pressure. If the same client is allowed to sit
up, even more venous pooling will occur, less blood will return
to the heart, and blood pressure will fall substantially. This phe- Figure 1-4 Placing an Endotracheal Tube in the Trachea
nomenon of having a large drop in blood pressure when sitting with Direct Visualization by Laryngoscopy
up or standing is called orthostatic hypotension. Orthostatic
signifies that it involves body position, and hypotension means
low blood pressure. Clients who have had a spinal or epidural produce unconsciousness, and additional anesthetic is then
block are more likely to have orthostatic hypotension the higher inhaled (Table 1-1).
in the spinal column the level of their block. Immediately after the induction of general anesthesia, the
anesthesia provider secures the airway using a cuffed endotra-
cheal tube (ETT) (Figure 1-4). An ETT provides a breathing
GENERAL ANESTHESIA passage from outside the client to within the client’s trachea.
General anesthesia involves unconsciousness, complete
insensibility to pain, amnesia, motionlessness, and muscle Maintenance
relaxation. With general anesthesia, the body also loses the General anesthesia is maintained with some combination of
ability to control many important functions, including the IV and inhaled drugs. Figure 1-5 shows a client connected to
abilities to maintain an airway, control vital functions such an anesthesia machine by a breathing circuit.
as breathing and heart rate, and regulate temperature. These
functions are controlled by the anesthesia provider during
administration of general anesthesia.
General anesthesia involves four overlapping stages:
induction (going to sleep), maintenance, emergence (waking
up), and recovery.

Induction and Airway

Management
The induction of general anesthesia is a short but critical
period during which the client is rendered unconscious, vital
functions are controlled, and enough anesthetic drug is intro-
duced into the body to keep the client asleep during surgery.
In adults, drugs are usually injected into an IV line to quickly

LIFE SPAN CONSIDERATIONS

Figure 1-5 A typical anesthesia machine is a complex
Induction of Anesthesia in Small equipment set. This machine has anesthetic vaporizers and
Children flowmeters to deliver oxygen, nitrous oxide, and air. It also
supports a ventilator and equipment to monitor ventilation,
Inhalation of an anesthetic vapor is used first, then oxygen content of inspired gas, client oxygen saturation, blood
an IV line is started and additional IV drugs are pressure, heart rate, and respiration. (Pictured above is the
administered. Datex-Ohmeda Aestiva/5 Anesthesia Delivery System equipped
with a Cardiocap/5 Monitor.) (Reprinted with permission of
Datex-Ohmeda, Inc.)

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 CHAPTER 1 Anesthesia 9

Skeletal Muscle Relaxation Oxygenation and Ventilation

Some types of surgery require complete relaxation of skel- Almost all anesthetics are respiratory depressants. Benzo-
etal muscles. In these cases, the anesthesia provider admin- diazepines, opioids, and inhalation anesthetic agents have
isters a skeletal muscle relaxant such as pancuronium bromide significant respiratory depressant effects. Any one of these
(Pavulon) or vecuronium bromide (Norcuron) to completely drugs may be used in a dose that causes apnea, or lack of
paralyze the client. These types of drugs prevent clients from respirations for more than 10 seconds, during a general
breathing on their own, requiring the anesthesia provider to anesthesia. When used in combination their effect on
ventilate clients during surgery. Paralysis is eliminated before respiration is at least additive. When the rate or depth of
emergence from anesthesia so the client can breathe indepen- respirations decrease, the elimination of carbon dioxide is
dently again. retarded, and carbon dioxide builds up in the blood and in
Inadequate reversal of paralysis presents as anything from the lungs. Oxygen saturation is monitored by pulse oxim-
total skeletal muscle paralysis to the inability of the client to etry. Even small amounts of supplemental oxygen given to
cough and clear the airway. If the client is having difficulty a client whose rate or depth of breathing is decreased adds
breathing, basic life support is provided until the arrival of an significantly to the amount of oxygen in the bloodstream.
anesthesia provider. This is the most important reason that oxygen is given to
even healthy clients when they are recovering from general
Emergence anesthesia.
Emergence from general anesthesia occurs when anesthetic
drugs are allowed to wear off. The anesthesia provider care- Heart Rate and Blood Pressure
fully controls the timing and amount of anesthetic drug given Few direct effects on heart rate (HR) and blood pressure
in order for the client to emerge from general anesthesia at the (BP) regulation are seen during recovery from general anes-
desired time. The initial phase of emergence is usually quite thesia. Some anesthetic techniques that are heavily based on
quick, allowing the client to awaken enough to respond to opioids, such as fentanyl citrate (Sublimaze) or sufentanil
verbal directions and maintain an airway. After this time, the citrate (Sufenta), can cause a slow HR, but as long as BP is
client’s breathing tube usually is removed, and the client is maintained, no specific treatment is necessary. Although most
taken to the postanesthesia care unit (recovery room). If, for general anesthetics are myocardial depressants, the depressive
some reason, the client is left on a ventilator and with a breath- effects of current agents are mild, especially after anesthetic
ing tube in place, the anesthesia provider takes the client to an administration is ended.
intensive care unit asleep instead of waking the client up from Most HR and BP changes seen during recovery result
the anesthetic. from factors related indirectly to the anesthetic. Both HR
and BP increase as a result of sympathetic stimulation. Pain,
Recovery hypoxia, and fear can all result in sympathetic stimulation
with an increase in HR and BP. Discovering and addressing
Recovery from general anesthesia is not complete simply the source of the client’s fear often reduces the anxiety. When
because the client has regained consciousness. The client the causes of sympathetic stimulation are addressed, HR and
may not remember what has happened for minutes or even BP should normalize.
hours after receiving an anesthetic. The ability to think clearly
often takes longer to return, with some residual thinking dif- Temperature Regulation and Shivering
ficulty persisting for several days or even weeks. Inhalation
anesthetics are eliminated from the body through the lungs, With general anesthesia, the body loses its natural ability to
and very small amounts of anesthetic are still being exhaled regulate temperature. General anesthetic agents dilate the
for several weeks. Many anesthetic drugs are stored in body blood vessels close to the surface of the body, exposing the
fat and released back into the bloodstream very slowly after client’s warm blood to the cool exterior. During anesthetiza-
anesthetic administration has ended. The speed of this release tion, the client is mostly uncovered in a cold operating room,
depends on the amount of anesthetic given during the sur- and the body’s surgical area is cleaned with cold solutions.
gery, the length of the surgery, and how deeply the client is After this is done, the client’s insulating covering (skin and
breathing. subcutaneous fat) is cut open to expose the warm interior
of the body and allow its heat to escape. Room temperature
intravenous (IV) fluids are infused into the veins, and the cli-
LIFE SPAN CONSIDERATIONS ent breathes cool gases. Surgical clients lose a great amount of
heat at a time when the body is least able to respond to warm
the tissues. Hypothermia adds to the CNS depression result-
Oxygenation and Ventilation in the ing from any residual anesthetics. Surface warming with a
Elderly Client forced-air warming blanket is an effective way to increase the
• Impaired mobility allows secretions to pool in the temperature of a client intraoperatively and when recovering
lungs. Therefore, elderly clients must be moni-
from general anesthesia; warm cloth blankets also maintain
body warmth. Figure 1-6 shows use of a forced-air warming
tored more closely, and secretions suctioned.
blanket.
• Most anesthetic agents cause decreased respira- All potent inhalation agents are associated with shivering
tory rate and decreased tidal volume, putting during emergence from general anesthesia when the blood
elderly clients at greater risk for hypoventilation. level of the anesthetic agent is very low. The cause of the
shivering is not clear but does not appear to be related to the
client’s body temperature. (Of course, postoperative clients

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10 UNIT 1 Essential Concepts

POSTOPERATIVE PAIN
MANAGEMENT
Pain has many causes. Postoperative pain results from tissue
injury, release of local and hormonal substances, inflammation,
mental outlook, and, perhaps, neural hyperexcitability related
to excessive noxious input. As such, baseline postoperative
pain, pain from pressure placed on an incision, and pain from
client movement each respond best to different pain-relieving
strategies.
The amount of medication needed to relieve pain
depends on the intensity and type of pain, the size of the cli-
ent, and the client’s age. The opioid dose for an elderly client
is started at 25−50% of the usual adult dose and then slowly
increased by 25–50% increments until the client reports a
mild pain level (McDonald, 2006). The opioid of choice
for elderly is morphine with hydromorphone hydrochloride
(Dilaudid) as the second choice (McDonald, 2006). Moni-
tor the elderly closely for opioid toxicity on a pain scale they
understand.

Figure 1-6 A forced-air warming blanket applied to Patient-Controlled

the upper abdomen, chest, and arms or lower torso of a
client during surgery. The unit on the floor to the left of the Analgesia
anesthesia provider (foreground) is the heating unit, which Patient-controlled analgesia (PCA) allows clients to self-
contains a fan that pushes warm air through the hose and into administer pain medication by pushing a button when they
the blanket, much like a furnace pushes warm air through experience pain. After an IV catheter is in place, a client-
heating ducts and into a house. Warm air exits hundreds of controlled analgesia pump is connected “piggyback” to the
pinholes on the surface of the blanket and next to the client. IV line. The pump is programmed to deliver a predetermined
(Courtesy of Mallinckrodt Medical, Inc.) dose of morphine, hydromorphone hydrochloride (Dilau-
did), or fentanyl citrate (Sublimaze) when the client pushes
also shiver when they are cold.) The key to eliminating shiver- a button. It will not, however, deliver unlimited amounts. A
ing postoperatively is to ensure client warmth and encourage set time must pass between each successive dose, and when
deep breathing so that the anesthetic is eliminated as quickly the total dose of opioid delivered in any hour reaches a preset
as possible. limit, the pump will not deliver any more medicine until the
next hour. This is referred to as lockout.
Properly programmed, PCA allows the client a great
Fluid Balance deal of control over when pain medicine is received, which
Surgical procedures and the injuries that necessitate them is likely to help decrease anxiety. Patient-controlled analgesia
have major effects on the body’s distribution of fluid. Appro- also results in a shorter interval between the need for pain
priate care during anesthesia sometimes necessitates the medicine and its administration, better pain relief than that
delivery of a large volume of IV fluid. This IV fluid does not obtained with intermittent IM injections, and a reduction in
stay in the vascular system long, moving out of the vascular nursing time necessary for the delivery of pain medicine. It
space to replace losses from the interstitial and intracellular does not, however, decrease the need for client assessment of
spaces. pain while the PCA machine is in use.
Trauma, whether caused by an accidental injury or a sur-
gical incision, results in fluid losses or shifts in three general
areas as follows: direct blood loss, evaporation through the Regional Analgesia
surgical wound, and fluid shifts. Large volumes of fluid are Regional analgesia and anesthesia have many applications in
lost to the air through the surgical wound, especially during the relief of postoperative pain. Regional anesthetics do not
abdominal procedures. A major abdominal procedure, for cease working when the surgery ends and provide pain relief for
example, can result in the loss of up to 10 mL/kg/hour of fluid a variable period of time afterward. The duration of postopera-
by evaporation. tive pain relief can be extended by continuing the infusion of
pain medication into the epidural space or by adding opioids
to either epidural or spinal anesthetics.
CRITICAL THINKING

Client Monitoring After Anesthesia Local Anesthetics

Local anesthetics, either alone or in combination with opioids,
Why must clients be monitored very closely after are administered into the epidural space at low concentrations
receiving an anesthetic? that do not cause complete anesthesia. This type of pain relief
is most commonly used for women in labor who receive
epidural analgesia. Local anesthetic in low concentrations is

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 CHAPTER 1 Anesthesia 11

CLIENTTEACHING PROFESSIONALTIP
Patient-Controlled Analgesia (PCA)
Postanesthetic Care
• Only the client should push the button to
administer more analgesic. • Immediately report to the anesthesia provider
or surgeon any client breathing difficulty or a
• The client should not ask visitors to push the
respiratory rate of 12 breaths per minute or less.
button.
• Immediately report to the surgeon or the anes-
thesia department a fall in the client’s BP or
increase in HR.
a powerful analgesic. If local anesthetic is administered in a • Verify client’s ability to stand or walk with nor-
way to relieve pain in the lower extremities, clients are usually
mal motor strength and coordination and with-
confined to bed, because even dilute concentrations of local
anesthetic may affect the strength of leg muscles enough to out any dizziness before allowing the client to
increase the risk of falling. Clients receiving analgesia via an get up without assistance.
epidural block are watched carefully to ensure that they do • Do not allow clients to rub their eyes. Clients
not develop pressure necrosis in the blocked areas. who are still drowsy may try to rub out protec-
tive eye moisturizer and, in the process, cause
Opioids painful corneal abrasions.
The spinal cord has receptors for opioids, and when opioids • Observe clients immediately and hourly for
are added to a spinal or epidural anesthetic, they provide pain bladder distention. Both regional and general
relief even after the anesthetic block has worn off. Morphine anesthesia can sometimes cause temporary uri-
added to a spinal or epidural anesthetic provides hours of nary retention.
postoperative pain relief, often enough so that no other pain
• If clients have an epidural catheter for post-
medication is needed; it may even provide better pain relief
than do IM injections or intravenous PCA. Opioids are added operative pain management, ensure that they
to spinal or epidural anesthetics as a single dose or be infused change positions from time to time to prevent
into the epidural space postoperatively. Although spinal and pressure necrosis. Do not allow the lateral
epidural morphine provide excellent pain relief, they may aspect of the leg to rest on the side rails.
also produce significant respiratory depression. Fortunately, • Report to the anesthesia department as soon
the respiratory depression after spinal or epidural morphine as possible any headache that gets worse when
administration is rarely rapid in onset. Respiratory depression the client sits up or stands.
is very rare with properly dosed epidural or spinal fentanyl
citrate (Sublimaze). With current client selection and dos- • Before giving discharge instructions, verify that
ing protocols, life-threatening respiratory depression is a rare the client’s ability to remember instructions has
event. When it does occur, it can be detected long before it returned. Always share discharge instructions
causes harm, by observing the client frequently, noting respi- with the individual responsible for taking the
ratory rate and depth, and periodically measuring oxygen client home and provide the client with a writ-
saturation by pulse oximetry. ten copy of the instructions.

SUMMARY
• In addition to ensuring an adequate level of anesthesia • General anesthesia produces unconsciousness, complete
throughout a surgical procedure, the anesthesia provider insensibility to pain, amnesia, motionlessness, and muscle
monitors and controls physiologic functions. relaxation.
• Some anesthesia providers prefer that clients not have • A person is unlikely to remember what has happened for
anything to eat or drink for at least 8 hours before surgery. minutes to hours after sedation or a general anesthetic.
Others allow water up to 2 hours before surgery. • Intravenous patient-controlled analgesia (PCA) allows
• Most scheduled medications that a client takes every day clients to self-administer pain medication by pushing a
are continued up to and including the morning of surgery. button on the PCA machine. Limits are programmed into
• Sedation depresses brain activity, decreasing awareness, the machine to prevent overdose.
reducing anxiety, and easing the induction of general • Local anesthetics, alone or in combination with
anesthesia. opioids, can be injected into the epidural space at low
• Oversedation results in respiratory depression, which can concentrations to provide postoperative analgesia.
cause airway obstruction, and places the client at risk for • Spinal and epidural morphine can produce dangerous
aspiration of gastric contents. respiratory depression. This can be detected by frequent
• Regional anesthesia by the injection of a local anesthetic observations of the client’s respiratory rate and depth and
temporarily renders a “region” of the body insensible to by periodic measurement of oxygen saturation via pulse
pain. oximetry.

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12 UNIT 1 Essential Concepts

CASE STUDY
C.P. is in the recovery room after outpatient surgery. She received a general anesthetic and is now awake, breath-
ing deeply, and talking to the staff. She has received morphine sulfate intravenously and is quite comfortable.
Before being discharged home from the surgery center, C.P. rests in an easy chair in the transitional recovery
area. The nurse taking care of her notices that she asks questions about things that have already been discussed
and has even asked one question three times.
The following questions will guide your development of a nursing care plan for the case study.
1. After making these observations, what nursing diagnoses and goals might the nurse identify for C.P.?
2. List nursing interventions in caring for C.P.
3. Identify teaching approaches.

REVIEW QUESTIONS
1. Clients are at risk for aspiration of gastric contents 3. Inhibition of protective airway reflexes.
into the lungs when receiving a general anesthetic 4. Sore muscles.
because: 6. A client returned from surgery and has a PCA for
1. general anesthesia causes stomach distention. pain. The main purpose of the PCA is:
2. general anesthesia eliminates protective airway 1. the client controls pain medication
reflexes. administration.
3. gastric peristalsis is reversed during general 2. so the nurse does not have to stop caring for
anesthesia. another client to administer medication to the
4. vomiting normally occurs during general client in pain.
anesthesia. 3. better pain relief for the client than intermittent
2. The most dangerous result of oversedation is: IM injections.
1. lack of response to verbal directions. 4. less time needed to assess the client’s pain level.
2. longer recovery time and resultant delayed discharge. 7. A client is given fentanyl citrate (Sublimaze) with
3. prolonged amnesia. a spinal anesthetic for pain relief. To adequately
4. inability to breathe adequately. assess the client for respiratory depression the nurse:
3. What is a sign that a client has a postdural puncture (Select all that apply.)
headache following a spinal or epidural regional 1. notes respiratory rate and depth.
block? 2. observes the color the mucous membranes.
1. The headache subsides after intake of plenty of 3. measures oxygen saturation with a pulse oximeter
liquids. on a regular basis.
2. The headache begins after the surgical procedure. 4. monitors the client’s ventilation by capnography.
3. The headache worsens when the client sits up or 5. checks apical and peripheral pulses.
stands. 6. observes symmetry of chest wall movements and
4. The client is confused in addition to having a use of accessory muscles.
headache. 8. A client had a regional anesthesia. During
4. After cessation of a general anesthetic, how long postoperative care, the nurse assesses for residual
might it be before the client can think as clearly as effects of the anesthesia by: (Select all that apply.)
before the client received the anesthetic? 1. asking the client questions and listening to his
1. Before being discharged from the recovery room. responses.
2. Within 2 hours. 2. asking the client to move an area blocked by the
3. Six hours. anesthesia.
4. Several days. 3. touching the client’s legs and asking if the touch
5. What effect might a spinal or epidural anesthetic feels normal.
block still have after normal sensation and motor 4. assisting the client to a sitting position and asking
function have returned? if she is dizzy.
1. Decrease in pulse rate when the client is lying in bed. 5. assessing the client’s mental alertness.
2. Decrease in blood pressure when the client stands up. 6. assessing the motor strength in her legs.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 1 Anesthesia 13

9. A client has a nonunion fracture of the fifth phalange and 10. The main priority of the anesthesia provider during
is having a nerve block as the anesthesia. What client a general anesthetic is monitoring the:
statement indicates to the nurse that more teaching is 1. blood pressure at frequent intervals.
needed about the anesthesia and scheduled procedure? 2. oxygenation by pulse oximetry.
1. I may be awake but sleepy throughout the surgery. 3. respiratory rate and pulmonary ventilation.
2. I will not be able to move my lower arm during 4. cardiac rhythm by an EKG.
surgery.
3. I will not have any painful feeling in my lower arm
or hand during surgery.
4. I will be unconscious and put to sleep prior to
and during the surgery.

REFERENCES/SUGGESTED READINGS
Adams, M., Holland, L., & Bostwick, P. (2008). Pharmacology for Berkowitz, C. (1997). Epidural pain control—Your job, too. RN, 60(8),
nurses: A pathophysiologic approach. Upper Saddle River, N.J.: 22–27.
Pearson Prentice Hall. Carroll, P. (2002). Procedural sedation: Capnography’s heightened role.
American Association of Nurse Anesthetists (AANA). (2001). RN, 65(10), 54–62.
Administration puts politics before patients; Implements Clinical News. (1999). “NPO after midnight” outdated? AJN, 99(2), 18.
cumbersome anesthesia care rule. Retrieved on Connolly, M. (1999). Postdural puncture headache. AJN, 99(11), 48–49.
April 2, 2009 at http://www.aana.com/Advocacy. Crenshaw, J. (1999). New guidelines for preoperative fasting. AJN,
aspx?ucNavMenu_TSMenuTargetID=49&ucNavMenu_ 99(4), 49.
TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=2575&ter Joint Commission. (2009). Standards for operative or other high-risk
ms=administration+puts+politics+before+patients%3a+implement procedures and/or the administration of moderate or deep
s+cumbersome+anesthesia+care+rule sedation or anesthesia. Retrieved on April 1, 2009 at http:
American Association of Nurse Anesthetists (AANA). (2002). //www.jointcommission.org/NR/rdonlyres/6530941D-98AD-
New Hampshire becomes fifth state to opt out of federal anesthesia 4AC7-8944-9DDE1116E503/0/OBS_Standards_Sampler_2007_
requirement. Retrieved on April 2, 2009 at http://www.aana.com/ final.pdf
news.aspx?ucNavMenu_TSMenuTargetID=171&ucNavMenu_ Joint Commission Resources. Joint Commission on Accreditation
TSMenuTargetType=4&ucNavMenu_ of Healthcare Organizations. (2000). New definitions, revised
TSMenuID=6&id=690&terms=opt+out standards address the continuum of sedation and anesthesia. Joint
American Association of Nurse Anesthetists (AANA). (2005). Commission Perspectives, 20(4), 10.
Governor Rounds removes physician supervision for South Dakota Kodali, B. (2008). Capnograms during procedural sedation. Retrieved
CRNAs. Retrieved on March 31, 2009 at http://www.aana.com/ on April 1, 2009 at http://www.capnography.com/new/index.
news.aspx?ucNavMenu_TSMenuTargetID=62&ucNavMenu_ php?option=com_contetn&view=article&id+245&
TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id= Kost, M. (1999). Conscious sedation: Guarding your patient against
854&terms=opt+out complications. Nursing99, 29(4), 34–39.
American Association of Nurse Anesthetists (AANA). (2008). Kreger, C. (2001). Spinal anesthesia and analgesia. Nursing2001, 31(6),
Education of nurse anesthetists in the United 36–41.
States–At a glance. Retrievedon March 31, 2009 McDonald, D. (2006). Postoperative pain management for the aging
at http://www.aana.com/BecomingCRNA. patient. Geriatrics Aging, 9(6), 395-398.
aspx?ucNavMenu_TSMenuTargetID=18&ucNavMenu_ Messinger, J., Hoffman, L., O’Donnell, J., & Dunworth, B. (1999).
TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1018 Getting conscious sedation right. AJN, 99(12), 44–49.
American Association of Nurse Anesthetists (AANA). (2009). O’Donnell, T., Bragg, K., & Sell, S. (2003). Procedural sedation: Safely
Qualifications and capabilities of the certified registered navigating the twilight zone. Nursing2003, 33(4), 36–41, 44.
nurse anesthetist. Retrieved on March 31, 2009 Pasero, C., & McCaffery, M. (1999). Providing epidural analgesia.
at http://www.aana.com/BecomingCRNA. Nursing99, 29(8), 34–39.
aspx?ucNavMenu_TSMenuTargetID=102&ucNavMenu_ Scott, J., & Stanski, D. (1987). Decreased fentanyl and alfentanil
TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=112 dose requirements with age: A simultaneous pharmacokinetic
American Society of Anesthesiologists (ASA). (1999). 1998 House and pharmacodynamic evaluation. Journal of Pharmacology and
of delegates passes two new practice guidelines. Retrieved on Experimental Therapeutics, 240, 159–166.
March 31, 2009 at http://www.asahq.org/Newsletters/1999/ Srinivasa, V., & Kodali, B. (2008). Applications of capnography.
02_99/1998_0299.html Retrieved on November 6, 2009 at http://www.capnography.com/
American Society of Anesthesiologists (ASA). (2007). Revised outside/sedation.htm
guidelines issued for anesthesia, pain relief during labor and Wong, D. (2003). Topical local anesthetics. AJN, 103(6), 42–45.
delivery. Retrieved on March 31, 2009 at http://www.asahq.org/ Woomer, J., & Berkheimer, D. (2003). Using capnography to monitor
news/asanews040207.htm ventilation. Nursing2003, 33(4), 42–43.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
14 UNIT 1 Essential Concepts

RESOURCES
American Association of Nurse Anesthetists, Anesthesia Patient Safety Foundation,
http://www.aana.com http://www.gasnet.org/societies/apsf/
American Society of Anesthesiologists, Foundation for Anesthesia Education and Research,
http://www.asahq.org http://www.faer.org
American Society of Peri Anesthesia Nurses, Society for Education in Anesthesia, http://www.seahq.org
http://www.aspan.org
American Society of Regional Anesthesia and Pain
Medicine, http://www.asra.com

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 CHAPTER 2
Surgery

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of perioperative nursing:
Adult Health Nursing • Cardiovascular System
• Anesthesia • Musculoskeletal System
• Respiratory System • Integumentary System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• List risk factors in a preoperative nursing assessment.
• List information in a general teaching plan for a preoperative client.
• Identify common nursing care for the preoperative, intraoperative, and
postoperative phases.
• Describe the principles of asepsis and their application to nursing practice.
• Discuss nursing interventions to prevent or treat postoperative complications.
• Identify information needed by the postoperative client before discharge.
• Discuss the physiologic changes of aging that affect the elderly client’s
response to surgery.
• Plan care for a postoperative client.

KEY TERMS
Aldrete Score evisceration preoperative phase
ambulatory surgery first assistant scrub nurse
asepsis informed consent sterile
aseptic technique intraoperative phase sterile conscience
circulating nurse perioperative sterile field
dehiscence postoperative phase surgery

15

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16 UNIT 1 Essential Concepts

the client’s illness, physical condition, related medical condi-

INTRODUCTION tions, and current surgical diagnosis. Regardless of how minor
Surgery refers to the treatment of injury, disease, or deformity the surgical procedure, a thorough health history is essential
through invasive operative methods. Surgery is a unique expe- and available to the perioperative team throughout the client’s
rience, with no two clients responding alike to similar opera- surgical experience.
tions. Even the same client may respond differently to two The psychological well-being of the client has an impact
separate surgical situations or to the same surgery performed on the surgical outcome. The surgical client is at risk for anxiety
at a later time. Surgery is a major stressor for every client. To related to the surgical experience and the outcome of surgery.
a client, there is no such thing as minor surgery; anxiety and Fear and anxiety are normal responses to the stress of surgery
fear are normal. Surgery, even when planned well in advance, and affect the client’s ability to cope with the proposed plan
is a stressor that produces both psychological (anxiety, fear) of care. Because individuals differ in their perceptions of the
and physiologic (neuroendocrine) stress reactions. Surgery meaning of surgery, the degree of anxiety and fear experienced
is a stressful experience because it involves entry into the varies. If fear and anxiety become excessive, however, these
human body. emotions interfere with recovery by magnifying the normal
Surgeries are classified as minor (presenting little risk to physiologic stress response. By assessing and being aware of
life) or major (possibly involving risk to life) and are performed the fears and anxieties of the surgical client, the nurse provides
for a variety of reasons. Table 2-1 lists indications for surgery. support and information so that stress does not become over-
The term perioperative encompasses the preopera- whelming. The most common fears related to surgery are:
tive (before surgery), intraoperative (during surgery), and • Fear of the unknown
postoperative (after surgery) phases of surgery. Each phase • Fear of pain and discomfort
refers to a particular time during the surgical experience, and • Fear of mutilation and disfigurement
each requires a wide range of specific nursing behaviors and
functions. Perioperative nursing has one continuous goal: • Fear of anesthesia
to provide a standard of excellence in the care of the client • Fear of disruption of life patterns
before, during, and after surgery. Nursing activities are geared — Separation from family/significant others
to meet the client’s psychosocial needs as well as immediate — Sexuality
physical needs. — Financial
Individuals face surgery with their own values. Each client — Permanent/temporary limitations
has specific expectations of the surgical experience and dis-
tinct hopes for the outcome of the surgery. The nurse takes an • Fear of death/not waking up
active part in the entire perioperative process to ensure quality • Fear of not being in control
and continuity of client care. Fear of the unknown is the most prevalent fear before surgery
and is the fear the nurse can most easily allay through client
education and preoperative teaching.
PREOPERATIVE PHASE
The preoperative phase is that time during the surgical Preoperative Physiologic
experience that begins with the client’s decision to have
surgery and ends with the transfer of the client to the operat- Assessment
ing table. Physiologic assessment includes a physical examination and a
The outcome of surgical treatment is tremendously review of the client’s laboratory values and diagnostic studies.
enhanced by accurate preoperative nursing assessment and Laboratory and diagnostic studies are divided into those that
careful preoperative preparation. The client must be assessed are routine and those that are performed specifically to evalu-
by the nurse both physiologically and psychologically. Assess- ate the client’s primary disease process or coexisting condi-
ment of the client involves the integration of factors relating to tion. The common preoperative laboratory tests include:

Table 2-1 Indications for Surgery

TYPE OF SURGERY PURPOSE EXAMPLE
Diagnostic Determine cause of symptoms Biopsy
Exploratory laparotomy

Curative Remove a diseased body part or replace a Cholecystectomy

body part to restore function Total knee arthroplasty
COURTESY OF DELMAR CENGAGE LEARNING

Palliative Relieve symptoms without curing disease Tumor resection associated with cancer

Restorative Strengthen a weakened area Herniorrhaphy

Cosmetic Improve appearance Face lift

Change shape Mammoplasty

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 CHAPTER 2 Surgery 17

• Hemoglobin and hematocrit (Hgb and Hct)

• White blood cell (WBC) count LIFE SPAN CONSIDERATIONS
• Blood typing and cross matching (screening)
• Serum electrolytes Surgery in the Elderly Client
• Prothrombin time (PT), International Normalized Ratio Morbidity and mortality rates for surgical clients
(INR), and partial thromboplastin time (PTT) older than age 90 years are much higher than
• Bilirubin for those age 70 to 75 years (Hogstel, 2001).
• Liver enzymes: alanine aminotransferase (ALT) and Elderly clients do not tolerate emergency or long,
aspartate aminotransferase (AST) complicated surgery as well as do younger clients
• Urinalysis because of a lesser ability to adapt to physical and
• Blood urea nitrogen (BUN) and creatinine psychological stress.
Although it is common practice to obtain a chest x-ray for many
clients admitted to the hospital, this study is increasingly
omitted for healthy children and healthy adults younger than risk for complications. Infants easily become dehydrated or
age 40 years in whom the physical examination is normal and fluid overloaded with resultant electrolyte imbalances. Be-
there is no reason to suspect pulmonary or cardiac disease. cause their metabolic rate is two to three times that of adults,
Additional radiographic or fluoroscopic examinations, sono- infants can receive formula up to 6 hours before surgery, and
grams, radioisotopic scans, magnetic resonance imaging, and breastfed infants can be nursed up to 4 hours before surgery.
computerized tomography scans provide useful information Infants may then have clear liquids for up to 2 hours before
about the nature of the disease process and its anatomic location surgery.
and extent. Any organ that is undergoing major surgery is ade- Body temperature regulation and the renal, immune,
quately evaluated with these techniques before the operation. and respiratory systems are different in infants than in adults.
Electrocardiograms (ECGs) are routinely performed in Renal function in the infant is comparatively less efficient
middle-age and elderly clients undergoing surgery because of because of a lower glomerular filtration rate and less efficient
the prevalence of ischemic heart disease in these age groups. It renal tubular function (Phillips, 2007). This leads to retention
is also of value to have a baseline study for comparison in case of anesthesia and medications and to fluid overload. Because
subsequent ECGs are needed. of a comparatively larger ratio of body surface area to body
Preoperative testing is completed several days before the mass, infants are also more prone to hypothermia when placed
date of surgery. The type and amount of screening depends on in a cool environment or when large areas of their body sur-
the age and condition of the client, the nature of the surgery, face is exposed. Furthermore, an immature immune system
and the surgeon’s preference. Surgeons (doctors who perform renders the infant more susceptible to infections. Because of
surgery) are coming under increasing economic pressure to a smaller and less developed anatomic structure and enlarged
minimize routine testing procedures. The current trend is tongue and lymphoid tissue, the infant is also more prone to
based on cost versus benefits, moving away from extensive respiratory obstruction. The nursing process and nursing care
testing in the absence of indicative/warranting data from the is tailored to meet the unique needs of the infant client.
health history and physical examination. Elderly clients experience many physiologic changes
The nurse’s role in preoperative testing is to ensure that associated with aging and are more likely to have degenera-
the ordered tests are performed, that the results are placed in tive disease in many organs. Elders are more likely to become
the client’s chart, and that abnormal results are reported to the dehydrated and are thus less able to adapt to fluid loss during
physician immediately. surgery. The elderly client is also more sensitive to central ner-
The physiologic nursing assessment is completed before vous system depressants used during the perioperative period;
surgery. Preoperative assessment takes place in the surgeon’s however, even elderly clients favorably tolerate extensive sur-
office, in the hospital during hospitalization, or in the hos- gery when carefully assessed and managed.
pital or ambulatory surgery unit on the day of surgery. The
nurse collects client health data by interviewing the client,
the family, significant others, and health-care providers. Data Nutritional Status
collection also is accomplished through review of the cli- Nutritional assessment includes evaluation of individual defi-
ent’s records, assessment, and/or consultation. Assessment ciencies or excesses that place the client at greater risk for comp-
is essential to establishing nursing diagnoses and predicting lications during surgery. Surgery increases the body’s need for
outcomes (Association of periOperative Registered Nurses nutrients necessary for tissue healing and resistance to infection.
[AORN], 2002b). When performing the nursing assessment, Nutritional deficiencies place the client at greater risk
the nurse screens the client for risks that may contribute to for fluid and electrolyte imbalance, delayed wound healing,
complications in the perioperative period. The nurse’s role in and wound infections. The malnourished individual has
the preoperative phase ensures client safety, understanding, diminished stores of carbohydrates and fats; in such instances,
and compliance with health care treatment. The variables proteins are used for energy instead of tissue building and
affecting surgical status are age, medications, nutrition, fluid restoration. In addition to carbohydrates and fats, vitamins
and electrolytes, and various body systems. B complex and C are also significant because these vitamins
are essential to healing. Poor nutritional status also adversely
affects liver and kidney function, leaving the client with a poor
Age tolerance for anesthetic agents and a tendency for bleeding.
Surgery is performed on individuals of any age, although per- Nutritional excesses or obesity increase the risk for
sons at both extremes of age (infants and elders) are at greater respiratory, cardiovascular, and gastrointestinal complications.

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18 UNIT 1 Essential Concepts

Obesity makes access to the surgical site more difficult, which Clients with chronic respiratory problems are more likely to
prolongs surgical time and increases the amount of anesthetic develop atelectasis and pneumonia.
agents required. Because inhalation anesthetics are absorbed Respiratory assessment as performed by the nurse
by and stored in adipose tissue and released postoperatively, includes assessing breath sounds, color of the skin and
recovery time from anesthesia is slower in the overweight cli- mucous membranes, and for shortness of breath (dyspnea)
ent. Adipose tissue is less vascular and more difficult to suture, and coughing. All clients, and especially those clients who smoke
which predisposes the client to wound infection, delayed and have chronic lung disease, are taught deep breathing, use of
wound healing, and increased incidence of wound complica- incentive spirometry, coughing, and preoperative turning.
tions, including postoperative incisional hernias. Failure to
exercise and ambulate increases the chances of decreased
respiratory function, accompanied by atelectasis and pneu- Cardiovascular Status
monia, and also leads to decreased wound healing and an Cardiovascular assessment focuses on such diseases as
increased risk of thrombus formation. Often, obese clients angina, recent myocardial infarction or cardiac surgery,
also have other chronic conditions, such as hypertension or hemophilia, hypertension, and congestive heart failure. Cli-
diabetes mellitus that increase the likelihood of surgical com- ents with a history of cardiac disease are prone to developing
plications. In some surgical situations, such as joint replace- complications such as dysrhythmias, hypotension, myocar-
ment, surgery is delayed until nutritional status improves and dial infarction, congestive heart failure, cardiac arrest, stroke,
the client loses weight. shock, deep vein thrombosis, thrombophlebitis, or pulmo-
nary embolism.
Also assess for anxiety; elevated blood pressure; slow,
Fluid and Electrolyte Status rapid, or irregular pulse; chest pain; edema; coolness or
Dehydration and hypovolemia, with correlating electrolyte cyanosis/discoloration of extremities; weakness; and short-
disturbances, predispose a client to complications during and ness of breath (dyspnea). All clients are taught postoperative
after surgery. Both are caused by diarrhea, excessive naso- leg exercises to prevent thrombophlebitis. The goal of nursing
gastric suctioning, inadequate oral intake, vomiting, and/or care is to improve the client’s cardiovascular condition to the
bleeding. The complications of fluid and electrolyte imbalance highest degree possible by promoting rest alternated with
are numerous and varied. Changes in fluid and electrolyte activity; encouraging a low-sodium and low-cholesterol diet;
balance affect cellular metabolism, renal function, and oxy- administering heart medications; and judiciously administer-
gen concentration in the circulation. Nursing care focuses on ing parenteral fluids and recording intake and output.
administering parenteral fluids or blood products as prescribed,
keeping a detailed intake and output record, and evaluating
results of laboratory studies. Renal and Hepatic Status
Because many medications and anesthetic agents are detoxified
by the liver and excreted by the kidneys, renal and hepatic suf-
Respiratory Status ficiency constitute a major concern. Renal disease affects fluid
Respiratory assessment includes detection of acute and and electrolyte balance and protein equilibrium. Liver disease
chronic problems. Because acute respiratory infections may causes bleeding tendencies and carbohydrate, fat, and amino
lead to bronchospasms or laryngospasms, surgery for clients acid imbalances that impair wound healing and increase the
with these conditions is delayed or contraindicated. Chronic risk of infection. Assess for symptoms of urinary frequency,
respiratory problems, such as asthma and chronic obstruc- dysuria, and anuria and record the color and amount of the
tive pulmonary disease, impair the client’s gas exchange and urine. Also assess for a history of bleeding tendencies, easy
increase the risk associated with inhalation anesthetic agents. bruising, nosebleeds, and use of anticoagulants. The most
commonly ordered preoperative tests to assess renal function
are urinalysis, blood urea nitrogen (BUN), and creatinine. The
PROFESSIONALTIP most common liver tests are prothrombin time (PT), partial
thromboplastin time (PTT), bilirubin, and the liver enzymes
Client’s Psychological Condition alanine aminotransferase (ALT) and aspartate aminotrans-
ferase (AST). Nursing care focuses on administering fluids and
The client “who fears dying while under anesthesia adequate nutrition, monitoring fluid intake and output, and
runs a greater risk of cardiac arrest on the evaluating results of laboratory tests.
operating table than [do] clients with known
cardiac disease” (Phillips, 2007). Neurological, Musculoskeletal,
• The psychological condition of the client can
have a stronger influence than does the physi-
and Integumentary Status
cal condition. Assess the client’s overall mental status, including level of
• Encourage clients to express their feelings and consciousness; orientation to person, place, and time; and
the ability to understand and follow instructions. Note skin
fears about receiving anesthetic and having
condition, including turgor and any rashes, bruises, lesions,
surgery.
or previous incisions. Assess client mobility and sensation
• Observe the client for nonverbal clues indicat- through observation of both range of motion and ability to
ing anxiety. ambulate and through client statements. Note any abnormali-
• To reduce client anxiety, explain what happens ties, injuries, or previous surgery and assess the risk for falls.
throughout the surgical experience. The presence of internal or external prostheses or implants
such as pacemakers, heart valves, or joint prosthesis is also

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 CHAPTER 2 Surgery 19

by the administration of insulin, glucose, or both. Besides

hyperglycemia and hypoglycemia, a diabetic client is more
CLIENTTEACHING prone to fluid and electrolyte imbalances, infection including
Postoperative Leg Exercises respiratory and urinary tract infections, neurogenic bladder,
impaired wound healing, ketoacidosis, deep vein thrombosis,
Activity Instructions thrombophlebitis, and pulmonary embolism.
Because the immunological system protects the client
Leg lifts 1. While lying on back or in a from infections, the immunocompromised surgical client is
semi-sitting position, raise very prone to infection. Clients receiving steroids or chemo-
the leg off the bed. therapy, or who have systemic lupus erythematosus, Addison’s
2. Hold for count of five. disease, or acquired immunodeficiency syndrome (AIDS) are
3. Lower leg to the bed. considered immunocompromised. The immune response in
4. Repeat five times then pro- these clients is weakened or deficient, resulting in an increased
ceed to other leg.
incidence of infection. Because surgery breaks the integrity
of the skin and the normal inflammatory response is sup-
Perform every hour.
pressed, wound healing may be impaired. Strict adherence to
Dorsiflexion 1. Flex ankles and raise toes aseptic technique (covered later in this chapter) is thus even
and hyper- toward head, stretching more imperative. Prevention of infection is crucial in these
extension of posterior calf. clients. The role of the nurse is to communicate the presence
ankles 2. Hold for a count of two. of potential immunosuppression to other health care team
members involved in the client’s care and to prevent infection
3. Relax.
by practicing aseptic technique.
4. Repeat five times then pro-
ceed to other foot.
Perform every hour. Medications
Foot circles 1. Point the toe and raise the
Knowledge of the client’s use of drugs for recreational or
leg slightly off the bed.
therapeutic purposes is essential to preoperative assessment.
The history of medication usage by the client should include
2. Use the great toe to trace a type and frequency of use for over-the-counter, prescrip-
circle in the air, first to the tion, and street drugs. The use of certain drugs affects the
right and then to the left. client’s reaction to anesthetic agents and surgery. Some
3. Repeat five times, then drugs increase surgical risks; these medications usually are
proceed to the other foot. temporarily discontinued before surgery. Other medications,
Perform every hour. such as heart or hypoglycemic medications, may still be given
even though the client is to undergo surgery; the surgeon or
anesthesia provider writes specific orders in such instances.
Dosages of medications may also be adjusted during the peri-
noted, because the presence of these may necessitate preop- operative period.
erative antibiotics.
Thin clients, clients undergoing long surgical proce-
dures or vascular procedures, and elderly clients are the
most vulnerable to neurological, musculoskeletal, or integu- PROFESSIONALTIP
mentary injuries. Some underlying disease processes, such
as edema, infection, cancer, osteoporosis, arthritic joints, Questions to Assess Psychosocial
or neck or back problems, also place a client at greater risk Status
for injury. Clients who are malnourished, anemic, obese,
• Why are you having surgery?
hypovolemic, paralyzed, or diabetic are also prone to skin
breakdown. Information gathered about the neurological, • When did this problem start?
musculoskeletal, and integumentary systems is used to • What do you think caused this problem?
prepare the surgical site, for surgical positioning, and as a • Has this caused any problems in your relation-
comparative basis for postoperative assessments and com-
ships with others?
plication screening.
• Has your problem prevented you from working?
• Are you able to take care of your own needs?
Endocrine and Immunological Status
• Are you experiencing any discomfort or pain?
Clients with diabetes are scheduled as early in the morning as
possible, and a fasting glucose drawn immediately before sur- • What are you expecting from this surgery?
gery. Surgery is a stressor, and stress raises the serum glucose • Is there anything that you do not understand
level in the client with diabetes. Thus the morning dose of regarding your surgery?
insulin usually is adjusted. • Are you worried about anything?
When anesthetized during surgery, the diabetic client
exhibits very few symptoms of glucose imbalance. Serum • Will someone be available to assist you when
glucose must therefore be checked frequently during sur- you return home?
gery, usually by the anesthesia provider. Stability is attained

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20 UNIT 1 Essential Concepts

Chronic alcohol use increases surgical risk because it is Most hospitals use a standard preprinted form. The infor-
often accompanied by impaired nutrition and liver disease. mation written by the health care personnel is specific to the
Postoperatively, the client may exhibit delirium tremens or individual client. The client’s signature on the consent form
acute withdrawal syndrome. Furthermore, pain medication indicates the information has been read and is correct. The
may be less effective. client has the right to refuse treatment even after signing the
consent. When this occurs, the nurse informs the physician
immediately of the client’s decision.
Psychosocial Health
Assessment Preoperative Teaching
The psychosocial health status of the client is also assessed. The client about to have surgery is at risk for knowledge deficit
The nurse elicits the client’s perceptions of surgery and the related to preoperative procedures and protocols and postop-
expected outcome. The nurse also ascertains the client’s cop- erative expectations. The potential benefits of preoperative
ing mechanisms and the client’s knowledge level and ability to teaching include reduced anxiety and more rapid recovery with
understand. The data collected are incorporated into nursing fewer complications and shorter hospitalization. Reduction in
care throughout the perioperative experience. anxiety has a secondary benefit: The client usually requires less
Cultural beliefs can influence a client’s perception of medication for pain. The purposes of preoperative teaching are
surgery. For example, some cultures believe that surgery is a to (1) answer questions and concerns about surgery, (2) ascer-
“final effort” performed only when all other possible treat- tain the client’s knowledge of the intended surgery, (3) ascertain
ments have been of no avail. Furthermore, surgeries that cause the need or desire for additional information, and (4) provide
changes in the appearance of the body can alter body image information in a manner most conducive to learning.
and self-esteem; the client may worry about being sexually One-on-one sessions constitute the most personal
attractive or active after surgery. method of instruction, but try to include the family or sig-
The nurse provides an opportunity for the client to nificant other when possible. The level of learning increases
express his spiritual values and beliefs. Many clients wish to when more than one teaching medium is used. For example,
see a member of the clergy before having surgery. using materials such as videotapes, charts, tours, anatomic
models, pictures, and brochures reinforces both visual and
Surgical Consent auditory learning. Demonstration followed by return demon-
stration is helpful. Written instructions serve as a reference for
An informed consent is a legal form signed by the client later use. Make instructions simple, using terms the client can
and witnessed by another person that grants permission to understand. Any unfamiliar words or concepts are thoroughly
the client’s physician to perform the procedure described by explained.
the physician. An informed consent is needed whenever these Clients are often interested in any information that
situations occur: describes the sights, sounds, tastes, feelings, odors, and tem-
• Anesthesia is used. perature of what they are about to experience. For example, the
• The procedure is considered invasive. feeling of relaxation from preoperative medications; the sounds
• The procedure is nonsurgical but has more than a slight of instruments or equipment in the operating room (OR); the
risk of complications (such as with an arteriogram). pressure from the automatic blood pressure cuff; the warmth or
coolness of skin-preparation solutions; or the brightness of the
• Radiation or cobalt therapy is used. OR lights are all sensations the client may experience. Analogies
Informed consent protects both the client (against or stories of real or fictitious situations of sensory experiences
unauthorized procedures) and the physician and the health help the client understand. The teaching methods used strongly
care facility and its employees (against claims that an unau- influence the client’s learning and retention of information.
thorized procedure was performed). Although the ultimate Preoperative teaching begins as soon as surgery is agreed
responsibility for obtaining the informed consent lies with the upon. Instructions given over the phone and/or mailed to
physician, the nurse often obtains and witnesses the client’s the client during the time leading up to surgery are beneficial.
signature and ensures that the client signs the consent form Just before surgery, a brief review with additional information
voluntarily and is alert and comprehending of the action. tailored to the needs of the client are given. Give the client an
opportunity to ask questions.
Information always is targeted to the client’s needs and
according to the client’s level of knowledge and anxiety.
Mild-to-moderate anxiety actually heightens a person’s alert-
ness and motivates learning. Mildly anxious clients receive
CULTURAL CONSIDERATIONS the most complete instructions. Moderately anxious clients
receive less information but more attention to specific areas of
concern. Severely anxious clients receive only basic informa-
Impending Surgery tion but are encouraged to verbalize their concerns. Clients in
• Some clients desire special religious rites before a state of panic are unable to learn; in such cases, no instruc-
surgery.
tion is given, and the surgeon is notified.
• Some clients may not want to receive blood
transfusions or other treatments. Physical Preparation
• All client beliefs are respected. Extremely close attention is given to identifying the proper
client both verbally and by reading the identification name

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 CHAPTER 2 Surgery 21

CLIENTTEACHING
Preoperative Teaching
• Introduce self
— Identify role in client’s care
• Determine client’s knowledge level and need or
desire for addition information

COURTESY OF DELMAR CENGAGE LEARNING

• Explain the routine for the day of surgery
— Restricted food or fluid intake
— Intravenous fluids
— Premedication
— Time of surgery
— Anticipated length of surgery
— Transportation to the OR
Figure 2-1 Common Surgical Incisions; A, Sternal Split;
— Special skin preparations B, Oblique Subcostal; C, Upper Vertical Midline; D, Thoraco-
— Type of surgical incision (Figure 2-1) abdominal; E, McBurney; F, Lower Vertical Midline;
• Familiarize client with the OR environment G, Pfannenstiel
— Operating room lights and table
— Accessory equipment Typically, the operative site is not shaved, but if shaving is to
be performed, it is done in the OR immediately before sur-
— Monitoring equipment gery. To reduce the number of bacteria in the gastrointestinal
— Anesthesia induction tract for gastrointestinal, peritoneal, perianal, or pelvic sur-
• Include significant others gery, an enema is ordered. Enemas prevent contamination of
— Time to arrive at the hospital
the peritoneal area by fecal content passed during surgery. The
reduction in colon size related to the loss of bulk also helps
— Location of the surgical waiting area prevent colon injury and increases visualization of the ope-
— What to expect when the client returns to rative site. Enemas are usually given the night before surgery.
the unit If the enema is done at home, give the client detailed instruc-
• Explain postanesthesia care unit (PACU) tions. Many types of surgery require special preparations. The
specific protocol for each surgical procedure is available from
— Location of recovery room the health care facility or the physician.
— Purpose of recovery room Check the client’s vital signs, including blood pressure,
— Routine of postanesthesia care temperature, pulse, and respirations. Some changes in vital
• Identify anticipated dressings, drains, catheters,
signs are normal as a result of anxiety. If marked differences
exist from the baseline data, however, the surgeon is notified.
casts, etc.
Assist the client in putting on a hospital gown, hair cap
• Demonstrate and evaluate client’s proficiency and, if ordered, antiembolic hose sized according to client
with: size. Institutional policy usually requires the removal of all
— Coughing and deep breathing exercises jewelry, including body jewelry. Hairpins, wigs, and prosthe-
— Turning
ses also are removed. The nurse is responsible for recording
the disposition of any personal items removed for surgery.
— Incentive spirometry If policy requires, nail polish (from at least one nail, if dark pol-
— Extremity exercises ish) is removed to read oxygen saturation via pulse oximetry.
— Any special transfer procedures or aids Makeup is also removed so that skin color is observed.
required after surgery
• Describe pain management strategies appropri-
ate for the specific surgical procedure SAFETY
Iodine Allergy, Latex Allergy
band and to verifying the operative procedure. This is com- • Each client is asked about allergy to iodine and
pleted through client statements, surgeon verification, and latex.
the signed surgical consent form. Particular attention is given to • If a client is allergic to either, document the
differentiating between right and left operative sites. allergy on the client’s record and inform the
Special care is given to the preparation of the operative surgeon and OR personnel so that an iodine-
site to lessen the chance of infection. The operative site is free solution and latex-free equipment is used.
thoroughly cleansed with an antiseptic soap such as povidone-
iodine to reduce the number of microorganisms on the skin.

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22 UNIT 1 Essential Concepts

Allergies to medication, food, and chemicals (including

contrast agents) are verified, as are previous blood reactions. LIFE SPAN CONSIDERATIONS
The nurse differentiates between a medication intolerance
and a true allergic reaction. With an intolerance to certain Preparation for Surgery
medications, the client may experience side effects that are
unpleasant. For example, many clients experience nausea For pediatric clients:
when given morphine; although unpleasant, this is not a drug • Provide physical and psychological preparation
allergy. A true allergy produces a skin reaction or anaphylactic at the child’s level of understanding.
reaction, where the client experiences cardiorespiratory reac- • Listen carefully to the child to promote under-
tions that may be life threatening, such as hypotension and standing.
pulmonary edema. A client with multiple food allergies is also
• Ask the child to point to the operative site on
prone to hypersensitivities to medications. When allergies
are identified, the client’s chart is marked accordingly, and an self or doll.
allergy wrist band is put on the client. By being aware of and • Be honest and truthful.
alerting other team members to the client’s allergies, client The elder client may have:
safety and comfort are maintained. • Increased risk of complications including infection.
Verify the NPO (nothing by mouth) status of the client
for the time specified by the surgeon’s order. Restricting oral • Increased incidence of coexisting conditions.
intake reduces the possibility of aspiration. If surgery takes • Unpredictable response to medications and
place in the afternoon, the client has a clear liquid breakfast if anesthetics.
ordered by the surgeon. Careful client instruction is required • Greater need for support from family and sig-
because surgery may need to be postponed if the client eats nificant other.
or drinks.
In addition to the previously outlined preparations, • Increased skin and bone fragility.
remove dentures and bridgework to prevent loss, damage, and • Nutritional and financial deficiencies.
possible dislodgement and airway obstruction during the sur- • Impaired vision and hearing.
gery. Ensure that the client has an empty bladder by allowing • Impaired or slowed thought processes and
time for the client to void before transfer to surgery.
cognitive abilities.
Identify any sensory deficits of the client and commu-
nicate this information to other health-care team members. • Fear of death, loss of independence, and
Glasses, contact lenses, and hearing aids are usually removed change in lifestyle.
to prevent loss or damage; if policy allows, however, it is best
to leave these items in place so the client is better able to see
and hear. Then the nurse is responsible for communicating the
presence of these aids to the surgical team members. When the surgical team is ready, the client is transported
The surgeon or anesthesiologist (a doctor trained in on a gurney by a member of the OR team, typically an orderly.
providing anesthesia) may order preoperative medication. The client is always transported feet first and with the side
The nurse gives the medication by the prescribed route (intra- rails up to ensure safety and minimize the likelihood of diz-
muscular, intravenous, or oral) at the specified time (typically ziness and nausea. The client may be taken to a preoperative
1 hour before surgery). Preoperative medications may be holding area first (Figure 2-2). The nurse instructs the family
ordered “on call,” which means that the nurse is notified by a or significant others where to wait.
member of the surgical team when the preoperative medica- The information collected as part of preoperative prepa-
tion is to be given. Before administering the medication, ask ration is documented in the client record, usually on a pre-
the client to void. After administering the preoperative medica- operative checklist. Figure 2-3 (p. 23) illustrates a typical
tion, raise the side rails of the gurney or bed, put the bed in the preoperative checklist. This checklist is completed before the
lowest position, and instruct the client not to get up without
assistance.

PROFESSIONALTIP

Implementing NPO Status

• Explain reasons for NPO status to the client.
COURTESY OF DELMAR CENGAGE LEARNING

• Remove any food and water from the client’s

overbed table and nightstand.
• Mark the client’s door and bed with an NPO
sign.
• Mark the client’s Kardex, electronic medical
records, and other nursing information sources.
• Notify the dietary department. Figure 2-2 The holding area is used for clients who are
waiting to have surgery.

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 CHAPTER 2 Surgery 23

CK NURSE
( ) COMMENTS CK ( )
COMPLETE NIGHT BEFORE SURGERY
List allergies
Procedure scheduled
Surgical permit signed/witnessed
History/physical on chart and/or dictated
Preanesthetic evaluation done
Able to state type and purpose
Demonstrates ability to perform: Deep breathing, turning and coughing exercises
Leg exercises
P.M. care with shower or bath given
Nail polish removed and makeup removed
Old chart requested and obtained
Type and crossmatch for ______ units of blood
Blood consent signed and witnessed
Labor work a. CBC ______ b. UA ______
Tonsillectomy and adenoidectomy patients: a. ___PTT b. ___PT c. ___Platelets
If ordered by MD: a. ECG ___ b. Chest X-ray ___
Add other lab work ordered (specify)
Notify surgeon of abnormal lab work
New progress note and physician order sheet on chart
Weight
NPO after midnight (if applicable)

Signature of Nurse _________________________________________ Date ______________

COMPLETE DAY OF SURGERY
Jewelry removed and secured with responsible party
Dental prosthesis and contact lenses removed
Voided on call to surgery
Indwelling catheter ordered and inserted
Tampon removed
Identiband and/or bloodband on/checked for accuracy
Time _______ Pulse _______ Resp _______ B/P _______ Temp. _______
Pre-op medicine given medication _____________________ Time _______ AM PM
Siderails up and bed to lowest level
Patient instructed not to get out of bed without nursing assistance
Addressograph plate/MARs on chart
VS 30 minutes after pre-op (if remains on unit)
BP _______ P _______ R _______ T _______
COURTESY OF DELMAR CENGAGE LEARNING

Old chart sent to surgery per request

Surgical prep done and checked
To surgery Time _______ Via _______

Signature of Nurse _________________________________________ Date ______________

Holding Room Nurse Signature _________________________________________ Date ______________

Figure 2-3 Sample Preoperative Checklist

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24 UNIT 1 Essential Concepts

client leaves the clinical unit or upon the client’s admission to may be foreign. These elements combined with the sight of
ambulatory surgery. The nurse also verbally communicates ominous overhead lights and the feel of the hard OR table may
to other health-care members any necessary information increase the client’s fear, anxiety, and feelings of powerlessness.
collected.

Members of the
INTRAOPERATIVE PHASE Surgical Team
The intraoperative phase is the time during the surgical The surgical team is a group of hospital personnel assigned
experience that begins when the client is transferred to the to see a client successfully through an operative procedure.
OR table and ends when the client is admitted to the postan- At no other time during hospitalization will the ratio of
esthesia care unit (PACU). personnel to client be greater than when the client is under-
going surgery. The surgical team includes sterile dressed
Physical Description of the (without microorganisms) team members: the surgeon, the
first assistant (a physician or RN who assists the surgeon in
Operating Room Environment performing hemostasis, tissue retraction, and wound closure),
For the purposes of preventing wound infections, the surgical and the scrub nurse (an LP/VN, RN, or surgical technologist
suite is environmentally controlled. Personnel restriction and who, under the direction of the circulating nurse, prepares and
geographic isolation from other areas of the hospital or clinic maintains the integrity, safety, and efficiency of the sterile
are part of this control. Constant filtered airflow and posi- field throughout the operation). These team members scrub
tive air pressure in the OR also aid in environmental control. their arms and hands, don sterile gowns and gloves, and then
Clean areas and contaminated areas are separated within the perform their duties in the sterile field. The sterile field is that
suite. Equipment and supplies needed for each client are in area surrounding the client and the surgical site that is free
the surgical suite so members of the surgical team do not have from all microorganisms. It is created by using sterile drapes
to leave the area. to drape the work area and the client. Other team members,
ORs vary in size depending on the amount of equipment dressed in nonsterile attire, include the anesthesia provider
needed for each particular type of operation. Supplies and (an anesthesiologist or anesthetist) and circulating nurse
furniture are limited to prevent dust collection and are usually (an RN responsible for management of personnel, equipment,
made of stainless steel to withstand corrosive disinfectants. Fur- supplies, environment, and communication throughout a sur-
niture and equipment are easily movable on wheels. In addition gical procedure). These team members perform their duties
to general illumination from ceiling lights, the operative site outside of the sterile field. Each team member has a clearly
is illuminated by overhead operating lights. Figure 2-4 shows defined role and duties. Clear communication among team
a typical OR. The temperature of the room can be adjusted members and coordination of their activities improve the
but usually is maintained at a cool 66°F to 68°F. This provides most favorable outcome for the client.
comfort for the surgical team (the members of which wear
gowns, gloves, and masks under hot lights). This temperature
also is an unfavorable environment for bacterial incubation and
Asepsis
growth. Prevention of infection is the responsibility of the entire surgi-
The client entering the OR is confronted with an envi- cal team. The environment of the surgical client contains both
ronment that is most likely unfamiliar. The OR is cold. The pathogenic (disease-producing) and nonpathogenic micro-
surgical team members dress in surgical scrubs and have their organisms. When the skin, a prime barrier to infection, is
hair covered by caps and their faces covered by surgical masks, broken, as during surgery, susceptibility to a bacterial invasion
making them appear impersonal and distant. The sounds of increases. Bacteria carried by dust or nose and throat droplets
equipment being prepared can be unfamiliar and alarming. are easily transported by air currents.
The terminology used in conversations among OR personnel Asepsis is the absence of pathogenic microorganisms.
Aseptic technique is a collection of principles used to
control and/or prevent the transfer of pathogenic microor-
ganisms from sources within (endogenous) and outside
(exogenous) the client. For example, scrubbed persons wear
sterile gowns and gloves; sterile drapes are used to create a
sterile field; items used in a sterile field are sterilized; and
those working within a sterile field maintain the integrity of the
sterile field. Aseptic technique is applicable to other nursing
functions such as changing dressings, inserting a Foley catheter,
or preparing for an obstetrical delivery. Thus, the practice of
aseptic technique is not confined to the OR, but applies to
other clinical nursing units and other procedures as well.
The practice of aseptic technique requires the develop-
ment of sterile conscience, an individual’s personal sense
of honesty and integrity with regard to adherence to the
principles of aseptic technique. Aseptic technique must be
strictly followed. Doing so requires constant assessment
Figure 2-4 Typical Operating Room and Proper Surgical and monitoring of self and others. It is sometimes easier or
Attire (Photo courtesy of the U.S. Army.) less expensive to overlook an infraction of aseptic technique

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 CHAPTER 2 Surgery 25

CRITICAL THINKING
Sterile Conscience
Operative
How can you use a sterile conscience when provid- site
ing nursing care?

rather than to correct that infraction. This must never be

allowed. Compromising the principles of aseptic technique

COURTESY OF DELMAR CENGAGE LEARNING

may increase the likelihood of infection and, thus, harm to
the client.

Surgical Hand Scrub

An item is considered sterile when all microorganisms are
removed. The skin, however, cannot be sterilized. For this rea-
son, the sterile team members wear gloves as barriers between
the sterile field and the skin. Because accidental tearing or Figure 2-5 Skin Preparation at Operative Site
puncturing of the surgical glove and resultant introduction
of microorganisms into the surgical wound are possible, the for other procedures such as intravenous (IV) insertion, chest
sterile team members must take measures to lower the number tube insertion, thoracentesis, or subclavian catheter placement.
of microorganisms on their hands and arms. The surgical hand Surgical skin preparation lasts 5 to 10 minutes. After the scrub
scrub, performed before gowning and gloving, removes soil and is completed, the area is blotted dry with sterile towels. An
transient (not always present and easily removed) microorgan- antiseptic solution, often also iodine based, is then applied in
isms from the hands and forearms. The antimicrobial soap used the same manner.
lowers the count of resident (almost always present and not
easily removed) microorganisms and continues to prevent sud-
den bacterial rebound or regrowth after the scrub is completed. Intraoperative Nursing Care
The surgical scrub thus reduces the possibility of transmission The success of nursing care in the OR is measured by cli-
of microorganisms from the surgical team to the client. ent outcomes. The AORN has established client outcome
Watches, rings, and bracelets are removed before the standards for evaluating perioperative clients upon comple-
surgical hand scrub. Fingernails must be short, clean, and tion of surgery. These outcomes state that the client is to be
healthy. Artificial nails cannot be worn (AORN, 2002a), free from infection and injury related to positioning, foreign
although unchipped fingernail polish that has been applied objects, or chemical, physical, and electrical hazards. In addi-
within the last 4 days may be allowed (AORN, 2002b). The tion, skin integrity and fluid and electrolyte balance are to be
hands and forearms should be free of breaks in skin integrity. maintained. Consequently, nursing care in the OR strives to
provide these standards to all clients undergoing surgery.
Surgical Skin Preparation Although the responsibilities of the circulating nurse and
scrub nurse may seem to be a series of tasks or duties, these
Like the skin of the surgical team members, the skin surface at same tasks and duties provide quality nursing care to the cli-
the client’s incision site also cannot be sterilized. As with the ent. The nurse planning for surgery is involved in selection of
surgical hand scrub, the goal of surgical skin preparation at the equipment and supplies, room preparation, and formation of
client’s incision site is to lower the number of microorganisms the sterile field before the delivery of actual nursing care.
on and near the incision site. After completion of surgery, the circulating nurse applies
Typically, the client is asked to shower or to wash the and secures the dressing. When the anesthesia provider is
operative site either before arriving at the surgical facility or ready, the client is transferred to a stretcher or a gurney. The
immediately before surgery. The client is then transferred to unconscious or semiconscious client is placed in a side-lying
the OR. After general anesthesia induction or regional block or semiprone position unless contraindicated by the surgical
completion or before local infiltration of the operative site,
the circulating nurse performs the surgical skin preparation.
Using aseptic technique, the circulating nurse scrubs the area SAFETY
with an antimicrobial soap. Typically the soap used is povidone-
iodine (containing iodine) or chlorhexidine, thus potential Electrical Equipment
allergies to iodine must be verified. The circulating nurse • Electrical equipment is plugged into grounded
scrubs a generous area surrounding the operative site to allow
outlets.
for extension of the surgical incision if the need arises. The
scrub is completed in an ever-widening circular motion from • Electrical equipment is regularly checked by a
the incision site, which is considered clean, to the periphery, bioelectronic technician.
which is considered dirty (Figure 2-5). Once the periphery is • A grounding pad is placed under the client and
reached, the sponge is discarded, never brought back toward in direct contact with the client’s skin.
the center of the area. The concept of cleansing from the center
(incision site) to the periphery also applies to skin preparation

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26 UNIT 1 Essential Concepts

procedure. If the client is supine, the client’s head is turned • Presence of artificial airway devices
to the side in case the client vomits. The client is then taken — Oral airway
to the PACU, accompanied by the anesthesia provider and — Nasopharyngeal airway
another surgical team member.
— Endotracheal airway
• Oxygen saturation
POSTOPERATIVE PHASE • Need for supplemental oxygen
— Mode of administration
The postoperative phase is the time during the surgical expe- — Flow rate
rience that begins with the end of the surgical procedure and • Breath sounds
lasts until the client is discharged not just from the hospital or
• Color of skin, nail beds, and lips
institution, but from medical care by the surgeon. Upon transfer
from the OR, the client usually goes to the PACU (Figure 2-6). • Presence of cardiac dysrhythmias
All clients who receive general anesthesia, spinal anesthesia, or • Other vital signs
regional anesthesia are admitted to the PACU. Occasionally, — Blood pressure, pulse
clients who have undergone surgery with local anesthesia or • Skin condition (moist or dry, warm or cool) and skin
no anesthesia or who have received only IV sedation are placed temperature
in the PACU for a short period to be monitored closely until • Initiate Aldrete Score
their conditions stabilize. The PACU is usually located next to
the OR. Typically, it is one large room with individual units for • Intravenous infusion
clients along the perimeter of the room. Each of these units has — Type of solution
an oxygen delivery system, suction, various other supplies, and — Amount in bottle or bag
cardiac, respiratory, and blood pressure monitoring devices. — Flow rate
Curtains are pulled to provide privacy if needed, but an open — Appearance and location of IV site
view allows continual assessment of all clients. • Dressings

Postoperative Nursing Care — Amount and character of drainage

• Drains and tubes
The postanesthesia care nurse is an RN specially trained — Intactness and function
in caring for immediate postoperative clients. The goal of
— Connection to drainage and/or suction
postanesthesia nursing care is to promote recovery from
anesthesia and the immediate effects of surgery. The post- — Amount and character of drainage
anesthesia nurse has knowledge and skill in recognizing and • Level of consciousness
treating anesthetic and surgical complications very quickly. • Activity level
The postanesthesia nurse is empathetic and is able to assess • Other assessments according to surgical procedure
and manage pain for the client who is not able to express • Pain
himself.
Upon the client’s arrival in the PACU, the anesthesia The postanesthesia nurse notes the client’s arrival time
provider verbally reviews the client’s anesthesia and operative to the unit and immediately begins to assess the patency
procedure with the postanesthesia nurse. The postanesthesia of the airway by placing a hand above the client’s nose and
nurse begins the following nursing assessment and care in the mouth to feel exhalation. The quality and quantity of respi-
immediate postoperative period: rations are then immediately observed, as is the presence of
an artificial airway. The client is attached to a pulse oximeter
• Time of arrival in recovery room (Figure 2-7), and breath sounds are auscultated. The color
• Patency of airway and condition of the skin are noted as part of the respira-
• Respirations tory assessment. The lips are checked for circumoral pallor.
COURTESY OF DELMAR CENGAGE LEARNING
COURTESY OF DELMAR CENGAGE LEARNING

Figure 2-6 Postanesthesia Care Unit (PACU) Figure 2-7 Client with Pulse Oximeter on Finger

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 CHAPTER 2 Surgery 27

Peripheral cyanosis may be an indication of hypothermia

rather than respiratory distress. Thus, correlating with the Table 2-2 Aldrete Score/Postanesthetic
“ABCs” of airway, breathing, and circulation, the respiratory Recovery Score
system is assessed first.
Because most clients admitted are unconscious and have Activity Able to move 4 extremities voluntarily
received muscle relaxants during surgery, respiratory exchange or on command 2
is often affected. Snoring, stridor, labored chest movement, ster- Able to move 2 extremities voluntarily
nal retractions, cyanosis, and apnea are all signs of respiratory or on command 1
distress. Respiratory distress is the gravest of all complications Able to move 0 extremities voluntarily
because respiratory crisis and subsequent death occurs in a mat-
or on command 0
ter of minutes if distress is not observed and treated quickly. In
the event of any signs of respiratory distress, the postanesthesia Respiration Able to breathe deeply and cough
nurse must be alert to the possibility of respiratory arrest and be freely 2
ready to initiate cardiopulmonary resuscitation. Dyspnea or limited breathing 1
The Aldrete Score, also known as the Postanesthetic
Apneic 0
Recovery Score, is used in PACUs to objectively assess the
physical status of clients recovering from anesthesia and Conscious- Fully awake 2
serves as a basis for discharge from the PACU (Table 2-2). ness Arousable on calling 1
The Aldrete Score was adapted to also assess the readiness Not responding 0
of clients for discharge from ambulatory surgery. The first
five items are used for discharge from the PACU. Clients are Circulation B/P ± 20% of preanesthetic level 2
assessed at the time of admission to the PACU and every B/P ± 20% to 50% of preanesthetic
15 minutes until discharge. The first five items include assess- level 1
ing activity, respiration, consciousness, circulation, and color B/P ± 50% of preanesthetic level 0
(oxygen saturation). Each of the five items is scored from
0 to 2, according to the degree of functional disturbance. Color Normal 2
The score is expressed as a total score, with 10 being the Pale, dusky, blotchy, jaundiced, other 1
maximum. Typically, a minimum score of 8 is required for Cyanotic 0
discharge from the PACU.
Fluid intake and output are assessed. The amounts Additional Assessments: Aldrete Score/
and types of IV solutions hanging are identified, as are Postanesthetic Recovery Score for Clients Having
any added medications. The IV fluids are infused according Anesthesia on an Ambulatory Basis
to the surgeon’s order and are run at a specified rate. The IV
Dressing Dry and clean 2
site is assessed for patency, redness, and swelling. The client is
restrained as necessary to maintain patency of the IV site. All Wet but stationary or marked 1
other infusions and irrigations are also assessed. Growing area of wetness 0
Dressings and/or peripads are checked for any evidence Pain Pain free 2
of bloody drainage and the amount noted so that any subse-
Mild pain handled by oral medication 1
quent appearance of blood may be accurately evaluated. All
drainage tubes are then connected, and the type of drain and Severe pain requiring parenteral
the drainage amount are recorded according to physicians’ medication 0
orders. Table 2-3 outlines common types of drains placed Ambulation Able to stand up and walk straight 2
in surgery. Urinary output is also monitored. Scanty urinary Vertigo when erect 1
drainage (<50 mL/hour or as ordered) is reported to the
Dizziness when supine 0
surgeon.
Surgical drains are placed so the wound can drain freely Fasting/ Able to drink fluids 2
of blood clots, body fluids, pus, and necrotic material that Feeding Nauseated 1
otherwise would collect in the wound and provide a rich Nausea and vomiting 0
medium for bacterial growth. Figure 2-8 illustrates com-
mon drainage devices. All drains are inserted at the opera- Urine Has voided 2
tive site and exit through the incision or a separate stab Output Unable to void but comfortable 1
wound adjacent to the incision. The type of drain is chosen Unable to void and uncomfortable 0
according to the location of wound, size of wound, and
type of drainage anticipated. The use of drains decreases Courtesy of J. Antonio Aldrete, M.D., M.S., Defuniak Springs, FL.
pain and infection and aids wound healing; however, if the
wound is draining, the skin is not closed, and a pathway
exists for the entrance of microorganisms. Drain sites can dislodged. Table 2-4 lists additional nursing care according
thus also be a source of infection. Potential complications to surgical procedure.
of drains include hemorrhage, sepsis, drain loss, and bowel Part of the neurological assessment involves assessing
herniation. Nursing care for drains includes assessing the the activity level or the ability to move extremities volun-
color, character, and odor of drainage; ensuring the patency tarily. The ability to move extremities on command indicates
of the drain (making sure there are no kinks in the tubing); voluntary movement. Hearing is the first sensation to return
and ensuring that the drain does not accidentally become to the client after having been anesthetized. Clients in the

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28 UNIT 1 Essential Concepts

Table 2-3 Description, Uses, and Nursing Care of Common Drainage

Devices Placed During Surgery
TYPE EXAMPLE DESCRIPTION USES NURSING CARE
Passive Penrose A single-lumen, soft To remove drain- • Inspect dressing
latex tube that works age when more • Check underneath client to ensure drainage has not
with gravity directly than a minimal leaked from the side of the dressing
from the surgical amount of drain-
incision age is expected • Always keep a dressing over drain
• Check safety pin through end of drain

Active Hemovac Closed wound drain- Used after • Assess the drainage system as appropriate to
Jackson- age system with drain multiple types of client’s condition for:
Pratt and reservoir having procedures; pro- 1. Continued drainage
self-suction when res- vides continuous
J-Vac ervoir is compressed gentle suction of 2. Maintained decompression
Relia Vac the operative site 3. Air-tight tubings
Surgivac to increase drain- 4. Need for emptying
age of serosan-
guinous fluid and • To reactivate suction, wash hands and wear gloves
collapse tissue to and eye/face protection
facilitate healing • Empty reservoirs every 8 hours, when drainage nears
the full line, or as ordered by the physician

Passive Davol Large, multilumen To drain intra- • Use one of the smaller or sump ports for continuous
or active Sump tube with a larger abdominal fluids irrigation
Axiom main port for drain- from abscesses, • Calculate intake and output carefully with irrigations
Sump age and/or suction cysts, or hema-
and with smaller side tomas • Place impervious pads underneath client
port(s) for irrigation • Change dressings frequently when saturated
and/or air venting to • Attach to catheter drainage bag if not attached to
help prevent tissue suction; do not plug sump ports
from being suctioned
against catheter and
damaged

Chest tube Large single-lumen To drain fluid or • Assess breath sounds and respirations, including
ThoraKlex drain attached to air from pleural depth, rate, symmetry of chest expansion, color of
closed water-seal cavity mucous membranes, and presence of crepitus with
Pleure Vac drainage system suction off or tubing clamped
• If present, assess amount and type of suction
• Ensure that connections are tight and sealed with tape
• Keep chest tube drainage reservoir lower than
client’s chest
• Observe for air leaks in air leak indicator or drainage
chamber of drainage reservoir
• Place petroleum jelly gauze nearby for quick access
should the tube become dislodged
• Measure drainage at least every 8 hours (more
COURTESY OF DELMAR CENGAGE LEARNING

frequently if in a critical care unit or client’s condition

warrants it)
• Clamp or milk the chest tube only if ordered by surgeon
• Notify surgeon if drainage is greater than 100 mL/hour
• Change drainage system when 2/3 full

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 CHAPTER 2 Surgery 29

and the room cleared of clutter. Special required equipment,

as directed by the postanesthesia nurse, is gathered. An emesis
basin and tissue are available. The nurse is ready to assess the
client in an organized manner, focusing on the body system
B affected by surgery.
A Upon the client’s arrival in the clinical unit, the nurse
assists in transferring the client to the bed. Nursing assess-
ment and care of the client upon admission to the clinical unit

COURTESY OF DELMAR CENGAGE LEARNING

includes the following:
• Time of arrival in unit
• Transfer from cart to bed
— Place bed in lowest, locked position, with side rails up
— Place client in position of comfort, or as ordered
• Vital signs including airway assessment and breath
sounds
Figure 2-8 Common Drainage Devices; A, Hemovac; • Color of skin, nail beds, and lips
B, Jackson-Pratt • Skin condition (moist or dry, warm or cool)
PACU are asked to squeeze the postanesthesia nurse’s hands • Level of consciousness
and to plantarflex and dorsiflex the feet. • Activity level
• Intravenous infusion
Continuing Nursing Care — Type of solution
in the PACU — Amount in bottle or bag
After the client has been admitted and assessed in PACU, the — Flow rate
postanesthesia nurse checks the surgeon’s and the anesthesia — Appearance and location of IV site
provider’s orders and initiates any therapy designated for the • Dressings
PACU. — Amount and character of drainage
The postanesthesia nurse charts on a separate nursing • Drains and tubes
record for the PACU. Anything unusual must be adequately
documented. If vital signs are in the normal range, the post- — Intactness and function
anesthesia nurse checks them every 15 minutes. If vital signs — Connection to drainage and/or suction
are unstable, they are checked every 5 minutes or as often as — Amount and character of drainage
necessary until stable. If vital signs fail to stabilize, the sur- • Urinary output
geon and anesthesia provider are notified. The surgical site is — Need to void or time of voiding
checked at least every 30 minutes. If any initial bleeding has
not subsided, the surgeon is notified. Routine checks are con- — Presence of patency and catheter; output/hour
tinued until the client is discharged from the PACU. • Pain
The postanesthesia nurse determines whether the client — Last dose of analgesia
meets the criteria for discharge from the PACU. Typically, — Current pain location, intensity, quality
the client’s vital signs are stable and within the client’s normal • Compare assessment with PACU report
limits. The Aldrete Score is 8 to 10. If the score is 7 or less,
a surgeon’s or anesthesia provider’s order is required for dis- • Call light within reach
charge. Also before client discharge, the dressing is checked, — Reorient client to usage
changed, or reinforced according to orders. All other param- • Location of family or significant others
eters are reassessed and charted. Institutional protocol dictates • Postoperative orders
minimum stay in the PACU. Adults are typically kept in the A brief assessment, including vital signs, is completed
PACU for a minimum of 1 hour, except outpatients, who every 15 minutes for 1 hour; every 30 minutes for 2 hours;
go to the ambulatory surgery unit when they are awake and and every hour for 4 hours, or as prescribed by the physician.
when postmedication time is fulfilled. Children are typically The possibilities of postanesthetic complications continue,
kept in the PACU until they are awake, stable, and have an but as time passes, different postsurgical complications may
Aldrete Score of 8 to 10. When criteria for discharge are met, develop; the nurse is responsible for managing these.
the postanesthesia nurse calls the clinical unit or ambulatory
surgery unit and reports the client’s name, vitals, surgery, and 1. The client is at risk for Ineffective Airway Clearance caused
any other pertinent information. The client is then transferred by atelectasis and hypostatic pneumonia. Respiratory
to the appropriate unit. complications can still occur with any anesthetized cli-
ent. As in the PACU, the postoperative client is at
risk for ineffective airway clearance, ineffective breath-
Later Postoperative ing patterns, and aspir.ation. Now, however, nursing
Nursing Care measures are directed toward preventing ineffective air-
way clearance caused by atelectasis and hypostatic pneu-
Before the client’s arrival in the clinical unit, the nurse prepares monia, both of which usually occur within the first 48
for the client. The linen is changed, the bed linen folded down, hours postoperatively. In postoperative atelectasis, the

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30 UNIT 1 Essential Concepts

Table 2-4 Additional Nursing Care According to Classification or

Type of Surgical Procedure
CLASSIFICATION OR
TYPE OF SURGICAL
PROCEDURE NURSING CARE
Orthopedic • Expose wet casts to the air.
• Check surgeon’s orders for positioning of client; operated extremities typically are elevated.
• Check for digital warmth, color, mobility, circulation (pulses), and sensation in affected
extremity.

Urologic • Attach all catheters to drainage.

• Closely monitor continuous irrigation to ensure that flow in and flow out are equal; if obstruct-
ed, the bladder could rupture.
• Increase or decrease irrigation flow rate according to amount of bleeding.
• Assess for chills or elevated pulse, possibly indicative of hemolysis or bacterial infection.
• Assess abdomen for signs of distension and rigidity and report, especially if client complains.

Oral • Suction frequently and carefully around sutures.

• Observe breathing; ensure that drainage or packing does not obstruct airway.
• Apply ice bag, when ordered.
• Remove dental packs as ordered and assess every 15 minutes for further bleeding.

Eye, ears, nose, and Eye surgery • Assess for facial paralysis.
throat (EENT) • Minimize head movement, coughing, vomiting, and restlessness.

Ear surgery • Assess edema and tracheal patency (listening for stridor and observing
for restlessness).

Nose surgery • Maintain open airway; suction orally; and apply ice.

Tonsillectomy • Place on side to facilitate drainage: elevate head of bed; have

suction available; and observe closely for bleeding, vomiting, and
obstruction.

Neurologic • Assess level of consciousness; be alert to drowsiness, slurred speech, disorientation, or

irritability that differs from that exhibited in the preoperative state.
• Observe for pupil changes: inequality, constriction, and nonreactivity to light.
• Assess for respiratory changes such as snoring, retraction of cheeks and trachea, shallow-
ness, and slowed rate.
• Monitor blood pressure and pulse; an elevated blood pressure coupled with a lowered pulse
leads to shock.
• Observe extremity movement for weakness, paralysis, and rigidity; observe for unilateral
drooping of facial features.
• Use caution when medicating.

Laminectomy or • Move only as ordered.

discectomy • Assess sensation, circulation, and motion of extremities distal to
incision.

Craniotomy • Position as ordered.

• Complete a neurological check.
• Use Trendelenburg position only with permission of the surgeon

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 CHAPTER 2 Surgery 31

Table 2-4 Additional Nursing Care According to Classification or

Type of Surgical Procedure (Continued)
CLASSIFICATION OR
TYPE OF SURGICAL
PROCEDURE NURSING CARE
Vascular (all grafts, • Assess color, sensation, warmth, and mobility of extremity.
carotid endarterectomy, • Observe presence and strength of pedal and post-tibial pulses.
femoral-popliteal bypass)
• Complete a neurological check for carotid endarterectomy.
• Frequently check all dressings and the area directly beneath the client.
• Drainage can roll around a curved body part leaving the dressing appearing dry. However,
check the area directly under curved body structures for bleeding.

Thoracic • Closely observe chest tube for patency, amount of bleeding, and air leaks. Tape all connec-
tions. Mark drainage container upon client’s admission and discharge. Assess fluctuation of
drainage in tubing. Attach suction as ordered.
• Observe respirations closely with regard to color change, restlessness, apprehension, dysp-
nea, or mediastinal shift.
• Elevate head of bed 30°, unless contraindicated.
• Encourage coughing and deep breathing.
• Use caution in administering narcotics, especially morphine sulfate, as client cannot afford
respiratory depression.

Pneumonectomy

COURTESY OF DELMAR CENGAGE LEARNING

• Do not turn on nonoperative side. Alternately turn from back to oper-
ated side.

Lobectomy and • May turn client to either side.

resection

Gynecologic • Assess vaginal drainage.

bronchioles of the lungs become plugged with mucus so ask the client to forcefully dorsiflex the foot. If pain is felt
that air cannot reach the alveoli. The alveoli then collapse. in the calf of the leg, it is considered a positive Homans’
The client develops dyspnea, fever, tachypnea, tachycar- sign; if no pain is felt, it is considered a negative finding.
dia, and cyanosis. In postoperative hypostatic pneumo- A positive Homans’ sign may indicate thrombophlebitis
nia, stagnant mucus promotes the growth of bacteria, and is reported to the surgeon. Deep vein thrombosis
and atelectasis then develops into a secondary infection. and thrombophlebitis may lead to a pulmonary embolus,
To prevent these complications, actively encourage the although there is no warning of pulmonary embolism.
client to cough, deep breathe (with and without incen- When pulmonary embolism occurs, the client experi-
tive spirometry), and turn as instructed preoperatively. ences dyspnea, chest pain, cyanosis, cough, hemoptysis,
Encourage the client to sit up and ambulate as soon and tachycardia, and fever coupled with an elevated white
as often as ordered. Ensure adequate pain relief measures blood cell count. If the embolism is large enough, shock
so that mobility is well tolerated. develops rapidly. Pulmonary embolism may be fatal.
2. The client is at risk for Peripheral Neurovascular To prevent the formation of deep vein thrombosis,
Dysfunction, Excess/Deficient Fluid Volume, and Activity thrombophlebitis, and pulmonary embolism, encour-
Intolerance. The client continues to be at risk for decreased age the client to ambulate to the extent the client is
cardiac output and fluid volume deficit. Implement mea- able. When in bed, encourage the client to perform
sures to prevent deep vein thrombosis, thrombophlebitis, postoperative leg exercises each hour. Antiembolism
pulmonary embolism, complications of fluid overload, stockings are ordered, or a sequential compression
fluid deficit, hypokalemia, and syncope. device, which is a boot applied to the legs to simulate
The stress response to surgery, inactivity, pressure walking by alternate inflation. Remove the boots and
related to body position, obesity, and injury to pelvic antiembolism stockings every day to cleanse the skin.
veins during surgery contributes to the formation of Antiembolism stockings and the sequential com-
deep vein thrombosis, thrombophlebitis, or pulmonary pression device are not substitutes for leg exercises.
embolism. These complications may appear immediately Encourage the client to perform leg exercises.
after surgery or 1 to 2 weeks later. Routinely assess for a When ordered, low-molecular-weight heparin, en-
positive Homans’ sign and for warm, tender, reddened, oxaparin (Lovenox), is administered to hemostatically
hardened areas in the calves. To assess for Homans’ sign, stable clients who have undergone pelvic, abdominal,

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32 UNIT 1 Essential Concepts

or thoracic surgery. It is given subcutaneously every 12 abdominal distention might include irrigation of the
hours or daily as ordered until discharge. If preopera- nasogastric tube, if present. Irrigating the nasogastric
tive INR levels were within normal range, no labora- tube may also relieve hiccups.
tory test is necessary to determine the drug’s effect. Constipation is a major source of discomfort for the
The regimen is ordered at the surgeon’s discretion. client. Analgesics combined with decreased activity and
Measure intake and output and monitor laboratory NPO status are very constipating. Oral fluids and activ-
findings (e.g., electrolytes, hematocrit, hemoglobin, ity are encouraged. If ordered, the medical regimen of
and serum osmolality) and signs and symptoms of stool softeners and suppositories are indicated.
hemorrhage by assessing vital signs, skin color and con- 4. The client is at risk for developing Urinary Retention
dition, dressings, drains, and tubes, as in the PACU. related to anesthesia, immobility, and pain. The cli-
Clients often experience syncope when changing ent is also at Risk for Infection related to Foley catheter
from a lying position to a sitting or standing position. placement. The quantity and quality of urine are more
Assist the client to change positions slowly, proceed in directly related to cardiac output and the perfusion of
steps, and allow time for the client’s internal equilibrium the kidneys than to anesthesia, immobility, and pain;
to adjust. Check the radial pulse frequently and ask the although a stress response following surgery causes the
client if he is dizzy or nauseated. If syncope occurs body to retain fluids for 24 to 48 hours after surgery.
during ambulation, ask for assistance in obtaining a Urine output should be at least 30 mL per hour if a cath-
wheelchair for the client, use a nearby chair, or lower eter is in place. The catheter is assessed for patency. If not
the client to the floor until the client recovers. Although catheterized, the client should void at least 200 mL at the
frightening for the client, syncope is not physiologically first postoperative voiding. Most clients void within 6 to
threatening unless the client is injured in a fall. 8 hours after surgery; however, urinary retention occurs
3. The client may be at risk for Imbalanced Nutrition: Less frequently in the postoperative period, especially follow-
than Body Requirements related to nausea and vomiting, ing abdominal or pelvic surgery. Anesthesia depresses
hiccups, abdominal distension, constipation, and NPO the urge to void. Narcotics, vagolytic agents (anticho-
status. Gastrointestinal complications become more linergics), and spinal anesthesia also interfere with the
prevalent after immediate postoperative recovery. The ability to initiate voiding. Facilitate voiding by encour-
client may also experience pain related to hiccups and aging fluid intake and assisting the client to void in an
slowed gastrointestinal function. anatomically correct position depending on the client’s
Anesthetic agents, narcotics, hypotension, and the condition. Privacy, running water, indirect bladder pres-
manipulation of the bowel during surgery cause nausea sure (placing a firm hand over the bladder), and warm
and vomiting. Handling of the bowel during pelvic and water over the perineum may also encourage voiding.
abdominal surgery causes peristalsis to stop or severely If the client has not voided, use a noninvasive bladder
slow. Bowel function normally returns 2 to 5 days after ultrasound instrument to measure the bladder volume.
surgery. If bowel inactivity persists, a paralytic ileus If the facility does not have a bladder scanner, palpate,
develops. As bowel function resumes, continue to assess inspect, and percuss the bladder to check for distention.
the client for bowel sounds and, if a nasogastric tube is The surgeon orders a Foley catheter inserted if the client
present, a reduction in drainage. As peristalsis returns in a has a distended bladder or has not voided after 8-10 hours.
discontinuous fashion, the client experiences distention 5. The client may become at risk for Disturbed Sensory
along with flatulence and gas pains. After bowel sounds Perception related to anesthesia, narcotics, change of
resume in all quadrants, the client is removed from NPO environment, fluid and electrolyte imbalances, sleep
status according to the surgeon’s orders. Provide good deprivation, hypoxia, and sensory deprivation or over-
oral hygiene when the client is NPO and administer load. The client may also experience Acute Pain related
antiemetics as needed for nausea and vomiting. to the surgical incision; Hypothermia related to anesthe-
Hiccups are caused by irritation of the phrenic sia and surgical environment; and Hyperthermia related
nerve. Impulses then cause the diaphragm to contract to infection. Alterations in neurological function vary
rhythmically and violently. Abdominal distention, and manifest as pain, fever, or delirium. Assessing the
gastric distention, and the presence of a nasogastric level of consciousness is a priority. A change in level
tube are common causes, but electrolyte and acid– of consciousness may be the first indication of a stroke
base disturbances, intestinal obstruction, and intra- and/or increased intracranial pressure. Determining
abdominal bleeding also initiate hiccups. Notify the the level of consciousness is difficult, especially in the
surgeon when hiccups are prolonged. elderly client or at night, when clients are groggy from
Gas pains and signs and symptoms of abdomi- being awakened. Often, thoughts will clear if the client
nal distention are minimized by early and frequent is given the opportunity to thoroughly awaken. Encour-
ambulation and resumption of oral intake. Frequently aging the presence of loved ones, offering explanations,
repositioning the client encourages movement of air and listening to the client decreases sensory percep-
through the intestines, relieving gas pains. As air rises tual alterations. Encouraging previous sleep patterns,
and peristalsis moves from right to left, the client is providing uninterrupted sleep, and alternating rest and
moved from lying on the left side (where air will rise activity also is beneficial.
on the right), to lying supine, to lying on the right side Assess and record subjective data regarding pain
(where air will rise on the left). If the client can toler- location, intensity on a scale of 0 to 10, quality,
ate it and there are no contraindications, lying prone and duration as well as factors contributing to pain.
with the head turned to the side places pressure on Objective data such as grimacing and crying are also
the abdomen, forcing air to rise and move out through recorded. Analgesics are usually ordered for admin-
the rectum. Other nursing care measures to relieve istration via patient-controlled analgesia (PCA) or
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 CHAPTER 2 Surgery 33

epidural analgesia or intravenously, intramuscularly, an area of extensive tissue removal to begin healing. The
or orally, all on a PRN (as needed) basis. Encour- edges of the wound are closed 4 to 6 days later. Because
age the client to ask for medication before the pain areas of granulation tissue are brought together at this
becomes severe. Offer medication before activity or time, the scar is usually much wider (Figure 2-9).
painful procedures such as wound irrigation. Attend Wound dehiscence and evisceration are serious com-
to analgesic requests promptly. Ensuring comfort plications of wound healing. Dehiscence occurs when
encourages the client’s full participation in coughing, the wound edges separate. Evisceration occurs when
deep breathing, turning, and ambulation. the wound separates completely and the viscera pro-
Hypothermia is common in the first few hours fol- trude from the wound (Figure 2-10). Both are more
lowing surgery. Offer blankets as needed. Because of likely to occur 7 to 10 days after surgery and are pre-
the normal inflammatory response, temperature may ceded by a sudden spillage of serosanguinous drainage.
later elevate to a low-grade fever. If temperature rises
higher than 101°F, notify the surgeon. Atelectasis and
dehydration cause elevated temperature (higher than
101°F) in the first 24 to 48 hours after surgery. After
48 hours, temperature higher than 101°F indicates a
wound, respiratory, or urinary tract infection; throm-
bophlebitis; or pulmonary embolism.
The nurse’s primary role is to prevent infection by
using aseptic technique. Once a fever has occurred,
follow orders to ascertain the cause of the elevation by
taking urine, wound, blood, or sputum cultures. Admin-
ister antipyretics as ordered. Providing light covers and
clothing, performing frequent linen changes, offering
cool washcloths, and ensuring a cool environment are
measures that may increase comfort.
6. The surgical client is at Risk for Impaired Skin Integrity
and Risk for Infection related to surgical incision. The
nurse generally does not remove the primary dressing A
without an order to do so. Bleeding is monitored by
circling the drainage on the dressing and then reas-
sessing later to ascertain whether the drainage area has
increased in size. The dressing also is reinforced with
additional absorbent dressings as needed. In some insti-
tutions, the dressing is changed as necessary after the
first dressing change. Some surgeons prefer no dressing
if there is no drainage or drains.
Drainage on dressings and in drains typically
changes from sanguinous to serosanguinous to serous
over several hours to several days, depending on the
type of surgery. The amount also decreases over the
same time period. Purulent, odorous drainage is a sign
of infection. A sudden increase in drainage is a sign of
impending wound separation. Always notify the sur-
geon of any excessive or abnormal drainage. B
All wounds heal by primary, secondary, or tertiary
intention. In primary intention, the wound layers
are sutured together and have no gaping edges. The
wound generally heals in 8 to 10 days but may take up
to 3 months. There is minimal scar formation. Most
surgical wounds are of this type.
In secondary intention, the wound heals by filling
in with granulation tissue and by contracting where
the skin edges are not approximated. This method
COURTESY OF DELMAR CENGAGE LEARNING

is used for ulcers when there is not enough tissue to

approximate the edges or for infected wounds when
drainage is desirable. Wounds healing by secondary
intention are assessed according to the presence of
granulation tissue having a red, granular appearance.
Wound healing is slow, possibly taking many months
or years. Thus wound healing by primary intention is C
preferable.
In tertiary intention, the approximation of tissue Figure 2-9 Wound Healing; A, Primary Intention;
edges is delayed. This allows an infection to drain or B, Secondary Intention; and C, Tertiary Intention

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34 UNIT 1 Essential Concepts

The major principles to keep in mind when cleans-

ing a surgical incision are:
• Use Standard Precautions at all times.
• Use a sterile swab or gauze and work from the

COURTESY OF DELMAR CENGAGE LEARNING

clean area out toward the dirtier area. Begin over
the incision line and swab downward from top to
bottom. Change the swab and proceed again on
either side of the incision, using a new swab each
time (Figure 2-11).
A B The surface closures (staples or sutures) are
removed as the incision heals. Continuous sutures are
Figure 2-10 A, Dehiscence; B, Evisceration made with one thread and tied at the beginning and
end of the suture line. Intermittent sutures are each
tied individually. In blanket continuous sutures, the
Dehiscence and evisceration are more likely to occur single thread is grounded again in the last suture exit
in the very elderly client, the malnourished client, the (Figure 2-12). Some surgical wounds are closed with
client with an infection, or the client with abdominal dissolvable sutures and special tape strips and others
distention who is straining severely. If evisceration with special adhesive glue. The dissolvable sutures
occurs, the viscera is immediately covered with sterile are not removed and the glue wears off. Sometimes
saline dressings and the surgeon notified of the wound no bandage is applied when the wound is closed with
disruption. glue.
When dressings are changed, the surgical incision is The incisional dressing keeps the incision clean
cleansed to remove debris and bacteria from the inci- and protects it from physical trauma and bacterial
sion. The choice of cleansing agent depends on the invasion. Generally, the same kind of dressing is put
physician’s prescription as well as institutional proto- on as was taken off. As the incision heals and drainage
col. It is recommended that isotonic solutions such as lessens, a small, thinner dressing usually is applied.
normal saline or lactated ringers be used. Bandages and binders are applied over the incision

3
1
2 7 8
5 6
3 4
1 2

A B
COURTESY OF DELMAR CENGAGE LEARNING

1 2 3

Figure 2-11 Use a clean, sterile swab for each stroke when cleansing a surgical incision. A, Gently clean the incision, then each side
alternately; B, Gently wipe swab outward, away from the incision; C, Clean around a drain site in a circular motion.

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 CHAPTER 2 Surgery 35

Postoperative Care
For proper home care, the client and family must
A be given information about the following topics:
• Medication regimen
• Diet
• Activity restrictions
• Follow-up appointments
• Wound care
• Special instructions
B
The specifics for each topic will vary with each cli-
ent and will depend on the surgical procedure and
the client’s age and physical condition.

Binders are bandages made for specific body parts,

COURTESY OF DELMAR CENGAGE LEARNING

C usually the abdomen or arm (sling) (Figure 2-14).

Abdominal binders support the abdomen of an obese
client following abdominal surgery. A sling is a cloth
support with adjustable straps that wrap around the
back to provide support for an injured arm; it main-
tains the arm in a set position.
D During dressing changes and after the dressing
has been removed, the surgical wound is assessed
Figure 2-12 Skin Closure Methods; A, Continuous; for skin edge approximation, edema, and bleeding.
B, Intermittent; C, Blanket Continuous; D, Staples
The skin edges may be slightly reddened and swol-
len from the normal inflammatory response. Possible
signs of a wound infection include increased suture
dressing to secure, immobilize, or support a body tension, warmth, erythema, drainage, odor, pain, and
part; to hold the dressing in place; or to prevent or induration around the incision site. Wound healing
minimize swelling of a body part. Bandages are long is enhanced by promoting nutrition, discouraging
rolls of material, such as gauze, webbing, or muslin, smoking, and performing proper wound cleansing.
designed for wrapping around body parts. Figure 2-13 The practice of aseptic technique cannot be empha-
illustrates several different methods of bandaging. sized enough in preventing nosocomial infections in
a surgical incision.
7. Clients are at risk for Anxiety or Ineffective Coping related
to disturbance in body image, change in lifestyle, finan-
cial strain, or a poor prognosis. Many clients undergo
Dressing Wounds a psychological adjustment to surgery. Taking time to
listen to the client as well as offering simple explanations
• Because of early discharge, clients are often and reassurances supports the client needs to combat
sent home with incisions that need dressing anxiety.
changes. As the client recovers and is ready for discharge
• Ascertain the client’s support system, including
from the hospital, the client is at risk for Deficient
Knowledge related to home care. Ideally, the client
caregivers, the home environment, and avail-
receives home care instructions from the moment
able resources. of admission. Adequate teaching about home care
• Teach the client and/or home caregiver the cor- results in a quicker recovery, fewer complications, and
rect method of changing the dressing. greater independence.
• Have the client and/or home caregiver change Minimally invasive surgery (MIS) is replacing
the dressing before the client is discharged. much of the traditional types of surgery. MIS is
completed with three to five small incisions in which
• Provide a list of signs and symptoms of compli- a videoscope and specialized instruments are inserted
cations of wound healing. into the small incisions to complete the surgery (see
• At times, a referral for home care nursing is nec- Figure 2-15). The same traditional type of surgery
essary. would require a much longer incision through larger
areas of tissue and muscle. The layout of the surgical

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36 UNIT 1 Essential Concepts

3
5 2
4
B 6
8

COURTESY OF DELMAR CENGAGE LEARNING

Figure 2-13 Common Bandaging Methods; A, Circular turns are wrapped around a body part several times to anchor the bandage
or supply support. B, Spiral turns begin with a circular turn and then proceed up the body part, with each turn covering two-thirds the
width of the preceding turn. C, Spiral reverse turns begin with a circular turn. The bandage is then reversed or twisted, once each turn, to
accommodate a limb that gets larger as the bandaging progresses. D, Figure-eight turns crisscross in the shape of a figure eight and are used
on a joint that requires movement. E, Recurrent turns are anchored with circular turns, follow a back-and-forth motion, and are completed
with circular turns; they are used to cover a fingertip, head, or residual limb.

room is different than the usual surgery suite. See the various system chapters (Ohio State University
Figure 2-16 for a layout of the surgical room and Medical Center, 2009; George Washington University
surgical system of a console, patient cart, and vision Hospital, 2009).
cart. Abdominal, thoracic, pelvic, and spine surgeries
are performed by MIS. The advantages of MIS are
less postoperative pain, decreased hospital stay, less
risk of infection, prompt return to normal activities
AMBULATORY SURGERY
and work, and less overall postoperative complica- Ambulatory surgery is defined as surgical care performed
tions. Specific MIS surgery is discussed throughout under general, regional, or local anesthesia involving less than

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 CHAPTER 2 Surgery 37

Image not available due to copyright restrictions

COURTESY OF DELMAR CENGAGE LEARNING

Figure 2-14 Common Binders: A, Abdominal; B, Arm Sling

24 hours of hospitalization. Other names for ambulatory

surgery include same-day, one-day, outpatient, in and out, or
short-stay surgery.
The trend in health care is to promote wellness. Clients
are encouraged to accept more personal responsibility for
their state of health. In the past, the message sent to clients
was that the client is sick, and the medical community will

PROFESSIONALTIP
provide all care. Today, ambulatory surgery clients are sent
Ambulatory Surgery an entirely different message: that the postoperative client
is not sick and, except for a few minor limitations, can often
• Precertification documents are approved before resume normal daily activities soon after undergoing anes-
the preadmission visit. thesia and surgery.
• Preadmission diagnostic tests, preoperative Ambulatory surgery provides the longest period of time
nursing assessment, and initial teaching are usu- for the client to receive skilled postoperative care or monitor-
ally performed the day before the scheduled ing without formal admission to the hospital. The practice of
surgery.
ambulatory surgery attempts to overcome the risk of premature
dismissal while meeting fiscal requirements. The emphasis
• On the day of surgery, care is focused on the on cost containment coupled with government reductions in
immediate needs of the client. Medicare and Medicaid payments has further promoted the
concept of ambulatory surgery.

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38 UNIT 1 Essential Concepts

Image not available due to copyright restrictions

To further reduce health care costs, few clients are admit- ies such as open-heart surgery (a coronary artery bypass),
ted to the hospital before the day of surgery. Most surgical craniotomy, or total joint replacement are admitted the day
clients are processed through the ambulatory surgery unit. of surgery. Then, after discharge from the perioperative suite,
These clients are called “day of surgery” or “A.M. admit” the client either is admitted to the hospital as an inpatient or is
clients. Necessary laboratory work, radiology tests, or other sent home from the ambulatory surgery unit.
examinations are completed on an outpatient basis before In addition to fiscal considerations, the growth of
the day of surgery. Even clients undergoing extensive surger- ambulatory surgery can also be traced to technological

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 CHAPTER 2 Surgery 39

advances. Clients now require shorter recovery periods as assessments were added to the Aldrete Score for this pur-
a result of new procedural technology, such as laparoscopic pose (Table 2-2). Attainment of these criteria indicates that
cholecystectomy. The introduction of shorter-acting anes- clients can care for themselves at home and accomplish
thetic agents also decreases the immediate postoperative activities of daily living independently and safely. The
recovery time, facilitating the client’s ability to function points are totaled at regular intervals (usually every half
independently upon discharge from the ambulatory surgery hour), and clients are discharged home when their total
setting. score is 18 or higher.
The benefits of ambulatory surgery are many. Ambu-
latory surgery decreases cost to the client, institution,
insurance carriers, and governmental agencies. The risk of
acquiring a nosocomial infection is also decreased. The client ELDERLY CLIENTS HAVING
experiences less disruption to personal life and less psycho-
logical distress related to hospitalization. With ambulatory
SURGERY
surgery, the client especially benefits from early postoperative Elderly clients (older than 65 years of age) are at risk
ambulation. for developing complications from surgery or anesthesia.
Ambulatory surgery is performed in several differ- Unfortunately, because an increased incidence of disease
ent settings. Hospital-based integrated facilities are formal correlates with increasing age, more elderly clients require
ambulatory surgery programs incorporated into existing surgery than does any other age group. As the percentage of
inpatient surgery programs. Clients are cared for preop- elderly persons in the whole population rises, the number
eratively and postoperatively in the ambulatory surgery unit of surgeries on elders is increasing. Because of the complex
but are mixed with inpatients on the OR schedule. This needs of the elderly client undergoing surgery, knowledge
type of facility also allows preoperative processing of day- in promoting health and rehabilitation in the elderly client
of-surgery clients. Hospital-affiliated facilities consist of a is necessary.
separate department with designated preoperative, intraoper- Surgery is a stressor. Because of depleted energy sources,
ative, and postoperative areas. Such a facility is located within the elderly client may not have sufficient resilience to react
the hospital, adjacent to the hospital, or at a satellite location. defensively to this stressor. The risk of complications from
Freestanding facilities are independently owned and operated surgery further increases in elderly clients who have one or
and are not affiliated with a hospital or medical center. In the more chronic diseases. In these clients, surgery then can be
past, physicians generally owned such facilities, but today the source of a downward spiraling effect toward debilitation
the trend is for health care corporations to own these facili- or possibly death.
ties. Some doctors’ offices also have facilities for performing Elderly clients vary in their abilities to respond to the
minor ambulatory surgery. stress of surgery. Physiologic changes related to the aging
The Aldrete Score has been modified for use with process inhibit the elderly client from readily coping with sur-
clients having anesthesia on an ambulatory basis. Five gery. The number of physiologic changes in the very elderly

Table 2-5 Physiologic Changes of Aging and Related Postoperative

Nursing Interventions
BODY SYSTEM CHANGES NURSING INTERVENTIONS

Cardiovascular • Decreased elasticity of the vascular • Closely monitor vital signs and peripheral pulses
system • Encourage early ambulation
• Decreased cardiac output • Use antiembolism stockings
• Decreased peripheral circulation • Monitor intake and output, including blood loss
• Monitor preoperative response to activity and com-
pare to postoperative response

Respiratory • Decreased vital capacity • Closely monitor respirations

• Decreased alveolar volume • Auscultate breath sounds frequently
• Decreased movement of cilia • Encourage coughing and deep breathing
• Turn frequently
• Monitor oxygen saturation

(Continues)

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40 UNIT 1 Essential Concepts

Table 2-5 Physiologic Changes of Aging and Related Postoperative Nursing

Interventions (Continued)
BODY SYSTEM CHANGES NURSING INTERVENTIONS
Urinary • Decreased glomerular filtration rate • Monitor intake and output every 1 to 2 hours
• Decreased bladder muscle tone • Assist frequently with toileting
• Weakened perineal muscles • Monitor fluid and electrolyte status

Gastrointestinal • Decreased gastric and intestinal • Assess for obesity and malnutrition
motility • Encourage fluids and activity
• Altered digestion and absorption • Encourage high-protein foods and supplements
• Decreased food consumption • Assist with meals as needed
• Provide companionship during mealtime

Immunological • Decreased level of gamma globulin • Follow strict aseptic technique

• Decreased plasma proteins • Monitor temperature
• Assess incision site

Neurological • Decreased conduction velocity • Allow use of glasses and hearing aids
• Decreased visual acuity • Orient to environment
• Loss of hearing • Provide for safe environment
• Decreased sensation • Repeat information as needed
• Use medications sparingly
• Provide written instructions
• Allow for extra education time

Integumentary • Lack of elasticity • To prevent shearing forces on skin when positioning

• Loss of collagen client, lift rather than slide client

• Decreased subcutaneous fat • Pad bony prominences

• Use tape that is easy to remove
• Use warm prepping solutions, irrigating solutions,
and IV solutions intraoperatively

COURTESY OF DELMAR CENGAGE LEARNING

• Provide extra blankets
• Ensure warm room temperature
• Turn frequently
• Encourage early ambulation

client (older than 80 years of age) is markedly greater than ferently to similar situations. Simply talking with the client
that in those in their sixties and seventies. Breathing capacity, to provide information or listening to the client’s fears helps
renal blood flow, cardiac output, and conduction velocity of prepare the client for upcoming surgery.
the nervous system all diminish. Table 2-5 lists the physi- Third-party reimbursement policies often require
ologic changes in the elderly client along with correlating elderly clients to undergo surgical procedures on an outpa-
nursing interventions for postoperative care. Aging affects all tient basis. Because many elderly clients have neurological
body systems, and the nurse’s knowledge of these changes and deficits and other chronic disease processes, the elderly
the interventions geared toward each assist in preventing and outpatient poses a particular challenge. Additional post-
detecting complications of surgery. operative self-care deficits may result from the surgical
The elderly client has a lifetime of experiences that procedure and the effects of anesthesia. Elderly clients often
affects the response to surgery. A lifetime of watching family live alone and lack the support systems necessary for home
and friends experience surgery, illness, and death particularly care. In order to provide realistic discharge planning, the
influences personal reactions to impending surgery. Because nurse assesses the ability of the client, family, and friends to
of the variation in such experiences, each client reacts dif- provide care at home.

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 CHAPTER 2 Surgery 41

CASE STUDY
G.S., a 74-year-old retired school teacher who is married and the father of four and the grandfather of
sixteen, weighs 275 lbs. He has undergone a right hemicolectomy, wherein the right side of his colon was
removed because of cancer. He has a history of smoking but has no other health problems. The surgery was
uncomplicated, and he is in the PACU. He has a midline incision with a Penrose drain and a stab wound with
a Jackson-Pratt drain adjacent to the incision. He also has a nasogastric tube attached to low intermittent
suction. He is alert and oriented and moves all four extremities freely. His blood pressure is normal for him in
comparison to his preoperative levels. He is breathing regularly and easily at a rate of 16 breaths per minute,
and his skin color is normal. His oxygen saturation, however, is 86% with additional oxygen given via mask.
The following questions will guide your development of a nursing care plan for the case study.
1. What risk factors for developing postoperative complications can you identify for G.S.?
2. What is his Aldrete Score at this point?
3. What nursing measures can you institute to promote oxygenation?
4. What type of drainage is expected from the incision and the drains during the first 1 to 2 days?
5. What nursing observations can be made and reported to indicate to the surgeon that the nasogastric tube can
be removed?
6. What nursing measures can be implemented to prevent deep vein thrombosis, thrombophlebitis, and pulmo-
nary embolism?
7. Write and prioritize three individualized nursing diagnoses and goals for G.S.
8. What information will G.S. need before discharge?

SUMMARY
• Surgery is a major stressor for all clients. Anxiety and • Nursing care in the OR focuses on the safety and
fear are normal. Fear of the unknown is both the most protection of the client.
prevalent fear before surgery and the fear easiest for the • Postoperative nursing assessments are completed in an
nurse to help the client overcome. organized manner, focusing first on the priorities of airway,
• The outcome of surgical treatment is tremendously breathing, and circulation, and then on the body system
enhanced by accurate preoperative nursing assessment and affected by surgery.
careful preoperative preparation. Information gathered • The nurse prevents the formation of deep vein thrombosis,
through preoperative assessment and risk screening is later thrombophlebitis, and pulmonary embolism through
used to prepare the surgical site, for surgical positioning, encouraging early ambulation and postoperative leg
and as a comparative basis for postoperative assessments exercises and by providing antiembolism stockings and/or
and complication screening. sequential stockings, if ordered.
• The teaching methods that the nurse uses strongly • Ambulatory surgery is defined as surgical care
influence the degree of learning and the retention of performed under general, regional, or local anesthesia
information. and involving fewer than 24 hours of hospitalization.
• Aseptic technique is a collection of principles used to Cost containment, governmental changes, and
control and/or prevent the transfer of microorganisms technological advances promote the concept of
from sources within (endogenous) and outside ambulatory surgery.
(exogenous) the client. All clinical nursing units • Because of the physiologic changes and complex needs
practice these principles. The sterile conscience governs of the elderly client undergoing surgery, the nurse’s
personal behavior with regard to adherence to aseptic knowledge assists in promoting health and rehabilitation
technique. in the elderly surgical client.

REVIEW QUESTIONS
1. Client education is: 2. A client is scheduled for surgery. The role of the
1. completed when time allows. nurse in obtaining consent includes:
2. started when discharge is scheduled. 1. judging the quality of the explanation and
3. always more beneficial when completed in a ascertaining the client’s understanding of the
structured group setting. consent form.
4. directed toward the client’s family when the client 2. acting as a witness to the signature of the
is unable to learn. client.

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42 UNIT 1 Essential Concepts

3. administering the preoperative medication before 7. The surgical client’s most common fear is of the
the client signs the consent. unknown. The nurse can ease the client’s fears by:
4. ensuring that coercion was used to obtain the 1. listening to the client’s concerns about surgery.
client’s signature on the consent. 2. taking time from busy schedule and sitting beside
3. Upon the client’s admission to the PACU, the nurse the client for a few minutes.
knows to first: 3. asking the client’s family to stay with the client.
1. take the client’s blood pressure. 4. teaching the client about the surgical process and
2. assess the airway. answer questions.
3. assess the client’s level of consciousness. 8. A 73-year-old client is scheduled for prostate surgery.
4. check the incision site. His vital signs are T 98.2, P 74, R 14, and BP160/92.
4. The nurse is making a preoperative assessment on a He drinks heavily and smokes a pack of cigarettes
client. Of the following findings, the most important a day. What is the client’s risk factors pending his
item to know for a client who is having general upcoming surgery? (Select all that apply.)
anesthesia is: 1. Hepatic status.
1. hearing impaired. 2. Fluid and electrolyte status.
2. a right-leg amputee. 3. Age.
3. color blind. 4. Cardiovascular status.
4. a smoker. 5. Respiratory status.
5. The nursing intervention that has the greatest 6. Musculoskeletal system.
impact on reducing overall surgical risk is: 9. The PACU nurse asks a new surgical client if he has
1. encouraging activity and early ambulation. the ability to wiggle his toes and move his feet. She
2. assessing blood pressure. is assessing his: (Select all that apply.)
3. ensuring adequate nutrition. 1. hearing since that is the first sensation to return
4. monitoring intake and output. after anesthesia.
6. An elderly client is returning to the unit from 2. ability to pull his drain from the wound.
surgery. The nursing interventions specifically 3. likeliness of becoming combative after surgery.
geared toward elderly care are: (Select all that 4. ability to voluntarily move his extremity.
apply.) 5. Homans’ sign in both lower extremities.
1. carefully monitoring vital signs and peripheral 6. circulation to the extremities.
pulses. 10. A client returns to the PACU following a
2. lifting the client rather than sliding client when craniotomy. After assessing the airway, the first
repositioning. priority of the nurse is to:
3. encouraging early ambulation. 1. attach all tubes to drainage.
4. repeating information as needed. 2. place the client in Trendelenburg position.
5. following strict aseptic technique. 3. check abdomen for bowel sounds.
6. using tape that is easily removed. 4. assess level of consciousness and extremity
movement.

REFERENCES/SUGGESTED READINGS
Aldrete, J. (1995). The post-anesthesia recovery score revisited. Journal Erwin-Toth, P., & Hocevar, B. (1995). Wound care: Selecting the right
of Clinical Anesthesiology, 7(1), 89–91. dressing. AJN, 95(2), 46–51.
Association of periOperative Registered Nurses (AORN). (2002a). Fort, C. (2002). Get pumped to prevent DVT. Nursing2002, 32(9),
Artificial nails. AORN Online Journal. [Online]. Available: www. 50–52.
aorn.org/journal/2002/juneci.htm George Washington University Hospital. (2009). Thinking big about
Association of periOperative Registered Nurses (2002b). Standards, small incisions. George Washington University Hospital Health News.
recommended practices, and guidelines, Denver, CO: Author. Retrieved on April 25, 2009 at http://gwashington.uhspublications.
Brenner, Z. (1999). Preventing postoperative complications. Nursing99, com/spring2009/story1.html
29(10), 34-39. Gilchrist, B. (1990). Washing and dressings after surgery. Journal of the
Bryant, R., & Nix, D. (2006). Acute and chronic wounds: Current Wound Care Society, 86(50), 71.
management concepts (3rd ed.). St. Louis, MO: Mosby Grogan, T. (1999). Bringing bloodless surgery into the mainstream.
Burden, N., Defazio-Quinn, D., & O’Brien, D. (2000). Ambulatory Nursing99, 29(11), 58–61.
surgical nursing. Philadelphia: W. B. Saunders. Hogstel, M. (2001). Gerontology: Nursing care of the older adult. Clifton
Cizzell, J. (1994). Back to basics: Test your wound assessment skills. Park, NY: Delmar Cengage Learning.
AJN, 94(6), 34–35. Lewis, S., Collier, I., & Heitkemper, M. (2002). Medical–surgical
Crenshaw, J., & Winslow, E. (2002). Preoperative fasting: Old habits nursing: Assessment and management of clinical problems (5th ed.). St.
die hard. AJN, 102(5), 36–44. Louis, MO: Mosby.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 2 Surgery 43

Monahan, F., Sands, J., Neighbors, M., Marek, J., & Green-Nigro, Surgical Associates at Virginia Hospital Center. (2009). Surgical wound
C. (2006). Phipps’ medical-surgical nursing: Health and illness care: Frequently asked questions. Retrieved on April 25, 2009 at
perspectives (8th ed.). St. Louis, MO: Mosby. http://www.SurgicalAssociatesVHC.com
Motta, G. (1993). How moisture retentive dressings promote healing. Talabiska, D. (1995). Malnutrition in the elderly. Newlines in Multi-
Nursing 93, 23(12), 26–33. Vitamin Infusion, 4(2), 1, 2, 6.
Ohio State Universtity Medical Center. (2009). What is minimally Vernon, S., & Molnar-Pfeifer, G. (1997). Are you ready for bloodless
invasive surgery? Retrieved on April 25, 2009 at http://cmis.osu. surgery? AJN, 97(9), 40–47.
edu/8880.cfm Winslow, E., & Jacobson, A. (2001). The case against artificial nails.
Phillips, J. (1998). Wound dehiscence. Nursing98, 28(3), 33. Nursing2001, 31(10), 30.
Phillips, N. (2007). Berry and Kohn’s operating room technique (11th
ed.). St. Louis, MO: C.V. Mosby Co.
Smeltzer, S., Bare, B. Hinkle, S., & Cheever, K. (2008). Brunner
and Suddarth’s textbook of medical-surgical nursing (11th ed.).
Philadelphia: Lippincott Williams & Wilkins.

RESOURCES
Association of periOperative Registered Nurses (AORN), Intuitive Surgical, Inc.,
http://www.aorn.org http://www.intuitivesurgical.com

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 CHAPTER 3
Oncology

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of oncology nursing:
Adult Health Nursing • Endocrine System
• Surgery • Reproductive System
• Hematologic and Lymphatic Systems • Integumentary System
• Gastrointestinal System • Immune System
• Neurological System • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Explain how the behavior of cancer cells differs from that of normal cells.
• Describe the role of the nurse in cancer detection.
• Discuss three medical treatments for cancer.
• Describe four complications that can occur in advanced cancer.
• Discuss ways the licensed practical/vocational nurse can aid the client in
coping with cancer.

KEY TERMS
alopecia carcinogen neoplasm
anorexia carcinoma oncology
antineoplastic chemotherapy palliative surgery
benign curative surgery photodynamic therapy (PDT)
biologic response modifier differentiation radiotherapy
(BRM) extravasation reconstructive surgery
bone marrow transplantation leukemia sarcoma
(BMT) lymphoma stomatitis
cachexia malignant tumor marker
cancer metastasis vesicant

44

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 CHAPTER 3 Oncology 45

The ACS estimates that 1,437,180 new cancer cases were

INTRODUCTION diagnosed in the United States in 2008. Not included in this
Cancer is a disease resulting from the uncontrolled growth of estimate are basal- and squamous-cell skin cancers and nonin-
abnormal cells, which causes malignant cellular tumors. One vasive cancers except for urinary bladder cancer. More than 1
in three Americans will develop some type of cancer during million cases of highly curable basal- and squamous-cell skin
their lifetime. Cancer is the second-leading cause of death in cancers were estimated to be diagnosed in 2008 (ACS, 2008).
the United States and can develop in individuals of any race, In 2008, approximately 170,000 cancer deaths were esti-
gender, age, socioeconomic status, or culture. It is not a single mated to be caused by tobacco. About one-third of the
disease but, rather, a group of more than 200 different diseases 565,650 cancer deaths estimated for 2008 are related to nutri-
that can attack any tissue or organ of the body. tion, physical inactivity, obesity, and other lifestyle factors and
According to the American Cancer Society (ACS), in the could be prevented (ACS, 2008).
1930s fewer than one in five cancer clients survived 5 years
after diagnosis. In the 1940s, one in four survived 5 years.
Today, 66% of people diagnosed with cancer will be alive in 5
years (ACS, 2003; ACS, 2008). Survival rates are influenced
PATHOPHYSIOLOGY
by the type of cancer, the progression of the disease at diagno- Cancer is a disease characterized by neoplasia, an uncon-
sis, and the client’s response to the treatment. trolled growth of abnormal cells. Unlike normal cells, which
reproduce in an orderly manner and grow for a purpose,
cancer cells develop rapidly and undiscriminatingly, and they
INCIDENCE serve no useful function because they grow at the expense
of healthy tissue. Neoplasms, any abnormal growth of new
In the United States, men have a one in two lifetime risk tissue, can be found in any body tissue. Neoplasms may be
of developing cancer, whereas women have a risk of one in benign (not progressive and, thus, favorable for recovery) or
three (ACS, 2008). Incidence and mortality rates are usually malignant (becoming progressively worse and often resulting
greater for African Americans than for Anglo Americans. in death).
The incidence of cancer is greater in the elderly population Benign neoplasms are not cancerous and are usually
than in any other age group. In men, the most common harmless. They grow slowly, are encapsulated and well-
cancers are prostate, lung, colorectal, and urinary bladder; in defined, and do not spread to neighboring tissues. Unless
women, they are breast, lung, colorectal, and uterine cancer their location interferes with vital functions, benign neo-
(Figure 3-1). plasms are associated with a favorable prognosis.

Leading Sites of New Cancer Cases and Deaths—2008 Estimates*

Estimated New Cases* Estimated Deaths
MALE FEMALE MALE FEMALE

Prostate Breast Lung & bronchus Lung & bronchus

186,320 (25%) 182,460 (26%) 90,810 (31%) 71,030 (26%)
Lung & bronchus Lung & bronchus Prostate Breast
114,690 (15%) 100,330 (14%) 28,660 (10%) 40,480 (15%)
Colon & rectum Colon & rectum Colon & rectum Colon & rectum
77,250 (10%) 71,560 (10%) 24,260 (8%) 25,700 (9%)
Urinary bladder Uterine corpus Pancreas Pancreas
51,230 (7%) 40,100 (6%) 17,500 (6%) 16,790 (6%)
Non-Hodgkin lymphoma Non-Hodgkin lymphoma Liver & intrahepatic bile duct Ovary
35,450 (5%) 30,670 (4%) 12,570 (4%) 15,520 (6%)
Melanoma of the skin Thyroid Leukemia Non-Hodgkin lymphoma
34,950 (5%) 28,410 (4%) 12,460 (4%) 9,370 (3%)
Kidney & renal pelvis Melanoma of the skin Esophagus Leukemia
33,130 (4%) 27,530 (4%) 11,250 (4%) 9,250 (3%)
Oral cavity & pharynx Ovary Urinary bladder Uterine corpus
25,310 (3%) 21,650 (3%) 9,950 (3%) 7,470 (3%)
Leukemia Kidney & renal pelvis Non-Hodgkin lymphoma Liver & intrahepatic bile duct
25,180 (3%) 21,260 (3%) 9,790 (3%) 5,840 (2%)
Pancreas Leukemia Kidney & renal pelvis Brain & other nervous system
18,770 (3%) 19,090 (3%) 8,100 (3%) 5,650 (2%)
All sites All sites All sites All sites
745,180 (100%) 692,000 (100%) 294,120 (100%) 271,530 (100%)
*Excluding basal and squamous cell skin cancer and in situ carcinomas except urinary bladder.
Percentages may not total 100% due to rounding.

Figure 3-1 Leading Sites of New Cancer Cases and Deaths—2008 Estimates (American Cancer Society Cancer Facts and Figures,
2008. Reprinted with Permission.)

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46 UNIT 1 Essential Concepts

Malignant neoplasms form irregularly shaped masses

with fingerlike projections. They usually multiply quickly
and spread to distant body parts through the bloodstream
CLIENTTEACHING
or the lymph system. This process is called metastasis. Dietary Guidelines to Reduce the
Patterns of metastasis will differ depending on the type of Risk of Cancer
cancer.
Cancers are usually named according to the site of • Choose most foods from plant sources.
the primary tumor or to the type of tissue involved. There — Eat five or more servings of fruits and vegeta-
are four main classifications of cancer according to tissue bles each day, especially green and dark-yellow
type: vegetables and those in the cabbage family.
• Lymphomas (cancers occurring in infection-fighting — Consume other foods from plant sources
organs, such as lymphatic tissue) including breads, cereals, pastas, beans
• Leukemias (cancers occurring in blood-forming organs, (legumes), and soy products.
such as the spleen, and in bone marrow)
• Limit intake of high-fat foods, particularly from
• Sarcomas (cancers occurring in connective tissue, such as animal sources.
bone)
— Choose foods low in fat.
• Carcinomas (cancers occurring in epithelial tissue, such
as the skin) — Limit consumption of meats, especially red
The exact mechanism that causes cancer is unknown, meats and high-fat meats.
but most authorities believe that cancer develops from a • Be physically active and achieve and maintain a
combination of factors rather than from a single factor. Envi- healthy weight.
ronmental, genetic, and viral factors have been implicated in — Physical activity can help by balancing caloric
the development of cancer. Chemical substances that initiate intake with energy expenditures or by other
or promote the development of cancer are known as carcino-
mechanisms.
gens. These agents are thought to alter the DNA in the cell
nucleus. • Limit or eliminate consumption of alcoholic bev-
erages.
(ACS, 2002; ACS, 2008)

RISK FACTORS
Many risk factors, such as environmental, lifestyle, genetic,
and viral, may increase an individual’s chances of developing
cancer. Approximately 3,000 nonsmoking adults die each year
of lung cancer from breathing secondhand smoke (ACS,
Environmental Factors 2008).

The first environmental carcinogen was discovered in 1760,

when Percival Pott noted that chimney sweeps had a very Lifestyle Factors
high rate of what is now known to be scrotal cancer because Lifestyle factors include the use of tobacco, sun exposure,
they were exposed to cancer-causing oils in the soot that alcohol consumption, and diet. Tobacco accounts for nearly
was rubbed into their clothing. Since that time, hundreds of one in five deaths in the United States (ACS, 2008). Tobacco
chemical carcinogens have been identified. use includes cigarettes, cigars, pipes, and smokeless forms
Many individuals come into contact with cancer-causing (e.g., snuff and chewing tobacco). The same carcinogens are
agents through occupational exposure. Industrial chemicals, found in all forms of tobacco, causing cancer of the oral cavity,
such as asbestos or vinyl chlorides, have been found to be esophagus, pharynx, and larynx. When tobacco is smoked,
carcinogenic. For workers who handle these chemicals, the it can also cause cancer of the lung, pancreas, uterus, cervix,
risk of developing cancers is greatly increased if occupational kidney, and bladder.
exposure is combined with cigarette smoking. Tobacco may Overexposure to the sun’s ultraviolet rays over long
act synergistically with other substances to promote cancer periods of time is the cause of many skin cancers. The most
development. Occupational exposure to coal tar, creosote, serious form of skin cancer is melanoma. The ACS (2008)
arsenic compounds, or radium constitutes a risk factor for estimates 62,480 newly diagnosed cases of melanoma in 2008.
development of skin cancer. The effects of carcinogenic Other factors predisposing a person to skin cancer are family
agents are usually dose dependent. The larger the dose or history, multiple nevi, and atypical nevi.
the longer the duration of exposure, the greater is the risk of Heavy alcohol consumption has also been implicated in
cancer development. It is estimated that 80% of all cancers mouth, throat, esophageal, and liver cancers. Alcohol is hypo-
are associated with environmental exposures and might be thesized to cause 5% of cancer deaths. Alcohol and tobacco
prevented if exposure is avoided. Occupational Safety and used together greatly increase the risk of oral and esopha-
Health Administration (OSHA) established safety standards geal cancers. The combined effect of alcohol and tobacco is
and levels of exposure for those likely to be exposed to chemi- greater than the sum of their individual effects (ACS, 2008).
cal carcinogens at work. Despite the epidemiological evidence linking alcohol to can-
In 1993, the U.S. Environmental Protection Agency cer, the exact carcinogen in alcohol is yet to be determined.
(EPA) declared secondhand smoke a human carcinogen. Table 3-1 lists some risk factors for cancer.

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 CHAPTER 3 Oncology 47

Research suggests that an increase in dietary fiber may

Table 3-1 Risk Factors for Cancer help prevent colon cancer. Some studies have suggested that
obesity is a significant risk factor for breast, colon, endome-
Breast Cancer trial, and prostate cancers. Studies have also shown that diets
• Family history (immediate female relatives) high in salt-cured, smoked, and nitrite-cured foods increase
• High-fat diet
an individual’s risk for cancer of the stomach and esophagus.
Food substances that may reduce cancer risk include cru-
• Obesity after menopause ciferous vegetables (cabbage, broccoli, cauliflower, brussels
• Early menarche, late menopause sprouts, kohlrabi); possibly vitamins A, E, and C; and sele-
• Alcohol consumption nium. Some foods have been found to contain carcinogens
in the forms of additives or as by-products of storage. On
• Postmenopausal estrogen and progestin
the basis of current knowledge, the ACS has offered dietary
• First child after age 30 guidelines to reduce cancer risk.
Cervical Cancer
• Multiple sexual partners
Genetic Factors
• Having sex at early age
Some families have a high incidence of certain types of can-
cer. Women whose mothers, grandmothers, or sisters have
• Exposure to human papillomavirus had breast cancer have twice the risk of developing cancer as
• Smoking those whose first-degree relatives have not had the disease
(ACS, 2008). Leukemia and cancers of the colon, stomach,
Colorectal Cancer prostate, lung, and ovary may also run in families. Therefore,
relatives of persons with these cancers should be carefully
• Family history (immediate relatives)
monitored.
• Low-fiber diet
• History of rectal polyps
Viral Factors
Esophageal Cancer Although viruses have been linked to several cancers, their
• Heavy alcohol consumption
exact role is unclear. It has been theorized that they incorporate
themselves into the genetic structure of the cell. Herpes sim-
• Smoking plex II virus and some of the human papillomaviruses that are
transmitted sexually are known to predispose women to cervi-
Lung Cancer cal cancer. Reducing the number of sexual partners can reduce
• Cigarette smoking the risk of contracting these viruses.
• Asbestos, arsenic, and radon exposure
• Secondhand smoke
• Tuberculosis

Skin Cancer CLIENTTEACHING

• Excessive exposure to ultraviolet radiation (sun) Lifestyle Guidelines to Reduce the
• Fair complexion Risk of Cancer
• Work with coal, tar, pitch, or creosote
• Do not smoke or use tobacco in any form.
• Multiple or atypical nevi (males)
• Avoid overexposure to the sun and indoor
Stomach Cancer tanning.
• Eat a healthy diet.
• Family history
• Get plenty of exercise.
• Diet heavy in smoked, pickled, or salted foods
• Have a physical examination on a routine basis,
Testicular Cancer including a mammogram, Pap smear, testicular,
and colon examinations.
• Undescended testicles
• Get plenty of sleep (6 to 8 hours per night).
• Consumption of hormones by mother during
• Keep weight within normal limits.
COURTESY OF DELMAR CENGAGE LEARNING

pregnancy
• Practice regular self-examinations and see your
Prostate Cancer physician if any changes are noted.
• Increasing age • Know and follow health and safety rules at the
workplace.
• Family history
• Avoid unprotected sexual behaviors.
• Diet high in animal fat

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48 UNIT 1 Essential Concepts

CRITICAL THINKING
DETECTION
When cancer develops, the earlier it is detected the more Cancer Detection
likely it is to be controlled. In some cases, a diagnosis is
Which diagnostic tests should a person have as
made before symptoms become apparent. Cancer is usu-
ally found by the affected individual, who notices a warn- part of a routine physical to detect cancer?
ing sign, or by a health-care provider during a checkup. A
cancer checkup is recommended every 3 years for persons
ages 20 to 39 years and annually for those ages 40 years and
older. Risk assessment is the first step in cancer prevention.
The cancer examination includes both a medical history of specific proteins, antigens, genes, hormones, or enzymes
exposures to environmental agents and a comprehensive that are found in the serum and indicate the possible pres-
family history. ence of malignancy. Tumor markers are not 100% accurate
If cancer is suspected, various diagnostic studies are per- because benign processes can also cause elevations; they
formed depending on the suspected primary or metastatic site are, however, useful in monitoring response to treatment
of the cancer. They include laboratory studies or blood tests, or detecting a relapse. (See Table 3-2 for cancer-screening
radiologic studies, endoscopy, cytology, and biopsy. Nurses guidelines.)
educate clients about such tests as well as assist in client
preparation.
Although no one blood test can confirm a cancer diag-
nosis, some malignancies do alter the chemical composi- COMMON DIAGNOSTIC TESTS
tion of the blood. Specialized laboratory tests have been
Commonly used diagnostic tests for clients who present with
developed to detect tumor markers, substances such as
symptoms of cancer are listed in Table 3-3. See Basic Nursing
Diagnostic Tests, for explanation/normal values and nursing
responsibilities related to each test.

CLIENTTEACHING STAGING OF TUMORS

Warning Signs of Cancer Staging determines the extent of the spread of cancer.
The professional nurse educates individuals about The TNM classification proposed by the American Joint
the warning signs of cancer. The seven warning
Commission on Cancer is one of the most frequently used
systems. The T refers to the anatomical size of the primary
signs can be easily remembered through an
tumor; N, the extent of lymph node involvement; and M,
acronym, CAUTION. the presence or absence of metastasis (Table 3-4). Use of
C: Change in bladder or bowel habits, such as this internationally recognized staging system for tumors
absence of urination or bowel movement or ensures a reliable comparison of clients in many different
excessive urination or stool. hospitals. Staging is important because it influences deci-
A: A sore that does not heal within a realistic sions about treatment modalities and helps predict overall
period of time. prognosis.
U: Unusual bleeding or discharge from any body
orifice, such as the vagina, the nipple, or the
penis. The unusual discharge can be bloody, GRADING OF TUMORS
purulent, clear, or viscous. The keywords are Normal body cells have individual characteristics that allow
unusual and any body orifice. them to perform different body functions. This process is
T: Thickening or the presence of a lump of the called differentiation. Tumor cells that retain many of
breast, testicle, or any part of the body. the identifiable tissue characteristics of the original cell are
I: Indigestion or difficulty swallowing for a pro- termed well differentiated. Tumor cells having little similar-
longed period of time.
ity to the tissue of origin are termed undifferentiated. Tumor
grading is based primarily on the degree of differentiation of
O: Obvious change in a wart or mole, such as color, malignant cells. Grading evaluates tumor cells in comparison
size, texture. with normal cells. Pathologists indicate tumor cell grades by
N: Nagging cough or hoarseness that is prolonged. using the Roman numerals I through IV; the higher the grade,
If any of these warning signs are observed, encour- the higher the number and the worse the prognosis. Thus, a
age client to see a health-care provider.
grade I tumor is the most differentiated, and a grade IV tumor
is the most undifferentiated (or least differentiated). Tumors
Courtesy of Daniels, R, Nosek, L., & Nicoll, L. (2010).
containing poorly differentiated cells are more aggressive
Contemporary medical-surgical nursing. Clifton in growth and may display uncharacteristic behaviors, lead-
Park, NY: Delmar, Cengage Learning. ing to a poorer prognosis. Grading criteria vary for different
neoplasms.

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 CHAPTER 3 Oncology 49

Table 3-2 Screening Guidelines

SITE AGE TO BEGIN RECOMMENDATIONS PREFERRED/ALTERNATIVE
Colorectal 50 One of the following initially: fecal oc- Combination testing rather than a single
cult blood or fecal immunochemical diagnostic test.
test annually; flexible sigmoidoscopy
every 5 years; barium enema every
5 years; colonoscopy every 10 years.

Prostate 50 Protein-specific antigen (PSA) test Begin at age 45 for African-American men
and digital rectal exam (DRE) to men and men with a strong family history.
who have a life expectancy of at least
10 years

Breast 20 Beginning at age 20, breast self-exams Women at greater risk may begin mam-
monthly and clinical breast exams mograms at earlier age, or have additional
every 3 years. tests performed (MRI, ultrasound, etc.).
Beginning at age 40, add annual mam-
mograms and clinical breast exams.

Cervical 21, or 3 years Pap test annually. After total hysterec- Pap test may be every 2 years, with a
after beginning tomy with cervix removal screening is liquid-based test. A woman 30 or older
vaginal inter- not necessary unless the surgery was with three normal test results in a row
course performed as treatment for cervical may be screened every 2−3 years. As an
cancer. alternative HPV DNA testing and cytology
could be done every 3 years. High-risk
women may get screened more often.
Women older than 70 years of age with
three or more consecutive normal Pap
tests in past 10 years may choose to stop
screening.

Endometrium 35 Annual screening with biopsy for wom- All women at menopause should be edu-
en with or at risk for HNPCC (hereditary cated about risks and symptoms and be
nonpolyposis colon cancer). encouraged to report any unexpected
spotting or bleeding.

From Cancer facts & figures, by ACS Recommendations, 2006, Atlanta, GA: American Cancer Society; Understanding Neoplasms, by R. Teasley, in press.

surrounding tissue, and the regional lymph nodes. Surgery

TREATMENT MODALITIES most often has curative results when performed in the early
stages of cervical, breast, or skin cancer.
After cancer is diagnosed, staged, and graded, a medical treat-
ment plan is developed. The most common treatment meth-
ods used are surgery, radiation therapy, and chemotherapy
(use of drugs to treat illness); biotherapy/immunotherapy, CRITICAL THINKING
hormone therapy, targeted therapy, photodynamic therapy,
and bone marrow transplantation also are used. These meth- Teaching Risk Factors for Cancer
ods may be used alone or in combination.
A neighbor, a 45-year-old female, asks you if there

Surgery is anything she can do to “cancer-proof” her life-

style. She tells you that there have been several
Surgery is the oldest form of cancer treatment and remains incidences of cancer diagnosed in family members,
the most common method of treatment today. Surgery is although none have been in her immediate family.
classified as curative, palliative, or reconstructive. What is the best answer you can give her?
The goal of curative surgery is to heal or restore to
health; this involves excising all of the tumor, the involved

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50 UNIT 1 Essential Concepts

Table 3-3 Common Diagnostic Tests Cell death occurs hours, days, or even years after treatment,
for Cancer Detection depending on the rate of mitosis.
The goal of radiation therapy is to eradicate malignant
Laboratory Tests cells without causing harm to healthy tissues. Some cells are
• Acid phosphatase (elevated) more sensitive to radiation than others. Better vascularized,
better oxygenated cells and those that divide rapidly are the
• Alkaline phosphatase (elevated)
most sensitive.
• Bence Jones protein It is used alone or as an adjunct to other therapies. As a
• CA-15-3 single treatment modality, it is most often used when the dis-
ease is localized. Preoperative radiation is frequently used to
• CA-19-9 reduce the tumor mass before surgery. Postoperative radiation
• CA-125 therapy is frequently used to decrease the risk of local recur-
• CEA (carcinoembryonic antigen) rence after surgery. Some chemotherapeutic drugs increase
the sensitivity of cancer cells to radiation and thus are used
• Fecal occult blood test (FOBT) or fecal immuno- together with radiation. Radiation therapy is classified as cura-
chemical test (FIT) tive or palliative. It is frequently used to alleviate symptoms of
• PSA (prostate-specific antigen) metastasis, such as pain.
There are two types of radiation therapy: external radia-
• Stool for occult blood (Guaiac)
tion and internal radiation.
• Serum calcitonin

Radiologic Studies External Radiation

• X-ray studies External radiation, or teletherapy, is performed with special
equipment that can deliver high-energy radiation. Treat-
• Computerized axial tomography (CT scan or CAT ments are usually administered on an outpatient basis,
scan) divided over many days or weeks. Customized shielding
• Magnetic resonance imaging (MRI) blocks are created to protect healthy tissues, and immobiliza-
• Scans (radioisotope test)
tion devices are used to maintain the exact position for each
treatment. Dyes or tattoos may be used to designate refer-
• Ultrasound ence points on the skin.
• Mammograms Nursing care is directed toward client teaching, safety,
COURTESY OF DELMAR CENGAGE LEARNING

and performing interventions that provide relief from side

Invasive Diagnostic Techniques effects. Undesirable side effects that are most likely to occur
• Endoscopy include varying degrees of skin reactions and gastrointestinal
discomfort, such as abdominal cramping, diarrhea, loss of
• Cytology appetite, and fatigue. Treatments have a cumulative effect
• Biopsy and may thus produce symptoms after the therapy has been
completed.

Internal Radiation
Internal radiation delivers radioactive isotopes directly within
Because 70% of clients show evidence of metastasis at the body. Clients treated with internal sources of radiation are
diagnosis, cure is not always possible, and palliative surgery a source of radioactivity. Isotopes are introduced into the body
may be necessary. This surgery is effective in relieving symp- by sealed or unsealed sources.
toms in more advanced stages of cancer, although it does not With sealed sources, radioactive elements are encapsu-
alter the course of the disease. It is usually performed in an lated in special containers such as tubes, wires, needles, seeds,
attempt to relieve complications such as obstructions or to or capsules. These containers are implanted close to the cancer
surgically interrupt nerve pathways for intractable pain. It cells to deliver a highly concentrated dose of radiation to the
may also be used to insert special access devices or to place cancer cells. Radioactive implants are used in the treatment of
tubes for enteral nutrition.
Reconstructive surgery is performed to reestablish
function or rebuild for a better cosmetic effect. Reconstruc-
tive surgery to areas such as the head, neck, breast, and CLIENTTEACHING
extremities minimizes deformity. The surgery is completed
all at once or done in stages. External Radiation
• Do not wash off the skin markings used to des-
Radiation Therapy ignate reference points for treatment.
Radiation therapy is the second most common method of • Client is alone in the room during treatment.
treating cancer. Radiation therapy, or radiotherapy, uses • Client must lie absolutely still.
high-energy ionizing radiation to kill cancer. Ionizing radia- • Treatment typically lasts 1 to 3 minutes.
tion penetrates tissue cells and deposits energy within them.
This intense energy causes breakage in chromosomes within • Treatment is usually painless.
the cell, thus preventing the ability of the cell to replicate.

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 CHAPTER 3 Oncology 51

Table 3-4 Staging of Tumors: TNM Classification

STAGE TUMOR LYMPH NODE METASTASIS
I <2 cm diameter No involvement No evidence
Mobile
Often superficial
Confined to organ of origin

II 2 to 5 cm diameter Palpable, mobile No evidence

No as mobile >2 to 3 cm diameter
Extension into adjacent tissue Firmer than normal

III a >5 cm diameter No involvement No evidence

Not mobile
Regional involvement

III b <2 to >5 cm diameter >2 to 3 cm diameter No evidence

Mobile or not mobile Firmer than normal
Localized or extended

IV a >10 cm diameter No involvement No evidence

Extension into another organ; major or >2 to 3 cm diameter
arteries, veins, or nerves; or bone Firmer than normal

IV b No evidence to >10 cm diameter 3 to 5 cm diameter No evidence

Partially mobile
Firm to hard; or >5 cam diameter

COURTESY OF DELMAR CENGAGE LEARNING

Extended and fixed to bone, large
blood vessels, skin, or nerves

IV c No evidence to >10 cm diameter No evidence to >10 cm diameter Solitary or

Fixed and destructive multiple

Extension to second or distant stations

cancers of the tongue, lip, breast, vagina, cervix, endometrium,

SAFETY rectum, bladder, and brain.
Because sources are sealed, body fluids are not radioac-
Internal Radiation tive. Personnel caring for clients who have sealed sources
must still be familiar with the hazards of radiation, however.
Client care is modified based on the three factors
Generally, the degree of exposure is dependent on three
related to the degree of exposure to sealed-source factors:
radiation by:
• The distance between the individual and the source
• Preparing everything outside of the room so
(Figure 3-2)
that as little time as possible is spent close to
• The amount of time an individual is exposed
the client.
• The type of shielding provided
• Having several nurses assigned to care for the
client so that the time of exposure for each
Radioactive isotopes also are placed in suspensions or
solutions as unsealed sources of radiation. They are given
nurse is lessened.
orally or parenterally or instilled into intrapleural or peritoneal
• Wearing a lead apron or other shielding device, spaces.
as provided. Some radioactive elements used in unsealed radia-
tion sources are eliminated in body secretions, including
urine and stool; thus health care workers must take special

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52 UNIT 1 Essential Concepts

PROFESSIONALTIP

Chemotherapy and Protective

Equipment
• Because many chemotherapy drugs are carcino-
genic, the nurse preparing and administering
the chemotherapy wears protective equipment.
• All personnel involved in any aspect of handling
chemotherapeutic agents receive instructions
about the known risks of the drugs, the proper
use of protective equipment, the applicable skill
3 feet 9 feet procedures, and the policies regarding pregnant
personnel.
Figure 3-2 Radiation dose decreases with distance.
(Courtesy of the U.S. Nuclear Regulatory Commission.)

precautions to avoid exposure. Agency policies and proce- drug at the tumor site, including intrathecal injection and
dures as well as Standard Precautions are followed closely. intracavity instillation. Table 3-5 lists some commonly used
Unsealed sources are not usually radioactive as long as the drugs.
sealed sources. Careful attention is given to intravenous administration.
Leakage of fluid from the vein into the surrounding tissues
Chemotherapy during infusion is called extravasation. Because most che-
motherapeutic drugs are irritating to the tissues, extravasa-
Chemotherapy is used to cure, prevent, or relieve cancer tion is a potentially serious problem, especially if the drugs
symptoms. Drugs used in chemotherapy are called anti- administered are vesicants. These agents are so irritating
neoplastics because they inhibit the growth and repro- that they can cause blistering and even necrosis. All sites
duction of malignant cells. To understand how anticancer must be monitored carefully. Pain, swelling, redness, and the
drugs work, one must have a basic understanding of the cell presence of vesicles are all signs of extravasation. Additional
cycle. signs include the following:
Almost all anticancer drugs kill cancer cells by affecting
DNA synthesis or function, but they vary in how they exert
their activity within the cell cycle. Most chemotherapeutic
drugs are classified as cell-cycle specific (CCS) or cell-cycle
nonspecific (CCNS).
CCS drugs attack cancer cells when the cells enter a cer-
tain phase of reproduction. These agents are most effective Home Care After Chemotherapy
against rapidly growing tumors. Many of the drugs are “sched- Teach clients receiving chemotherapy to monitor
ule dependent” because they produce a greater cell kill when
the side effects of therapy at home.
given in multiple, repeated doses.
CCNS drugs can destroy cancer cells in any phase • Inspect the skin daily for any signs of rash or
of the cell cycle and are used for large tumors that have dermatitis, which indicates hypersensitivity to a
fewer actively dividing cells. These drugs are not schedule drug.
dependent but, rather, dose dependent. This means that the • Report taste loss and tingling in the face,
number of cells destroyed is determined by the amount of fingers, or toes, which may signal peripheral
drug given. neuropathy.
Anticancer agents are cytotoxic (toxic to cells) and
• Report signs of dizziness, headache, confusion,
destroy both normal and abnormal cells. They are most effec-
tive against cells that reproduce rapidly, such as those in bone slurred speech, or convulsions, which are signs
marrow, gastrointestinal lining, hair follicles, and the ova and of central nervous system (CNS) toxicity.
sperm. Because cells multiply at their most rapid rate at the • Report signs of unusual bleeding or bruising;
beginning of the disease, the drugs work best against cancer in fever; sore throat; or mouth sores, which may
its earliest stages. signal developing myelosuppression.
Many of these drugs are given in combination with or • Report signs of jaundice; yellowing of the eyes;
after radiation or surgery to achieve maximum effect. They
clay-colored stools; or dark urine, which signals
are usually given intermittently over an extended period. Drug
resistance can occur. developing hepatic dysfunction.
The most common routes of administration are oral • Report a continued cough or shortness of
and intravenous. A few drugs are given topically, subcuta- breath, which indicates developing pulmonary
neously, or intramuscularly. Recently, other methods have fibrosis.
been introduced to increase the local concentration of the

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 CHAPTER 3 Oncology 53

Table 3-5 Drugs Commonly Used in Chemotherapy

Antimetabolites (CC5) Antibiotics (CCNS) Antihormonal Agents (CCNS)
cytarabine (Cytosar) dactinomycin (Cosmegan)* flutamide (Eulexin)
fluorouracil (Adrucil 5-FU) daunorubicin (Cerubidine)* goserelin acetate (Zoladex)
methotrexate (Mexate, Folex) doxorubicin hydrochloride tamoxifen (Nolvadex)
6-mercaptopurine (Purinethol) (Adriamycin)*
mitomycin (Mutamycin)*
mithramycin (Mithracin)
bleomycin (Blenoxane)

Vinca Plant Alkaloids (CCS) Hormones (CCNS) Nitrosureas (CCNS)

vinblastine sulfate (Velban)* diethylstilbestrol (DES) carmustine (BiCNU)
vincristine sulfate (Oncovin)* megestrol acetate (Megace) lomustine (CeeNU)
medroxyprogesterone acetate
(Depo-Provera)
testosterone (Histerone, Testoderm)
tamoxifen citrate (Nolvadex)

Alkylating Agents (CCNS) Corticosteroids Miscellaneous Agents

busulfan (Myleran) dexamethasone (Decadron) etoposide (VePesid)
chlorambucil (Leukeran) hydrocortisone sodium succinate L-asparaginase (Elspar)
cisplatin (Platinol) (Solu-Cortef) procarbazine hydrochloride
cyclophosphamide (Cytoxan) prednisone (Deltasone) (Matulane)
mechlorethamine hydrochloride
(Mustargen)*
melphalan (Alkeran)
thiotepa (Thiotepa)

Frequently Used Combinations

CAF cyclophosphamide, doxorubicin, and fluorourcil (5-FU)
CHOP cyclophosphamide, doxorubicin, vincristine (Oncovin), and prednisolone
C-VAMP cyclophosphamide, vincristine, doxorubicin, and methyl-prednisolone
CVP cyclophosphamide, vincristine, and prednisone
ECF epirubicin, cisplatin, and fluorourcil
FEC fluorourcil, epirubicin, and cyclophosphamide
COURTESY OF DELMAR CENGAGE LEARNING
MMM mitomycin, methotrexate, and mitoxantrone
MOPP mechlorethamine hydrochloride (Mustargen), vincristine, procarbazine, and prednisone
MVP mitomycin, vinblastine, and cisplatin

*= vesicant drug

• Pain or burning at the site or along the vein If extravasation occurs, the drug is stopped immediately
• Absent or sluggish blood return and protocols for treatment initiated.
• Redness 6 to 12 hours later Improved infusion techniques, control of symptoms
such as nausea and vomiting, and cost-containment restric-
• Swelling tions have reduced the length of hospitalizations for cli-
• Diffuse hardening ents undergoing chemotherapy. Teaching clients and family

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54 UNIT 1 Essential Concepts

members to monitor side effects in the home setting is thus procedure, and there are fewer side effects. The side effects
an essential function of the oncology (study of tumors) of PDT are discomfort from local swelling, nausea, fever,
nurse. and constipation. The client experiences sunburn, redness,
Clients also are advised that their lifestyle may need adjust- and swelling if the skin and eyes are exposed to a bright light
ment to accommodate the side effects of chemotherapy. Clients or sunlight.
are instructed to pace themselves according to their energy level
and allow time for rest throughout the day. It is also important
to inform clients that even between treatments they may not Hormone Therapy
have the same amount of energy as before treatment initiation. Some cancerous cells need estrogen, progesterone, or tes-
Many clients do not experience any adverse effects, but some tosterone to grow. The goal of hormone therapy is to
experience life-threatening toxicity. Nursing care of the client deprive the cancerous cells of these hormones. Clients may
receiving chemotherapy requires not only a thorough under- have the ovaries (oophorectomy) or testicles (orchiec-
standing of the drugs used to destroy the cancer, but also skills tomy) removed. Another method of depriving the cells
in helping clients and families cope with the side effects of the of hormonal stimulation is to give women with early-stage
therapy. breast cancer tamoxifen citrate (Nolvadex) and to give men
luteinizing hormone-releasing hormone (LHRH). LHRH
Biotherapy prevents the testes from producing testosterone. Tamoxifen
is a systemic treatment and increases the chances for endo-
Biotherapy/immunotherapy is performed with biologic metrial cancer. Hormone therapy is effective for a time in
response modifiers (BRMs), agents that stimulate the men, but eventually prostate cancer grows without hormone
body’s natural immune system to control and destroy malig- stimulation. The hormone therapy is no longer effective
nant cells. Some BRMs are being evaluated in trial studies. when this occurs (Cancer Treatment Centers of America,
Biotherapy is used after surgery, radiation, and chemo- 2009c).
therapy have removed the bulk of the tumor. Some agents
currently used include interferons, monoclonal antibod-
ies, interleukin-2, tumor necrosis factor, bacillus Calmette-
Targeted Cancer Therapy
Guérin (BCG), and colony-stimulating factors. Side effects Most targeted cancer therapies are in preclinical testing (ani-
are usually less severe than those seen in chemotherapy and mal research) and clinical trial (human research). Some drugs
include fever, malaise, myalgia, and headache. Because an have been approved by the U.S. Food and Drug Administra-
anaphylactic reaction can occur, the client must be closely tion (FDA). The goal of targeted cancer therapy is to stop the
monitored. growth and spread of cancer cells by preventing normal cells
from changing into cancerous cells at the molecular or cellular
Photodynamic Therapy level. This therapy is more effective than present treatments
and causes less harm to healthy cells. An example of targeted
Photodynamic therapy (PDT) has a 90% effective rate therapy is STI-571, or imatinib mesylate (Gleevac®), which is
when used for esophageal cancer and early-stage lung can- a small-molecule drug used to treat gastrointestinal stromal
cer (Cancer Treatment Centers of America, 2009b). PDT tumor and chronic myeloid leukemia (National Cancer Insti-
is also used as an investigation therapy for obstructive lung tute, 2006).
cancer, Barrett’s esophagus, and head, neck and skin cancer.
The client is injected with a light-activated drug (Photof-
rin) that targets cancerous cells. Twenty-four to 48 hours
Bone Marrow
after injecting the drug, a low-power laser light is directed Transplantation
by a fiberoptic guide to the cancerous tissue area through Bone marrow transplantation (BMT) is used for cancers
an endoscope. The light stimulates the drug to destroy the that respond to high doses of chemotherapy or radiation
cancerous cells, but the surrounding healthy tissue is not therapy. Treatment involves aspirating and storing a fraction of
harmed. An advantage of PDT is the client has the proce- bone marrow, exposing the client to high-dose drug therapy or
dure performed on an outpatient basis with slight sedation total-body irradiation, and then reinfusing the bone marrow
and is relatively pain free. There is less risk than with a surgical after the treatment is complete.
The bone marrow used in transplantation can be the cli-
ent’s own marrow (autologous), marrow taken from an identi-
cal twin (syngeneic), or marrow taken from a histocompatibly
matched donor, preferably a sibling (allogeneic).
SAFETY Client expenses for BMT are high, ranging from $50,000
to $100,000 for an autologous transplant, and $100,000
Chemotherapy and Contamination to $200,000 for an allogeneic transplant unless covered or
• Any personnel handling blood, vomitus, or partially covered by insurance (NBMTLink, 2009). The
excreta from clients who have received che-
average length of hospital stay is 35 to 40 days. Complica-
tions can be life-threatening and include infection, bleeding,
motherapy within the previous 48 hours wears
gastrointestinal effects, renal insufficiency, veno-occlusive
disposable latex gloves and a disposable gown. disease (deposits of fibrin obstruct venules of liver), and
• Place contaminated linen in specially marked graft-versus-host disease (new bone marrow cells recognize
laundry bags according to agency procedures. environment as foreign and try to destroy the host). Clients
who undergo autologous BMT do not experience graft-
versus-host disease.

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 CHAPTER 3 Oncology 55

SYMPTOM MANAGEMENT CLIENTTEACHING

Cancer clients undergoing treatment experience a variety of
secondary problems. One of the most important responsi- Increasing Nutritional Intake
bilities of the oncology nurse is to formulate nursing interven- • Drink 4 ounces of a nutritional supplement
tions to manage these problems.
before breakfast.

Bone Marrow Dysfunction

• Eat breakfast (if desired), and then take a walk.
Doing so will help build muscle and increase
Cancer treatments kill both malignant cells and normal cells appetite.
in bone marrow. Blood counts are monitored carefully during • Drink another 4 ounces of nutritional supple-
and after treatment. ment 1 hour before having a lunch consisting of
A low white-cell count increases the risk of infection. A
whatever foods are appealing.
decreased neutrophil count (<500 mm3) is an indicator that
special infection prevention measures should be initiated. Scru- • Have another 4 ounces of nutritional supple-
pulous hand hygiene is the most effective method of control- ment at midafternoon and at bedtime.
ling bacterial infection. Personnel maintain strict asepsis when • If not hungry for dinner, take another walk.
changing dressings or performing invasive procedures. Clients
avoid contact with anyone who is ill. Antimicrobial soaps are
used for bathing clients. The skin and mucous membranes are
inspected daily for signs of infection. Vital signs are taken every
4 hours and the client observed for fever and chilling. CLIENTTEACHING
Clients with a platelet count of <50,000 mm3 are moni-
tored for bleeding. Their skin is inspected daily for bruises Enhancing Taste Sensation
or petechiae. Shaving is undertaken with an electric razor to • Tart food usually enhances taste sensation.
minimize the chance of cutting the skin. Stool and urine are
monitored for occult blood. Observe the client for bleeding • Many foods taste better if they are cold or at
from the vagina, rectum, nose, mouth, and venipuncture sites. room temperature.
If bleeding occurs, pressure is applied to the site for 5 minutes. • Using plastic utensils reduces metallic taste.
Any bleeding that does not stop in 5 minutes is reported. A
soft toothbrush is recommended for oral care. Aspirin or any
medication containing acetylsalicylic acid is not given.
clients to eat small, frequent, high-calorie (carbohydrate
Nutritional Alterations and fat-rich) meals. Try to ascertain the client’s likes and
dislikes. Highly seasoned foods help increase taste. Clients
Cytokines are substances secreted by the tumor in an attempt are encouraged to eat when they are feeling best. Weight is
to cannibalize the body and by the immune system to fight monitored weekly.
the tumor. Cytokines make the body digest muscle for energy
instead of using stored fat for this purpose. This state of mal- Nausea and Vomiting
nutrition and protein (muscle) wasting is called cachexia. It
occurs in conjunction with lung, pancreatic, stomach, bowel, Nausea and vomiting usually occur within 3 to 4 hours after
and prostate cancers but rarely with breast cancer. chemotherapy is administered and may last up to 72 hours.
In some cases, untreated cachexia, rather than the cancer Antiemetics are given before chemotherapy and continued
itself, is the cause of death. Untreated cachexia also decreases afterward as needed (Table 3-6). Small, frequent feedings of
the effectiveness of cancer treatments and increases the side complex carbohydrates may be beneficial. Liquids are given
effects of these treatments. Treating cachexia with drugs has 30 to 60 minutes before meals. Although highly seasoned
met with little success. foods may increase taste, they often also increase nausea
A registered dietitian understands cancer cachexia and and vomiting. Cool, bland foods are more easily tolerated.
can identify appetizing foods that are nutrient and calorie Avoid foods with strong odors. Frequent mouth care helps
dense. Foods that appeal to the client are eaten anytime. The remove the taste of chemotherapy and increase the likeli-
use of liquid nutritional supplements and a multivitamin is hood of the client’s wanting to eat. The client should be
often recommended (Wilkes, 2000). monitored for dehydration and electrolyte imbalances.
Hallmarks of malnutrition are a weight loss of 10% or
more or a serum albumin level <3.4 g/dL. Clients unable Table 3-6 Commonly Used
to maintain sufficient oral intake for long periods are given
enteral or total parenteral nutrition (TPN). Nutritional Antiemetics
COURTESY OF DELMAR CENGAGE LEARNING

problems associated with cachexia include anorexia, nausea prochlorperazine (Compazine)

and vomiting, altered taste sensation, mucosal inflammation, metoclopramide (Reglan)
and dysphagia.
ondansetron hydrochloride (Zofron)
Anorexia lorazepam (Ativan)
Anorexia, or the loss of appetite, is a common concern dolasetron (Anzemet)
among individuals with cancer. It is generally best for these

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56 UNIT 1 Essential Concepts

PROFESSIONALTIP CLIENTTEACHING
Stomatitis
Mucosal Inflammation
• Use soft bristle toothbrush.
• The condition of the client’s mouth provides a
• Avoid flossing if bleeding or discomfort occurs.
clue to the appearance and integrity of other
• Avoid tobacco products and alcohol because of
areas of the gastrointestinal tract because
their drying effects.
mucosal inflammation caused by cancer
treatments affects all mucosa.
• Mucositis (inflammation of the mucous
membrane) in the esophagus, also called
esophagitis, causes painful swallowing. Pain usually does not occur until the advanced stages of the
• In female clients, mucosal inflammation is disease. The most common causes of pain are metastatic
bone disease, venous or lymphatic obstruction, or nerve
found in the vagina, causing pain, itching,
compression.
and discharge.
Pain causes anxiety, depression, and feelings of helpless-
ness in addition to physical discomfort. It can affect the client’s
sleeping habits, eating patterns, work, family, and social rela-
tionships. Ultimately, pain can affect the client’s quality of life.
Noninvasive pain-relief techniques are useful in pain man-
agement. They include cutaneous stimulation (heat, cold,
Altered Taste Sensation massage); transcutaneous electrical nerve stimulation (TENS);
Taste sensation is altered because cancer cells release sub- relaxation techniques; imagery; and hypnosis. Most of these
stances that stimulate bitter taste buds, causing a bitter or techniques are inexpensive and easy to perform. They have few
metallic taste in the mouths of some clients. Some find they side effects and can usually be done in any environment. They
no longer enjoy the taste of red meat, and others say they have also give the client some control over the treatment of pain.
an aversion to sweets. Although not every client responds successfully to these mea-
sures, it is worthwhile to attempt them before using invasive
Mucosal Inflammation techniques.
Stomatitis, or inflammation of the mucous membrane of The Agency for Health Care Policy and Research (AHCPR,
the oral cavity, occurs in one-half of cancer clients receiving 1994) developed Cancer Pain Guidelines for clients, family
treatment. It usually occurs 7 to 14 days after chemotherapy members, and health care professionals. Some points empha-
administration and lasts 2 to 3 weeks. To minimize stomatitis, sized by the guidelines include:
assess for early signs and symptoms such as edema, ulcer- • Cancer pain can be managed effectively through relatively
ation, erythema, excessive saliva, and infection. If the client is simple means in up to 90% of cancer clients in the United
receiving a chemotherapy drug that is known to cause stoma- States. Skin patches, slow-release tablets, and client-
titis (e.g., methotrexate) oral care is administered at least four controlled pumps are now available to complement
times a day. standard drugs.
Avoid rough, chewy foods and acidic foods. Straws are • The mainstay of pain assessment is the client self-report.
beneficial because food is taken in the back of the mouth and Because there is no standard test for pain, the nurse must
swallowed. Popsicles and frozen fruit bars sometimes help respect the client’s report of pain and regard it as the single
numb and lessen pain. Avoid commercial mouthwashes con- most reliable indicator.
taining alcohol. A saline rinse may be helpful after meals. If the • The simplest dosage schedules and least invasive pain
client has dentures, remove them at night. Viscous Xylocaine management modalities are used first. Nonopioids are the
rinses are ordered for pain. Lemon and glycerine swabs are not first step in the analgesic ladder. They are tried first for
used because lemon is irritating to mouth lesions. mild to moderate pain.
Dysphagia
Dysphagia, difficulty in swallowing, often occurs in clients
with esophageal cancers, or in those receiving radiotherapy.
Artificial saliva is ordered for severe dryness. A softer diet PROFESSIONALTIP
along with nutritional supplements is prescribed. Dry foods
such as toast can scratch the delicate tissues of the throat. Food
puréed in a blender is easier to tolerate. Encourage clients to Inadequate Pain Control in the Cancer
take plenty of time to chew and swallow. Client
A major reason given for inadequate pain control in
Pain the cancer client is the fear of inducing respiratory
Approximately 60% to 90% of all individuals with progres- depression. This, however, is a rare occurrence in
sive malignancy experience pain. The pain may be acute, the cancer client.
but it is more likely to be chronic (>3 months in duration).

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 CHAPTER 3 Oncology 57

• Morphine is the most commonly used opioid for moderate

to severe pain because it is available in a wide variety of
Odors
dosage forms, it has well-characterized pharmacokinetics Unpleasant odors emanating from the cancer client are a
and pharmacodynamics, and it is relatively low in source of embarrassment. These odors are usually associ-
cost. Morphine can be given orally, subcutaneously, ated with drainage, exudates, or incontinence. Fortunately,
intramuscularly, intravenously, rectally, and intraspinally. meticulous nursing care can eliminate most offending odors.
It can also be given in sustained-release preparations. Change soiled linens, drainage pads, and dressings imme-
• Health-care providers work to prevent pain rather than diately. Wash the client’s skin gently with soap and warm
try to treat pain after it has occurred. Analgesics work water. Protective creams are used if the areas are not receiving
better when given regularly around the clock before pain radiation. Room deodorizers are helpful but should be used
becomes severe. A major nursing responsibility is to teach cautiously because many clients experience nausea when
the client to request pain medication before the pain exposed to the odors from room fresheners. Placing a drop
becomes severe. When medication is ordered around the of oil of wintergreen or oil of cloves on a cotton ball near the
clock, the nurse does not hesitate to wake the client to ventilation system can sometimes lend a light freshness to the
administer analgesics. environment.
If pain control is not achieved with noninvasive tech-
niques or medications, neurosurgical procedures such as Dyspnea
nerve blocks are an option. One-half of all clients with terminal cancer experience dys-
pnea, or difficulty in breathing. Possible causes include fluid
Fatigue accumulation in the chest, infection such as pneumonia,
fibrosis caused by radiation, and anemia. Lungs are auscul-
Fatigue occurs as a direct result of cancer treatment or because tated every 4 hours. Oxygen is ordered. Fluid is drained by
of anemia, chronic pain, stress, depression, insufficient rest, an invasive procedure called a thoracentesis. High-Fowler
or inadequate nutritional intake. Although the etiology is not positioning maximizes ventilation. Plan care to keep activity
well understood, fatigue is often related to the effects of the to a minimum to balance oxygen requirements and oxygen
tumor itself (Greifzu, 1998). Fatigue contributes to client supply. Oxygen status is monitored with a pulse oximeter.
noncompliance with the treatment regimen. Report a sustained reading of less than 90%. Avoid pulling the
Frequent rest periods are provided for the client. Assess privacy curtain or shutting the client’s door unless absolutely
for the presence and pattern of fatigue. Proper planning allows necessary because either of these actions reduces air flow and
the client to be active when energy level is higher, which in creates more anxiety.
turn restore a greater sense of control. Evaluate factors that
increase or decrease fatigue, such as nutritional intake. Blood
count is monitored for anemia. Bowel Dysfunctions
Cancer clients frequently exhibit changes in bowel patterns.
Alopecia Constipation, diarrhea and subsequent perineal skin break-
Alopecia, the thinning or loss of hair, is induced by che- down, and bowel obstructions are common elimination dis-
motherapy or radiation treatments. The extent of hair loss orders.
depends on the dose and duration of the therapy. Scalp hair Constipation results from decreased motility of the
is most commonly affected, but pubic, axillary, and facial hair, colon. It is frequently caused by chemotherapy, opioid anal-
even eyebrows and eyelashes, also are affected. The treatments gesic, or inactivity. Monitor and record the frequency of the
cause hair loss by interfering with the growth processes in the client’s bowel movements. Constipation is an early sign of
hair follicle. This results in weakening of the hair shaft, thereby vincristine toxicity. Fluid consumption is encouraged and a
causing the hair to break off at the surface of the scalp. Hair stool softener is given daily. Clients at risk for constipation
loss usually begins 2 to 3 weeks after the initial treatment. are started on a high-fiber diet, with increased intake of bran
Drug-induced alopecia is not permanent. Hair usually begins and prune juice.
to grow back within 8 weeks after treatment is completed. The Common causes of diarrhea include radiation ther-
color and consistency of the hair may change. apy, chemotherapy, antibiotics, tube feedings, hyperosmolar
dietary supplements, stress, and fecal impactions. Clients
develop fluid and electrolyte imbalances from constant diar-
rhea. If the client is receiving a chemotherapy drug known to
CLIENTTEACHING cause diarrhea (such as fluorouracil [Adrucil] or doxorubicin
Alopecia, Threat to Body Image hydrochloride [Adriamycin]), a low-residue and lactose-free
diet is encouraged. Instruct the client to avoid foods that
Encourage client to: stimulate the gastrointestinal tract, such as warm liquids and
• Buy a wig or hairpiece before treatment actually coffee.
begins so that it will match the client’s normal Bananas (which are high in potassium) and sports drinks
hair. (which contain sodium and potassium) help replace lost fluids
and electrolytes without irritating the gastrointestinal tract.
• Wear hats, scarves, or bandanas to cope with
The perineum is kept clean and dry after each loose stool.
the change in body image caused by hair loss. Note signs of fluid and electrolyte imbalances, such as thirst,
• Focus on other positive aspects rather than on dry mucous membranes, and decreased skin turgor. The
just physical appearance. potassium level is monitored. Measure and record the amount,
frequency, and characteristics of all client bowel movements.

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58 UNIT 1 Essential Concepts

Antidiarrheal medications such as Lomotil or Imodium are

given for every loose stool. Sitz baths help soothe sore or MEDICAL EMERGENCIES

M
broken-down tissues.
Bowel obstructions occur more commonly in conjunc- edical emergencies occur in approximately 20% of cli-
tion with advanced abdominal malignancies and are sus- ents with advanced-stage cancer. Early recognition and
pected if the client has received radiation or has adhesions treatment can prevent irreversible complications and improve
from previous surgeries. Symptoms include nausea, vomit- the quality of life. Four complications with which to be famil-
ing, and abdominal pain. Surgery is required to relieve the iar are hypercalcemia, spinal cord compression, superior vena
obstruction. cava syndrome, and cardiac tamponade.

Pathological Fractures ■ HYPERCALCEMIA

H
Pathological fractures are a major problem in cancers that
metastasize to bone. These cancers weaken the bone to ypercalcemia occurs commonly and can be a potentially
the point that normal activities cause painful breaks. Thus, fatal complication if not detected early. It is found most
limbs are supported and handled gently, and extreme care often in clients with malignant tumors that have metastasized
is taken when moving clients. Special devices such as splints to bone, such as breast cancer. The condition occurs when the
are used for extra protection. Weight-bearing restrictions are serum calcium level rises >10.5 mg/dL.
ordered. Early symptoms of hypercalcemia, such as nausea, vomit-
ing, constipation, and weakness, may be overlooked because
Ascites these are common side effects of many cancer therapies. Later
symptoms such as dehydration, renal failure, coma, and car-
Abdominal cancers cause ascites, or fluid accumulation in diac arrest develop swiftly.
the abdomen. Clients experience abdominal swelling and Hypercalcemia is treated aggressively with intravenous
difficult breathing. Symptoms are treated temporarily with normal saline and furosemide (Lasix), which increase cal-
an invasive procedure called a paracentesis, wherein a small, cium excretion. Clients also are given drugs to decrease bone
plastic tube is advanced through the abdominal wall and reabsorption. Monitor the serum calcium level when Lasix is
excess fluid is withdrawn. Chemotherapy drugs sometimes administered. Teach clients early symptoms of hypercalce-
are instilled in an attempt to prevent the fluid from return- mia so they recognize a recurrence. These clients are also at
ing. Visually assess the abdomen. A protruding abdomen increased risk for pathological fractures because calcium has
indicates ascites as well as intestinal distention and enlarged been released from the bones, leaving them very fragile.
organs. Measure abdominal girth at the umbilicus daily
with a tape measure to monitor changes, then auscultate the
abdomen in all four quadrants. Gurgling bowel sounds heard
every 5 to 15 seconds indicate normal peristalsis. Decreased
■ SPINAL CORD COMPRESSION
or absent bowel sounds indicate peritonitis or paralytic ileus.
Fluid accumulation is confirmed by percussing for shifting
dullness. When a large amount of fluid is present, fluid waves
S pinal cord compression can result in permanent paralysis if
not treated promptly. Cancers of the lung, breast, and pros-
tate carry the greatest risk of metastasizing to the spinal cord.
are seen. Gentle palpation is used to detect pain and tender- The chief symptom of metastasis to the spinal cord is back
ness as well as abdominal masses. The nurse carefully docu- pain. The discomfort is aggravated by lying down, coughing,
ments any abnormal findings. or moving, and may be relieved by sitting upright.
Weigh the client daily to monitor weight gain. Fluid con- Treatment is aimed at reducing tumor size to decrease
sumption is restricted. Good skin care, especially to the abdo- pressure on the spinal cord. Radiation, surgery, and steroid
men, is essential. Fowler positioning maximizes ventilation. therapy are used. Pain medications are given frequently, and
Clients are observed closely for electrolyte imbalance if large clients are supported carefully during transfers.
amounts of fluids are withdrawn via paracentesis.

Sexual Alterations ■ SUPERIOR VENA CAVA

Many chemotherapy drugs interfere with sexual function- SYNDROME

S
ing and reproduction. Premenopausal women may become
infertile. Those younger than 35 years of age may regain uperior vena cava syndrome is a collection of symptoms
their fertility after therapy is completed. Men may experi- caused by an obstruction of the superior vena cava. It
ence impotence, decreased libido, interrupted sperm pro- occurs more frequently in conjunction with lung cancer and
duction, and ejaculation problems. Women experience lymphomas. Typically, clients experience dyspnea and swell-
vaginal dryness. ing of the face and neck. Edema in the upper extremities, chest
Encourage clients and their partners to express their feel- pain, and coughing may also occur. Central nervous system
ings and concerns to each other and to explore other avenues symptoms such as headache, visual disturbances, and altera-
of sexual expression, such as cuddling, kissing, and stroking. tion in consciousness rarely occur.
Birth control is practiced during therapy and for 1 or 2 years The goal of treatment is to reduce tumor size. Radiation
after therapy (depending on physician recommendation) to along with diuretics is usually ordered. Administer oxygen as
ensure that all chemotherapy drugs are eliminated and will ordered and provide a calm, restful environment. Encourage
have no ill effects on a pregnancy. Eggs and sperm may be the client to limit activities and lie in Fowler’s position. Care-
saved before treatment. fully monitor respirations. Lower extremities should not be

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 CHAPTER 3 Oncology 59

elevated, as doing so will increase venous return to an already to ask the physician. Encourage the client to express feelings
engorged area. and fears about the illness.
The initial treatment is very frightening for most cancer
clients. Allay anxiety by giving information about the treat-
■ CARDIAC TAMPONADE ment’s purpose, adverse reactions, and signs and symptoms

C
to report to the physician. Explaining procedures and answer-
ardiac tamponade is caused by the formation of pericar- ing questions in simple language help the client and family
dial fluid, which reduces cardiac output by compressing regain a feeling of some control. Treatment modalities cause
the heart. Tumor metastasis to the pericardium is associated many discomforts, but if the client knows what to expect, the
with lung cancer, breast cancer, Hodgkin’s disease, lymphoma, distress can generally be handled. Symptom management is
melanoma, gastrointestinal tumors, and sarcoma. Common critical in preventing lifestyle disruptions.
symptoms of cardiac tamponade include a rapid, weak pulse; Families and clients facing the terminal phase of cancer
distended neck veins during inspiration; ankle or sacral edema; are confronted with a complex set of problems. The client and
pleural effusion; ascites; enlarged spleen; lethargy; and altered family face separation and impending death. Some families
consciousness. demand that extraordinary measures be taken to keep the
Treatment is aimed at aspirating the fluid constricting client alive. Some search for meaning in life and experience a
the heart (pericardiocentesis). Reassure the client, explain the genuine closeness. Give the client and family privacy and time
procedure, and administer medication for pain. to share feelings. Sometimes, the only psychosocial support
the client needs is to have someone sitting by the bedside.
PSYCHOSOCIAL ALTERATIONS Touch, especially at times when words are hard to find, can

P
often be the most comforting intervention.
erhaps of all the problems that clients with cancer experience, As the client’s condition deteriorates, physical needs
none is more challenging than the associated psychosocial become more pronounced. Focus on keeping the client com-
alterations. The mere diagnosis of cancer invokes fear and mis- fortable and free of pain. Hospice care is designed to provide
understanding. A myriad of emotions may surface initially. These spiritual, emotional, and physical support during the final days
may range from deep depression to denial and total refusal of of illness. The goal of hospice is to keep the client as comfort-
treatment. Anxiety, sadness, and withdrawal are common. Some able as possible. Pain relief and symptom management are
clients feel that the disease is a punishment for some misguided stressed. The focus is shifted from cure to care. Care is given
deed. Each client responds differently to the diagnosis, depend- in an institution, but most hospice care is given in the home.
ing on individual coping mechanisms and support systems. Hospice care is medically managed and nurse coordinated.
Research has identified effective and ineffective coping Members of the hospice team typically include a chaplain,
mechanisms. Clients who seek information or share feelings physician, nurse, social worker, physical therapist, and home
tend to cope more effectively than do those who submit to health aide, as well as various volunteers. The team func-
treatment and procedures without asking questions or who tions to ensure that the client’s plan of care is carried out and
use small talk to avoid discussing threatening issues. that family members receive adequate support. The family is
Cancer affects not only the client, but the client’s family instructed in ways to provide care. Bereavement counseling is
as well. Responses of family members to the disease have a offered to help family members deal with their loss.
significant impact on the client’s coping. The client and family
face issues such as loss of control, changes in body image, and
financial burdens, which can be a huge problem. NURSING PROCESS
The nurse has several roles in this context. The client
needs time and space to adjust to the diagnosis. Be available to Assessment
offer support and reassurance. Answer questions, but do not
bombard the client with information. Interpret information Subjective Data
given by the physician and help the client formulate questions The client interview serves as a forum for ascertaining the
client’s perception of the illness, treatment, and prognosis;
health practices; and health concerns. The client’s significant
other also is interviewed to ascertain support systems.

Psychosocial Aspects of Cancer Objective Data

Vital signs are measured, and a head-to-toe assessment is
• Clients may see themselves as burdens to their performed. Past hospital records are reviewed along with the
families. current record. Laboratory reports, biopsy results, treatment
• Family caregivers may be angry that their own modalities, and comments from other health care profession-
needs must go unmet. als are studied.
• Family caregivers may feel inadequate with CRITICAL THINKING
regard to caring for the client.
• Medical equipment such as a hospital bed, com- Nursing Intervention Rationale
mode chair, or wheelchair may need to be What is the rationale for each nursing intervention
brought into the home. These may have an impact given for the possible nursing diagnoses identified
on family member state of mind and disposition in this chapter?
with regard to the family member with cancer.

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60 UNIT 1 Essential Concepts

Nursing diagnoses for a client with cancer includes the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fear related to cancer The client will express anxiet- Review the client’s previous experience with cancer to ascer-
diagnosis ies and fears to family and/or tain any current misconceptions based on past beliefs.
health care providers. Encourage the client to share feelings regarding the diagno-
sis to facilitate identification of coping strategies.
Explain hospital routines and focus on the recommended
treatment, including its purpose and potential side effects.
Accurate descriptions that convey what the client can
expect eases fears associated with the unknown. A calm,
reassuring environment also enhances coping abilities.

Anticipatory Grieving The client will express grief Open, honest discussions help the client cope with the situ-
related to potential loss of to family and/or health care ation. Be aware that mood swings, hostility, and other nega-
body function providers. tive behaviors often occur. Discuss the loss of body function
with the client. Ask what the loss of body function means to
the client.
Encourage the client to seek help and support from close
family members.

Imbalanced Nutrition: The client will maintain body Encourage the client to eat a high-calorie, nutrient-rich diet.
Less than Body Require- weight. Supplements are useful. Some clients benefit from frequent,
ments related to side small meals and snacks. Foods high in protein, such as
effects of chemotherapy cheese, fish, and poultry, are also recommended.
Provide oral hygiene before and after meals.
Administer antiemetics approximately 30 minutes before
meals. Mints, hard candies, and saltine crackers may help
if the client complains of metallic taste.
Nondietary interventions include varying the surround-
ings, using small plates, eating at a table with friends, and
minimizing food odors.
Monitor intake and output along with daily weight.

Risk for Impaired Skin The client will maintain skin Assess skin frequently for side effects of cancer therapy.
Integrity related to chemo- integrity. (A reddening or tanning effect develops with radiation.
therapy and radiation Skin reactions such as rashes, pruritus, and alopecia
develop with chemotherapy.)
Use lukewarm water and soap to gently wash the
client’s skin. Skin often becomes sensitive during
radiation treatments.

Risk for Infection related The client will remain free of Monitor vital signs at least every shift. White blood count is
to side effects of chemo- infection. monitored and protective isolation is instituted if the count
therapy falls <500 mm3.
Educate the client, staff, and visitors in all aspects of infec-
tion prophylaxis. Thorough hand hygiene is the most impor-
tant means of preventing and controlling the transmission
of organisms. Fresh flowers and raw fruits and vegetables
transmit microbes and therefore are eliminated. The client
should not be exposed to anyone who has an infection or
who has been recently vaccinated against or exposed to a
communicable disease. Visitors are limited.

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 CHAPTER 3 Oncology 61

Nursing diagnoses for a client with cancer includes the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related to The client will remain free of Every shift, assess the client for signs of bleeding (petechiae,
altered clotting factors injury related to bleeding. ecchymoses, hematomas, bleeding gums, epistaxis, tarry
secondary to side effects stools, hematuria, frank or prolonged bleeding from puncture
of chemotherapy sites) because transfusions may be indicated.
Monitor platelet count, which is an indicator of clotting
ability. Institute special precautions if the count falls
<50,000 mm3. Apply pressure to all puncture sites for
3 to 5 minutes. Doing so prevents prolonged bleeding,
which causes damage to underlying tissues such as nerves.
Instruct the client to use a soft toothbrush or sponge for
oral hygiene to prevent damage to oral mucosa, which is
particularly susceptible to bleeding. Instruct the client to use
an electric razor when shaving.

Fatigue related to anal- The client will experience Plan frequent rest periods for the client to restore energy,
gesics, anemia, stress, less fatigue. and schedule activities when the client has the most energy.
increased metabolism, Monitor nutritional intake, as adequate nutrients are neces-
and chemotherapy sary to meet energy needs.
Recognize that weakness places the client at increased
risk for injury. Because fatigue may make activities of daily
living difficult to complete, assistance may need to be
provided.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Lung Cancer
H.S. is a 54-year-old carpenter. He is admitted with pain over his left scapula and radiating to his left arm.
He describes having dyspnea and a productive cough. He denies any recent weight loss but does acknowl-
edge experiencing extreme fatigue for the last 2 months. H.S. has been a chronic smoker for 20 years.
A chest x-ray reveals an area of density in the left lung. A needle biopsy confirms small-cell lung cancer.
A computed tomography (CT) scan confirms extrathoracic involvement. His physician referred H.S. to
an oncologist for palliative chemotherapy. H.S. is to receive his first treatment of cisplatin (Platinol) and
etoposide (VePesid). H.S. states that he is not sure about this treatment because it will not cure him and
he does not know how he will keep breathing. He has never before been hospitalized.
NURSING DIAGNOSIS 1 Death Anxiety related to unfamiliar surroundings and uncertainty regard-
ing change in health status as evidenced by H.S.’s statement that he does not know how he will keep
breathing and the fact that he has never before been hospitalized
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Anxiety Control Anxiety Reduction
Acceptance: Health Status Coping Enhancement
Fear Control Emotional Support
(Continues)

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62 UNIT 1 Essential Concepts

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
H.S. will share his feelings regard- Ascertain what the physician has Helps decrease fear of the un-
ing his dyspnea. told H.S. and what conclusions known. Identifies the source of
H.S. has reached. Encourage H.S. any misconception that is increas-
to share his feelings concerning ing anxiety.
cancer.
H.S. will express less anxiety about Maintain frequent contact with Reassures H.S. that he is not
being in the hospital. H.S. Explain the hospital routine alone. An unfamiliar environment
and care H.S. will receive. increases anxiety.

EVALUATION
H.S. shares his feelings about his diagnosis and treatment regimen. H.S. exhibits less anxiety about the
change in his health status and hospitalization.
NURSING DIAGNOSIS 2 Impaired Gas Exchange related to decreased lung capacity and increased
secretions as evidenced by dyspnea, productive cough, and dense area in left lung
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Respiratory Status: Gas Exchange Airway Management
Respiratory Status: Ventilation Respiratory Monitoring
Tissue Perfusion: Pulmonary Oxygen Therapy

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

H.S. will report less dyspnea with Monitor pulmonary status by aus- Provides information regarding
oxygen saturation >90%. cultating breath sounds; checking pulmonary status changes indicat-
rate, depth, and pattern of respi- ing either improvement or onset
rations; evaluating skin color for of complications.
cyanosis; and monitoring
pulse oximetry.
Position H.S. in Fowler’s position. Promotes expansion of lungs and
respiratory muscles.
Administer oxygen at prescribed Corrects hypoxemia and provides
level. oxygen for metabolic needs.
Administer opioids with caution. Opioids can depress the respira-
tory center.
Monitor amount, color, and con- Changes in sputum suggest
sistency of sputum. infection or change in
pulmonary status.
Plan care and treatments within Oxygen demands increase with
H.S.’s tolerance. activity.

EVALUATION
Adequate ventilation with oxygen saturation >90% is maintained.

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 CHAPTER 3 Oncology 63

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 3 Acute Pain related to tumor growth and tissue destruction as evidenced by
verbal report of pain over left scapula radiating to left arm
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Pain Control Pain Management
Comfort Level Medication Management
Emotional Support

PLANNING/OUTCOMES INTERVENTIONS RATIONALE

H.S. will report less pain after Provide routine comfort measures Noninvasive pain-relief techniques
pain-relief measures. such as repositioning and backrub. are helpful in pain management.
Teach H.S. to request pain medica- Keeps pain under control.
tion before onset of pain.
Have H.S. rate pain on a scale of 0 Provides a method of evaluating
to 10 (0 = no pain and 10 = worst the subjective experience of pain.
pain).
Teach H.S. relaxation techniques. Decreases the perception of pain.
Document H.S.’s response to the Identifies effectiveness of pain-
pain-control regimen and adjust as relief techniques.
needed.

EVALUATION
H.S. reports less pain; <2 on a scale of 0 to 10.
NURSING DIAGNOSIS 4 Fatigue related to chronic pain and dyspnea as evidenced by client’s
description of dyspnea and extreme fatigue for 2 months
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Activity Tolerance Activity Therapy
Energy Conservation Energy Management

PLANNING/OUTCOMES INTERVENTIONS RATIONALE

H.S. will report feeling less Plan care to allow for rest periods. Helps conserve energy.
fatigued. Assess for related factors such as Reduces fatigue.
nutritional imbalances, lack of
sleep, and causes of stress.
Have H.S. rate fatigue on a scale Identifies peak energy and
of 0 to 10 (0 = not tired, 10 = total exhaustion times.
exhaustion) for a 24-hour period.
Teach energy-conservation strate- Decreases physical and psychologi-
gies such as planning ahead, setting cal stress.
priorities, scheduling rest periods,
and resting before a difficult task.
EVALUATION
H.S. exhibits less fatigue in light of having frequent rest periods daily.

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64 UNIT 1 Essential Concepts

NURSING DIAGNOSIS

Anticipatory Grieving related to loss of body function as evidenced by H.S.'s statement that he
does not know how he will keep breathing

NOC: Coping, Grief Resolution

NIC: Anticipatory Guidance, Coping Enhancement, Grief Work Facilitation

NURSING GOAL
H.S. will verbalize his loss and develop coping
skills as he acknowledges his illness as terminal.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Provide opportunities for H.S. to express 1. Helps identify H.S.’s coping strategies.
his feelings.

2. Answer all of H.S.’s questions honestly. 2. Helps H.S. cope.

3. Encourage H.S.’s participation in his care. 3. Gives H.S. a greater sense of control.

4. Encourage family support and visits from 4. Assures H.S. that he is not alone and
friends. provides time to discuss concerns openly.

5. Utilize appropriate referrals to professionals, 5. Facilitates the grief process and spiritual
such as clergy, as needed. care.

EVALUATION
Has H.S. come to terms with the reality of his
diagnosis and prognosis?

Concept Care Map 3-1

CASE STUDY
J.D. is a 70-year-old man with a history of prostate cancer, which was treated with palliative hormones and radia-
tion. His admitting diagnosis is adenocarcinoma of the prostate with widespread bone metastasis. J.D. is married
and has one grown daughter, who often helps with his care. His chief concern is severe back pain. The physician
has ordered intrathecal morphine sulfate and aspirin 10 g for pain relief.
The following questions will guide your development of a nursing care plan for the case study.
1. List symptoms typically seen in clients diagnosed with prostate cancer.
2. Identify the population most at risk for developing prostate cancer.
3. List three possible risk factors for prostate cancer.
4. Discuss the rationale for the physician’s orders including aspirin along with morphine sulfate.
5. Discuss the rationale for benzodiazepines not being used for pain relief.
6. List the subjective and objective data the nurse would want to obtain.
7. When you walk into J.D.’s room, he greets you with a smile and continues talking and joking with his daughter.
While assessing him, you note that his vital signs are normal. You ask him to rate his pain on a scale of 0 to 10.
He pauses to think about it, then rates the pain at 8. In the chart, you must record your nursing assessment by
circling the appropriate number on the scale. Which number do you think you should circle?
8. Write three individualized nursing diagnoses and goals for J.D.
9. Discuss which oncological emergency J.D. is most likely to develop.

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 CHAPTER 3 Oncology 65

SUMMARY
• Cancer is the second most common cause of death in the • Surgery is the treatment of choice for early cancers.
United States. • Chemotherapy is the treatment of choice for metastatic
• Most cancers are curable if treated early. cancers. It is also the treatment most responsible for
• Benign neoplasms are localized and encapsulated and do increasing cancer cure rates in recent years.
not spread. • Lung cancer is the leading cause of cancer death among
• Malignant neoplasms spread to neighboring tissues via men and women. Eighty percent of all cases are related to
blood and lymph. smoking.
• Biopsy is the most accurate diagnostic test for cancer. • Quality of life, not quantity of life, is the ultimate goal for
• The most common medical treatments for cancer are clients living with cancer.
surgery, radiation, and chemotherapy. They may be used
alone or in combination.

REVIEW QUESTIONS
1. The nurse carefully monitors the client’s intravenous news is not good; your tumor is classified as
chemotherapy. An early indicator that extravasation T2 N2 M1.” The nurse’s response is based on the
may be occurring is when: knowledge that:
1. the fluid stops infusing. 1. this is a local classification system used by the
2. edema is noted at the site. physicians at this particular hospital.
3. blood returns when the bottle is lowered. 2. this is an international system used by oncologists
4. burning occurs at the site. as a standardized method of defining a tumor and
2. A breast cancer client states that the doctor says he tumor activity.
is going to prescribe hormone therapy. Which of the 3. the numbers used are indicative of tumor growth
following hormones would probably be ordered? and spread, with the smaller numbers meaning
1. Thyroxin. more aggressive growth.
2. Parathormone. 4. only the physician can interpret any findings to
3. Progesterone. the client.
4. Testosterone. 7. A difference between normal cells and cancer cells is
3. A cancer client develops a low white-cell count. She that cancer cells:
is placed on neutropenic precautions. Which of the 1. adhere to their area of origin.
following menu selections would be best? 2. are well differentiated.
1. Meat loaf, mashed potatoes, green beans, and 3. multiply at will.
fruit gelatin. 4. cannot move freely around the body.
2. Meat loaf, mashed potatoes, marinated carrots, 8. Choose risk factors for cancer: (Select all that apply.)
and a garden salad. 1. use of oral birth control pills.
3. Meat loaf, mashed potatoes, chef salad, and 2. consumption of a high fiber diet.
tapioca. 3. heavy alcohol consumption.
4. Meat loaf, mashed potatoes, green beans, fruit 4. use of smokeless tobacco instead of smoking
salad, and a cookie. cigarettes.
4. When stomatitis develops, it is best to encourage the 5. consumption of five servings of fruits and
client to: vegetables daily.
1. drink plenty of orange juice. 6. multiple sexual partners with unprotected sex.
2. use lemon and glycerine swabs frequently. 9. A nurse is caring for a client with advanced cancer.
3. brush teeth before and after eating. The first priority of nursing intervention is:
4. rinse with commercial mouthwash as needed. 1. support limbs and gently turn client to prevent a
5. Clients receiving radiation are encouraged to: pathological fracture.
1. wash and dry the skin carefully and apply lotion. 2. monitor ascites by measuring abdominal girth at
2. not bathe. the umbilicus.
3. not apply deodorants or lotions. 3. listen to the client share her concerns about
4. wash the skin with soap and apply baby powder. losing her hair.
6. The client asks the nurse to explain the implications 4. administer oral morphine sulfate for break
of the TNM system. His physician told him “the through pain.

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66 UNIT 1 Essential Concepts

10. The nurse meets the psychosocial needs of the client 3. allaying anxiety by not giving any information
with cancer and his family’s needs by: about treatment options or adverse reactions.
1. conversing on a superficial level so she does not 4. providing all the physical care for the client so the
always have to think about her condition. family is not involved with these needs.
2. allowing the client personal time to adjust to
diagnosis but answer questions and provide
support as needed.

REFERENCES/SUGGESTED READINGS
Agency for Health Care Policy and Research. (1994). Clinical practice Erickson, J. (1994, November). Update on Hodgkin’s Disease. Nurse
guidelines: Management of cancer pain (AHCPR Publication No. Practitioner, 63–67.
94-0592). Rockville, MD: U.S. Department of Health & Human Estes, M. (2010). Health assessment & physical examination (4th ed.).
Services. Clifton Park, NY: Delmar Cengage Learning.
American Cancer Society (ACS). (2000). Cancer Facts & Figures 2000. Fieler, B. (1997). Side effects and quality of life in patients receiving
[Online]. Retrieved on May 2, 2009 from http://www.cancer. high-dose rate brachytherapy. Oncology Nursing Forum, 24(3), 545.
org/docroot/STT/stt_0_2000.asp?sitearea=STT&level=1 Galvan, T. (2001). Dysphagia: Going down and staying down. AJN,
American Cancer Society (ACS). (2002). Cancer news roundup. 101(1), 37–42.
Nursing2002, 32(10), 32hn6–32hn7. Greifzu, S. (1998). Fighting cancer fatigue. RN, 61(8), 41–43.
American Cancer Society (ACS). (2003). Cancer Facts & Figures 2003. Harris, L. (2002). Ovarian cancer: Screening for early detection. AJN,
[Online]. Retrieved on May 2, 2009 from http://www.cancer.org/ 102(10), 46–52.
docroot/STT/stt_0_2003.asp?sitearea=STT&level=1 Held-Warmkessel, J. (1998). Chemotherapy complications: Helping
American Cancer Society (ACS). (2006). Cancer facts & figures 2006. your patient cope with adverse reactions. Nursing98 4(28), 41–45.
Atlanta: American Cancer Society. Kediziera, P. (1998). The two faces of pain. RN, 61(2), 45–46.
American Cancer Society (ACS). (2007). Global Cancer: Facts & Kohr, J. (1995). Measuring your patient’s pain. RN, 58(4), 39–40.
Figures 2007. Retrieved on May 2, 2009 from http://www.cancer.org/ Langhorne, M., Fulton, J., & Otto, S. (2007). Oncology nursing (5th ed.).
downloads/STT/Global_Cancer_Facts_and_Figures_2007_rev.pdf St. Louis: Mosby.
American Cancer Society (ACS). (2008). Cancer Facts & Figures 2008. Lewis, S., Heitkemper, M., & Dirksen, S. (2007). Medical–surgical
Retrieved on May 2, 2009 from http://www.cancer.org/docroot/ nursing: Assessment and management of clinical problems (7th ed.).
STT/stt_0_2008.asp?sitearea=STT&level=1 St. Louis, MO: Mosby.
American Pain Society. (1992). Principles of analgesic use in the treatment Machia, J. (2001). Breast cancer: Risk, prevention & Tamoxifen. AJN,
of acute and chronic cancer pain (3rd ed.). Skokie, IL: Author. 101(4), 26–35.
Baird, S., Donehower, M., Stalsbroten, V., & Ades, T. (Eds.) (1997). McCaffery, M., & Ferrell, B. (1994, July). How to use the new AHCPR
A cancer source book for nurses (7th ed.). Atlanta, GA: American cancer pain guidelines. AJN, 42–47.
Cancer Society. McCarron, E. (1995, June). Supporting the families of cancer patients.
Belcher, A. (1992). Cancer nursing. St. Louis, MO: Mosby. Nursing95, 48–51.
Blackburn, G. (1998). Wasting away: Cancer cachexia. Health News, McConnell, E. (2001). Myth & Facts about dysphagia. Nursing2001,
4(4), 4. Waltham, MA: Massachusetts Medical Society. 31(7), 29.
Bral, E. (1998). Caring for adults with chronic cancer pain. AJN, 4(98), Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007).
27–32. Nursing Outcomes Classification (NOC) (4th ed). St. Louis, MO:
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. (2008). Elsevier—Health Sciences Division.
Nursing Interventions Classification (NIC) (5th ed.). St. Louis, MO: Monahan, F., Sands, J., Neighbors, M., & Marek, J. (2006). Phipps’
Mosby/Elsevier. medical-surgical nursing: Health and illness perspectives (8th ed.).
Cancerbackup. (2009). Combination chemotherapy regimen. St. Louis, MO: Mosby Elsevier.
Macmillan Cancer Support. Retrieved on May 5, 2009 from Myers, J. (2000). Chemotherapy-induced hypersensitivity reaction.
http://www.cancerbackup.org.uk/Treatments/Chemotherapy/ AJN, 100(4), 53–54.
Combinationregimen National Bone Marrow Transplant Link (NBMTLink). (2009).
Cancer Treatment Centers of America. (2009a). Biotherapy/ Resource guide for bone marrow/stem cell transplant. Retrieved on
Immunotherapy. Retrieved on May 1, 2009 from http://www. April 30, 2009 from http://www.nbmtlink.org/resources_support/
cancercneter.com/conventional-cancer-treatment/biotherapy- rg/rg_costs.htm
immunotherapy.cfm National Cancer Institute. (2006). Targeted cancer therapies:
Cancer Treatment Centers of America. (2009b). Photodynamic therapy. Questions and answers. National Cancer Institute Fact Sheet.
Retrieved on May 1, 2009 from http://www.cancercneter.com/ Retrieved on May 4, 2009 from http://www.cancer.gov/
conventional-cancer-treatment/photodynamic-therapy.cfm cacncertopics/factsheet/Therapy/targeted/print?page=&keyword
Cancer Treatment Centers of America. (2009c). Hormone Therapy. Otto, S. (2001). Oncology nursing (4th ed.). St. Louis, MO: Mosby.
Retrieved on May 1, 2009 from http://www.cancercneter.com/ Porth, C., & Matfin, G. (2008). Pathophysiology: Concepts of Altered
conventional-cancer-treatment/hormone-therapy.cfm Health States (8th ed.). Philadelphia: Lippincott Williams &
Chapman, D., & Goodman, M. (2000). Cancer nursing principles (5th ed.). Wilkins.
Boston, MA: Jones & Bartlett. Researchers say new drug may boost effects of cancer radiation. (1998,
Chiramannil, A. (1998). Lung cancer. AJN, 4(98), 46–47. May 12). Corpus Christi Caller Times.
Dell, D. (2001). Regaining range of motion after breast surgery. Resnick, B., & Belcher, A. (2002). Breast reconstruction. AJN, 102(4),
Nursing2001, 31(10), 50–52. 26–33.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 3 Oncology 67

Sargent, C., & Murphy, D. (2003). What you need to know about U.S. Preventive Services Task Force. (2002). Screening for colorectal
colorectal cancer. Nursing2003, 33(2), 36–41. cancer: Recommendations and rationale. AJN, 102(9), 107–114.
Schweid, L., & Werner-McCullough, M. (1994, September). Will you Watson, A., & Coyne, P. (2003). Recognizing the faces of cancer pain.
recognize these oncological crises? RN, 23–27. Nursing2003, 33(4), 32hn1–32hn8.
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Weber, M. (1995). Clinical snapshot: Chemotherapy-induced nausea
Suddarth’s Textbook of Medical Surgical Nursing, North American and vomiting. AJN, 95(4).
Edition (11th ed.) Philadelphia: Lippincott Williams & Wilkins White, L., & Spitz, M. (1994). Cancer risk and early detection
Tamoxifen for breast cancer prevention. (1998, December 15). assessment. Capsules and Comments in Oncology Nursing, 2(1), 2–3.
Healthnews, 4(15). Wilkes, G. (2000). Nutrition: The forgotten ingredient in cancer care.
Teasley, R. (in press). Understanding Neoplasms. AJN, 100(4), 46–51.
Thaler-DeMers, D. (2000). The cancer survival toolbox. AJN, Woodward, W., & Thobaben, M. (1994). Special home health care nursing
100(4), 52. challenges: Patients with cancer. Home Health Care Nurse, 12(3), 33–37.
Timby, B., Smith, N., & Scherer, J. (2002) Introductory Medical-Surgical Zuckerman, D. (2002). The breast cancer information gap. RN, 65(2),
Nursing (8th ed.) Philadelphia: Lippincott Williams & Wilkins. 39–41.

RESOURCES
American Cancer Society (ACS), http://www.cancer.org National Cancer Institute, http://www.cancer.gov
American Pain Society, http://www.ampainsoc.org/ National Coalition for Cancer Survivorship (NCCS),
Breast Cancer Network of Strength, http://www.canceradvocacy.org
http://www.networkofstrength.org/

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Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 2 Oxygenation and Perfusion
Chapter 4 Respiratory System / 70

Chapter 5 Cardiovascular System / 119

Chapter 6 Hematologic and Lymphatic Systems / 163

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 CHAPTER 4
Respiratory System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the respiratory system:
Adult Health Nursing Delmar’s Heart & Lung Sounds on
• Oncology StudyWare CD™: Lung Sounds
• Cardiovascular System
• Hematologic and Lymphatic Systems

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe components of a complete respiratory assessment.
• Identify normal parameters for common respiratory diagnostic studies.
• Discuss the etiology, medical–surgical management, and nursing care for
clients with respiratory disorders.
• Prepare a nursing care plan for a client with a respiratory disorder.

KEY TERMS
adventitious breath sound emphysema pleurisy
asthma empyema pneumonia
atelectasis epistaxis pneumothorax
audible wheeze external respiration primary tubercle
bronchial sound fine crackle respiration
bronchiectasis hemopneumothorax sibilant wheeze
bronchitis hemothorax sonorous wheeze
bronchovesicular sound internal respiration status asthmaticus
caseation liquefaction necrosis stridor
cavitation lung stretch receptor surfactant
chemoreceptor perfusion ventilation
coarse crackle pleural effusion vesicular sound
diffusion pleural friction rub

70

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 CHAPTER 4 Respiratory System 71

lining the thoracic cavity. The layers of the pleura are the parietal
INTRODUCTION pleura, which lie adjacent to the chest wall and produce pleural
Respiratory disorders account for millions of the dollars spent fluid, and the visceral pleura, which adhere to the surface of the
in the U.S. health care arena. From loss of time on the job lungs and absorb pleural fluid. The area between the two pleura
because of the common cold to care for those with chronic is known as the pleural space or pleural cavity.
respiratory disorders, the cost of respiratory disease is stagger- The pleural space contains 5 to 20 mL of fluid, which
ing. This chapter explores the various respiratory disorders, allows the layers of the pleura to slide on each other yet hold
with a focus on the nursing process. together. The pressure within the pleural space is less than that
of outside air. This difference in pressure creates a suction that
prevents the lungs from collapsing on exhalation.
ANATOMY AND PHYSIOLOGY The right lung is larger than the left and is divided into
three sections, or lobes: upper, middle, and lower. The left
REVIEW lung is divided into two lobes: upper and lower (Figure 4-1).
The upper portion of the lung is referred to as the apex (plural,
The primary function of the respiratory system is delivery of apices). The lower portion is called the base. The lungs pos-
oxygen to the lungs and removal of carbon dioxide from the sess a dual blood supply: bronchial circulation and pulmonary
lungs. circulation. Bronchial circulation begins with the bronchial
artery, which provides the passageways of the lungs with
Thoracic Cavity blood to meet nutritional needs and ends when the venous
The chest cage is a closed compartment bounded on the top blood enters the pulmonary veins. Pulmonary circulation is
by the neck muscles and at the bottom by the diaphragm. The the route by which blood is delivered to the alveoli for gas
walls of the chest cage are formed by the ribs and intercostal exchange (Figure 4-2).
muscles laterally, the thoracic vertebrae posteriorly, and the ster-
num anteriorly. The inside of the chest cage is called the thoracic
cavity. Contained within the thoracic cavity are the lungs. The Conducting Airways
lungs are cone-shaped, porous organs separated from the other The conducting airways are tube-like structures that provide a
chest organs by the mediastinum. The lungs lie free, except for passageway for air as it travels to the lungs. These are the nasal
their attachment to the heart and trachea, and are encased in passages, mouth, pharynx, larynx, trachea, bronchi, and bron-
the pleura, a thin, transparent double-layered serous membrane chioles (Figure 4-1). The conducting airways are lined with

Nasopharynx

Oropharynx
Nasal cavity
Laryngopharynx Nose
Parietal pleura Rib
Esophagus

Visceral pleura Epiglottis

Pleural space Larynx
Intercostal
muscles Lung Trachea

Main
Mainstem bronchus
bronchus
Secondary
Right bronchus
upper lobe Tertiary
bronchus
Right
middle lobe Left
upper lobe

Right Left
lower lobe lower lobe
Terminal
COURTESY OF DELMAR CENGAGE LEARNING

bronchiole
Alveoli
Alveolar
duct
Diaphragm
Mediastinum
Respiratory
bronchiole
Alveolar sacs

Figure 4-1 Structures of the Respiratory Tract

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72 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

The right bronchus is wider and more vertically posi-

tioned than the left. This difference in positioning allows
Terminal
bronchiole
foreign matter to enter the right bronchus more easily than the
left. Within the lungs, the bronchi branch off into increasingly
smaller diameter tubes until they become the terminal bronchi-
oles. These branch further, forming alveolar ducts that end in
numerous saclike, thin-walled structures called the alveoli. Col-
lectively, the alveoli and the alveolar ducts resemble a cluster
of grapes. The branching makes this portion of the respiratory
Respiratory tract resemble an inverted tree, giving rise to the term bronchial
bronchiole
tree (Figure 4-1).
Pulmonary
artery

Pulmonary
Respiratory Tissues
vein The respiratory tissues perform the function of gas exchange.
The alveoli constitute the primary site of gas exchange. The
alveolar ducts are smooth, muscular tubes containing abun-
dant alveolar macrophages that remove foreign particles

COURTESY OF DELMAR CENGAGE LEARNING

(e.g., bacteria). The alveoli, into which the alveolar ducts
terminate, consist of interconnected spaces with thin walls, or
septa, occupied by a network of capillaries called the alveolar
Alveoli
capillary membrane.
The alveoli contain two specialized types of cells. Type I
alveolar cells are flat, squamous, epithelial cells across which
Capillaries gas exchange occurs. Type II alveolar cells produce a phos-
pholipid substance called surfactant. Surfactant coats the
Figure 4-2 Gas exchange occurs at the alveolar capillary inner surfaces of the alveoli, reduces the surface tension of
membrane. pulmonary fluids, allows gas exchange, and prevents the col-
lapse of the airways. Each lung contains approximately 300
epithelial tissue containing serous glands, mucus-secreting million alveoli.
Goblet cells, and hair-like projections called cilia. The mucus
of the Goblet cells together with the cilia form a mucocili-
ary blanket that protects the respiratory system from foreign Respiration
particles. The constant upward motion of the cilia propels the Respiration is a process of gas exchange. This process is
mucociliary blanket toward the pharynx, where foreign matter necessary to supply cells with oxygen for metabolism and
is expectorated or swallowed. to remove the waste by-product carbon dioxide. There are
The nasal passages are the preferred route for air to enter two types of respiration: external respiration and internal
the respiratory tract. In addition to the function of filtering respiration. External respiration is the exchange of gases
inspired air, the nasal passages are richly supplied with blood between the inhaled air, now in the alveoli, and the blood
vessels that warm and moisten the air. Because the mouth lacks in the pulmonary capillaries. Internal respiration is the
cilia and abundant blood supply, breathing through the mouth exchange of gases at the cellular level between tissue cells
reduces the ability to filter, warm, and moisten inspired air. and blood in systemic capillaries (Figure 4-3). These func-
Connecting the nasal passages and mouth to the lower tions depend on the adequacy of ventilation, perfusion, and
parts of the respiratory tract is the pharynx. Located behind diffusion. Ventilation is the movement of gases into and
the oral cavity, the pharynx serves as a passageway for both out of the lung. Perfusion is the flow of blood through
inspired air into the larynx and ingested food passing into the the vessels of a specific organ or body part. Pertaining to
digestive system. At the distal portion of the pharynx is the the respiratory system, diffusion is the movement of gases
larynx, also known as the voice box. across the alveolar capillary membrane from areas of high
The larynx contains the vocal cords and is the passage- concentration to areas of lower concentration. Factors that
way for air entering and leaving the trachea. The larynx is affect ventilation, perfusion, and diffusion affect respiration
composed of four structures: the uppermost thyroid cartilage (Table 4-1).
(Adam’s apple), the cricoid cartilage (which lies at the lower
edge of the larynx), the epiglottis (a leaf-shaped structure that
covers the larynx during swallowing), and the glottis (the tri- Neuromuscular Control of
angular space between relaxed vocal cords).
The trachea, commonly known as the windpipe, is a Respiration
tube composed of connective tissue mucosa and smooth Unlike the heart muscle, the respiratory muscles must
muscle supported by C-shaped rings of cartilage that extends receive continuous neural stimuli to function. Regulation
into the bronchi. The trachea is 2.0 to 2.5 cm wide (approxi- of respiration is integrated by neurons located in the pons
mately 1 inch) and 10 to 12 cm long (approximately 4 to 6 and medulla of the brain. The control of respiration is
inches). The trachea terminates by branching into two tubes: influenced by involuntary (automatic) and voluntary com-
the right and left primary bronchi. The bronchi are somewhat ponents. Involuntary components include chemoreceptors,
smaller in diameter than the trachea, and each passes into its lung stretch receptors, and impulses from other sources.
respective lung. Chemoreceptors monitor the levels of carbon dioxide and

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 CHAPTER 4 Respiratory System 73

Air blown out Air drawn in

Table 4-1 Factors Affecting Ventilation,
Airways of Perfusion, and Diffusion
respiratory
tree Ventilation Position: Dependent areas receive
(ventilation)
majority of air.
Lung volume: Low volume results in
shunting air to lung apices.

Alveoli Disease: Bronchial constriction and airway

collapse decrease ventilation.

Perfusion Position: Dependent areas receive

O2
A
majority of blood.
External respiration (gas exchange between air Hypoxia: Results in vasoconstriction and
CO2 in alveoli and blood in pulmonary capillaries)
decreased perfusion.
Blood in

COURTESY OF DELMAR CENGAGE LEARNING

pulmonary capillaries Blockage: Results in decreased or absent
Blood flow CO2
perfusion to distal areas.
O2 B Diffusion Alveolar capillary membrane: Alterations

COURTESY OF DELMAR CENGAGE LEARNING

Internal
Blood in respiration may occur in thickness and permeability
systemic capillaries (gas of membrane.
Blood flow exchange
between
tissue
cells and
blood in

Gas Exchange
systemic
capillaries)

Gas exchange occurs at the alveolar capillary membrane

Figure 4-3 A, External Respiration; B, Internal Respiration
(Figure 4-2). Venous blood from the right ventricle is pumped
into the pulmonary arteries and travels to the alveolar capil-
lary network, where it is exposed to the inhaled air. Because
of the higher concentration of oxygen in the alveoli, oxygen
oxygen and the acidity/alkalinity (pH) of the blood. Nor- diffuses into the blood within the alveolar capillary network.
mally, chemoreceptors initiate respiration in response to an The majority of oxygen binds to the iron atoms of the hemo-
increase of carbon dioxide in the blood. With certain chronic globin molecule in the red blood cells. Approximately 1% to
pulmonary disorders, such as emphysema, chemoreceptors 3% of oxygen dissolves into the blood plasma.
become more responsive to a low level of oxygen. This The exchange of carbon dioxide also occurs within
becomes significant when administering oxygen to persons the alveoli. Within the alveolar capillary network, the car-
whose drive to breathe depends on a low level of oxygen in bon dioxide detaches from hemoglobin and diffuses into
the blood. Lung stretch receptors monitor the pattern of the alveolar space. Carbon dioxide is removed from the
breathing and prevent overexpansion of the tissues. Many alveolar space when exhalation occurs. The blood within
other sources involuntarily send impulses to the respiratory the pulmonary capillary network is now oxygenated and
center. For example, if a person becomes frightened or angry, travels to the heart via the pulmonary veins. Oxygenated
the respiratory rate increases in response to stimuli from the blood is sent to the body via the aorta and the arterial net-
autonomic nervous system. Voluntary components of respi- work (Figure 4-3).
ratory control integrate breathing with acts such as talking
and speaking.
The diaphragm acts as the primary muscle of respira-
tion. During inspiration, the diaphragm contracts and flat- ASSESSMENT
tens out in response to stimuli from the respiratory center, To understand the assessment of the respiratory system,
increasing the length of the thoracic cavity. At the same the student must be familiar with related terminology
time, the intercostal muscles contract, elevating the ribs (Table 4-2).
and increasing the diameter of the thoracic cavity. The total
thoracic space increases, reducing the pressure within the
thoracic cavity. The pressure within the thoracic cavity then
becomes negative in relation to that of atmospheric pressure, Health History
and air moves into the thoracic cavity. Upon expiration, the Nursing assessment begins with a complete history. The cli-
respiratory center signals the diaphragm and intercostal ent is questioned regarding allergies, occupation, lifestyle, and
muscles to relax. The thoracic cavity returns to its original health habits such as smoking or alcohol use (Box 4-1). Ask
size. Aided by the elastic recoil of the lungs, the decrease in about other health problems that affect the respiratory system,
size of the thoracic cavity increases pressure, and air moves such as pneumonia or cardiac problems. Symptoms such as
out of the lungs. dyspnea, decreased exercise tolerance, and cough are explored

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74 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Table 4-2 Respiratory Terms

TERM DEFINITION
Eupnea Normal breathing

Apnea Cessation of breathing, possibly temporary in nature

Dyspnea Labored or difficult breathing, possibly normal if associated with exercise

Bradypnea Abnormally slow breathing

Tachypnea Abnormally rapid breathing

Orthopnea Discomfort or difficulty with breathing in any but an upright sitting or standing position

Kussmaul’s Abnormal respiratory pattern characterized by irregular periods of increased rate and depth of
respirations respiration; most often seen with diabetic ketoacidosis

Biot’s respirations Abnormal respiratory pattern characterized by irregular periods of apnea alternating with short
periods of respiration of equal depth; most commonly seen with increased intracranial pressure

Cheyne-Stokes Abnormal respiratory pattern characterized by initially slow, shallow respirations that increase in
respirations rapidity and depth and then gradually decrease until respiration stops for 10 to 60 seconds; pat-
tern then repeats itself in the same manner

Anoxia Without oxygen

Hypoxia Lack of adequate oxygen in inspired air such as occurs at high altitude

Hypoxemia Insufficient amount of oxygen in the blood possibly due to respiratory, cardiovascular, or anemia-
related disorders

Cyanosis Bluish, grayish, or purplish discoloration of the skin caused by abnormal amounts of reduced
(oxygen-poor) hemoglobin in the blood; not always a reliable indicator of hypoxia

COURTESY OF DELMAR CENGAGE LEARNING

Acrocyanosis Cyanosis of the fingertips and toes; often caused by vasomotor disturbances associated with
vasoconstriction

Circumoral cyanosis Bluish discoloration encircling the mouth

Oxygen saturation Amount of oxygen combined with hemoglobin

in depth. Following a complete history, the nurse completes a areas of varying densities in the lung can be detected. The
physical assessment of the client. density of lung tissues changes with disease states such as
pneumonia, pneumothorax, and pleural effusion.
Inspection
Physical assessment of the respiratory system starts with Auscultation
inspection. Note the client’s color, level of consciousness, The client should breathe slowly through the mouth while the
and emotional state. Respirations are observed for their rate, listener assesses breath sounds at each location for the length
depth, quality, rhythm, and breathing pattern. Symmetry of of a complete inspiration and expiration. Breath sounds
chest wall movement is also noted. The nurse observes for are assessed for duration, pitch, and intensity. Figure 4-4
use of accessory muscles to aid breathing. The position the illustrates the recommended stethoscope location for each
client assumes provides information on respiratory status auscultation.
because individuals having trouble breathing often lean
forward. Normal Breath Sounds
Palpation and Percussion Under normal circumstances, bronchial sounds are heard
over the sternum (Figure 4-5). These loud, high-pitched
The next steps in the respiratory assessment are palpation and tubular, hollow-like sounds last longer during expiration than
percussion. These are normally done by the registered nurse during inspiration. When heard in areas other than the ster-
or physician. Through the use of palpation and percussion, num, bronchial sounds indicate fluid, exudate, or lung tissue

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 CHAPTER 4 Respiratory System 75

BOX 4-1 QUESTIONS TO ASK AND OBSERVATIONS TO MAKE WHEN COLLECTING DATA

Subjective Data
• Do you have seasonal or environmental allergies?
• Have you been coughing? If so, are you coughing up any mucous? What does it look like?
• Do you get frequent upper respiratory infections?
• Have you ever had pneumonia? If so, when and how often?
• Have you had the pneumonia vaccine?
• Do you get a flu shot annually?
• Do you have any chronic lung conditions such as asthma or emphysema?
• Are you experiencing any difficulty breathing?
• Have you experienced any shortness of breath with exertion or activity?
• Is your nose feeling stuffy and congested?
• Does your throat hurt or feel sore?
• Have you experienced changes in your voice?
• Do you currently or have you ever smoked?
• If you no longer smoke, when did you quit?
• If you smoke, how long have you smoked? What do you smoke? And, how much do you smoke each day?
• Does your chest feel tight when you breathe?
• Are you experiencing any chest pain or discomfort when breathing?

Objective Data
• Check vital signs.
• Check pulse oximetry levels.
• Observe respiratory effort.
• Observe use of accessory muscles.
• Assess color of mucous membranes and nail beds.
• Assess for sputum production.
• Record the quality, color, and odor of the sputum.
• Observe client’s activity tolerance.
• Assess supplemental oxygen requirements.
• Auscultate lung sounds.
• Report chest x-ray results or other diagnostic test results.
• Record the quality, color, and odor of the sputum.

compression. Bronchovesicular sounds are heard over pleural friction rub, and stridor. Table 4-3 describes
the anterior one-third of the chest near the sternum and also the general characteristics of these adventitious breath
around the scapula posteriorly (Figure 4-5). Bronchovesicular sounds.
sounds have a medium pitch and intensity with inspiration
and expiration being equal in duration. They may be heard
in the periphery of the lung when consolidation and fluid are COMMON DIAGNOSTIC TESTS
present. Commonly used diagnostic tests for clients with respiratory
Vesicular sounds are heard over the majority of the disorders are listed in Table 4-4. Table 4-5 lists normal values
lungs (Figure 4-5). These soft, low-pitched sounds are for arterial blood gases.
best heard during inspiration and may be inaudible during
expiration.
INFECTIOUS/INFLAMMATORY
Adventitious Breath Sounds DISORDERS
Abnormal breath sounds are called adventitious breath
sounds and include fine crackles (rales), coarse crackles
(rales), sonorous wheezes (rhonchi), sibilant wheezes,
I nfectious/inflammatory disorders of the upper respiratory
tract, pneumonia, tuberculosis, and pleurisy/pleural effu-
sion are discussed in the following sections.

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76 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

1 2
1 2
3 4
3 4
5 6 5 6
7 8 7 8
9 10 9 10
11 12

A B

1 1

COURTESY OF DELMAR CENGAGE LEARNING

2 2

3
3

4 4

C D

Figure 4-4 Stethoscope Locations for Each Auscultation; A, Anterior Thorax; B, Posterior Thorax; C, Right Lateral Thorax;
D, Left Lateral Thorax

Vesicular
Bronchovesicular
Bronchial
COURTESY OF DELMAR CENGAGE LEARNING

Anterior Thorax Posterior Thorax

Figure 4-5 Location of Breath Sounds

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 Table 4-3 Characteristics of Adventitious Breath Sounds
RESPIRATORY CLEAR WITH
BREATH SOUND PHASE TIMING DESCRIPTION COUGH ETIOLOGY CONDITIONS
Fine crackle (rale) Predominantly Discontinuous Dry, high-pitched No Air passing through COPD, congestive
inspiration crackling, popping, moisture in small heart failure (CHF),
short duration; roll hair airways that suddenly pneumonia,
near ears between reinflate pulmonary fibrosis,
your fingers to simu- atelectasis
late this sound

Coarse crackle Predominantly Discontinuous Moist, low-pitched Possibly Air passing through Pneumonia,
(coarse rale) inspiration crackling, gurgling; moisture in large pulmonary edema,
long duration airways that suddenly bronchitis,
reinflate atelectasis

Sonorous wheeze Predominantly Continuous Low pitched; snoring Possibly Narrowing of large Asthma, bronchitis,
(rhonchi) expiration airways or obstruc- airway edema, tumor,
Z Z Z Z
Z Z Z Z Z Z Z Z tion of bronchus bronchiolar spasm,
Z Z Z Z
Z Z Z Z
Z Z Z Z foreign body
Z Z Z Z
Z Z Z Z
obstruction

Sibilant wheeze Predominantly Continuous High pitched; musical Possibly Narrowing of large Asthma, chronic
expiration airways or obstruc- bronchitis,
tion of bronchus emphysema, tumor,
foreign body
obstruction

Pleural Inspiration and Continuous Creaking, No Inflamed parietal and Pleurisy,

friction rub expiration grating visceral pleura; can tuberculosis,
occasionally be felt pulmonary infarction,
on thoracic wall as two pneumonia,
pieces of dry leather lung abscess
rubbing against each
other

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CHAPTER 4 Respiratory System

Stridor Predominantly Continuous Crowing No Partial obstruction of Croup, foreign body

Z Z Z Z
Z Z Z Z inspiration the larynx, trachea obstruction, large
Z Z Z Z
Z Z Z Z
Z Z Z Z
Z Z Z Z airway tumor
Z
77

COURTESY OF DELMAR CENGAGE LEARNING

78 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Table 4-4 Common Diagnostic Tests

for Respiratory Disorders PROFESSIONALTIP
Laboratory Tests
• Hemoglobin Influenza
• Arterial blood gases (ABGs) Influenza (the flu) is a contagious respiratory
• Pulmonary function tests (PFTs) illness caused by influenza viruses that lead to mild
• Sputum analysis to severe illness and, at times, death. Influenza
viruses are spread from person to person in
Radiologic Studies
respiratory droplets of coughs and sneezes. The
• Chest x-ray Centers for Disease Control and Prevention (2009)
• Ventilation-perfusion scan (V/Q scan) estimates that 5% to 20% of Americans get the
• Computerized axial tomography flu, more than 200,000 people are hospitalized
(CAT scan) from flu complications, and about 36,000 people
• Pulmonary angiography die from influenza during each flu season, from

COURTESY OF DELMAR CENGAGE LEARNING

November to March. The best way to prevent the
Other
flu is to get a flu vaccination each year. There
• Pulse oximetry are two types of influenza vaccines available:
• Bronchoscopy the “flu shot” and the nasal-spray flu vaccine.
• Thoracentesis Currently there are four antiviral medications
• Magnetic resonance imaging (MRI) approved for treatment of influenza in the
United States. Oseltamivir (Tamiflu) and zanamivir
Table 4-5 Arterial Blood Gases: (Relenza) are recommended by the CDC due to
the emerging influenza A resistance to the other
Normal Values
two medications, amantadine (Symmetrel) and
MEASUREMENT NORMAL rimantadine (Flumadine) (National Institute of
IN BLOOD VALUE Allergy and Infectious Diseases, 2009). For more
Acidity or alkalinity (pH) 7.35 to 7.45 information on influenza, visit http://www.cdc.gov/
COURTESY OF DELMAR CENGAGE LEARNING

Partial pressure of oxygen (PaO2) 80 to 100 mm Hg flu/ or http://www3.niaid.nih.gov/topics/Flu/

Partial pressure of carbon dioxide 35 to 45 mm Hg

(PaCO2) 24 to 28 mm Hg headache. Drying of the mucous membranes coupled with
Bicarbonate ion (HCO3) 95% to 100% edema cause local discomfort such as sore throat. Cough and
Arterial oxygen saturation (SaO2) nasal or sinus discharge may occur. Nasal secretions that are
thick and purulent indicate bacterial infection.

■ INFECTIOUS/INFLAMMATORY
DISORDERS OF THE UPPER Medical–Surgical Management
RESPIRATORY TRACT Medical

I
Most clients with acute upper respiratory tract infections or
nfectious and inflammatory disorders of the upper respira- inflammatory disorders are treated in a clinic or office setting.
tory tract are common and usually self-limiting. Among the Unless the disorder becomes chronic or bacterial infection
causal factors of infectious and inflammatory disorders are occurs, treatment is symptomatic. When infection is sus-
various viruses (rhino viruses, influenza viruses) and bacteria pected, specimens for culture and sensitivity are obtained, and
(streptococci and pneumococci). Group A beta-hemolytic strepto- appropriate antibiotic therapy is initiated.
cocci infections of the upper respiratory system are associated
with serious sequelae such as rheumatic fever. Allergic reac- Surgical
tions frequently play a role in the development of sinusitis and
pharyngitis. Laryngitis is associated with factors such as pollu- Disorders that develop into chronic conditions (e.g., tonsillitis
tion, smoking, and excessive use of the voice. Breathing cold air and sinusitis) may require surgical intervention to remove or
decreases local immune responses of the respiratory tract. This drain affected tissues.
fact coupled with closer and prolonged contact with others
indoors during the colder months leads to an increased inci- Pharmacological
dence of acute upper respiratory tract inflammatory disorders. Nonprescription antipyretic, analgesic, anti-inflammatory
The signs and symptoms that occur with acute upper medications are used to reduce discomfort, fever, and inflam-
respiratory tract infection or inflammation are a result of the mation. Antitussives are used to suppress cough and allow for
inflammatory process. Early signs and symptoms include rest. To aid in removal of secretions, expectorants are used.
general malaise, low-grade fever, localized redness, and edema Bacterial infections are treated with various antibiotics accord-
of affected tissues. Joint pain is common with viral disorders. ing to culture and sensitivity studies. Comfort measures such
The client may complain of nasal or sinus congestion and as saline gargles may be useful.

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 CHAPTER 4 Respiratory System 79

Diet NURSING PROCESS

Fluids are advocated to liquefy secretions and hydrate dry
mucous membranes. Nausea may occur if secretions are
swallowed as opposed to expectorated. The client should
Assessment
cover cough to prevent spread and be encouraged to cough Subjective Data
up all secretions and dispose of them in a tissue. With severe Subjective data include information about present signs and
coughing, emesis may occur. The client is encouraged to symptoms, onset of symptoms, exposure to allergens or infected
rest before meals and may require an antitussive to reduce individuals, and frequency of the disorder. Common symptoms
coughing. include sore throat, nasal congestion, dyspnea, and headache.

Activity Objective Data

Normally, activity does not need to be restricted, but energy Objective data include fever and inflammation, redness,
level may decrease. The client who is infectious is encouraged edema, and drying of the mucous membranes of the orophar-
to avoid contact with others. Strenuous activity should be ynx. Secretions are evaluated for their color, viscosity,
avoided to reduce oxygen requirements and coughing. amount, and odor, which will help in identifying the specific
illness. The client may have hoarseness and a cough. Culture
Nursing Management and sensitivity studies may reveal a causative organism and,
thus, guide antibiotic therapy. If infection with group A
Client teaching about signs and symptoms of a respiratory beta-hemolytic streptococci is suspected, an antistreptolysin
infection, avoiding items causing an allergic response, and O (ASO) titer is done to reveal the presence of antibodies
taking all prescribed antibiotics is the main nursing respon- formed in reaction to this bacteria. Nonspecific diagnostic
sibility. Hand washing is vital in preventing the spread of studies include elevated white blood cell count and erythro-
infection. cyte sedimentation rate.

Nursing diagnoses for a client with an upper respiratory infection or

inflammatory disorder include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge related The client will be able to Educate client regarding signs and symptoms indicating
to signs and symptoms of state the signs and symp- a respiratory bacterial infection, such as purulent or green
respiratory bacterial infec- toms of bacterial infection. secretions, fever.
tion, potential allergens, and The client will be able to Assist physician in allergy testing. Teach client to avoid
antibiotic therapy identify individual potential those things that precipitate an allergic response.
allergens.
The client will complete Instruct client to complete the entire course of antibiotics.
entire course of antibiotic
therapy.

Ineffective Airway Clear- The client will verbalize a Encourage client to blow the nose and not “snuffle” secre-
ance related to nasal decrease or absence of tions back up into nose.
secretions nasal congestion.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

secrete exudate (an accumulation of fluid in the pulmonary

■ PNEUMONIA passageways). Eventually, the alveoli fill with the exudate,

P
resulting in consolidation. The exudate within the alveoli
neumonia is inflammation of the bronchioles and interferes with gas exchange.
alveoli accompanied by consolidation, or solidification Risk factors for the development of pneumonia include
of exudate, in the lungs. It can result from bacteria, viruses, immobility, depressed cough reflex (caused by anesthesia
mycoplasms, fungi, chemical exposures, or parasite inva- or cerebrovascular accident [CVA]), alterations in respi-
sions. Pneumonia can also be caused by aspiration, over- ratory function (e.g., chronic obstructive pulmonary dis-
sedation, or inadequate ventilation. Pneumonia remains ease [COPD]), advanced age, and numerous other chronic
a common cause of hospitalization and is often a cause of debilitating conditions (e.g., congestive heart failure [CHF],
death, particularly among the elderly. Under normal cir- diabetes mellitus). Common bacterial causes of pneumonia
cumstances, the alveolar macrophages are able to remove are Streptococcus pneumoniae, Pneumococcus, Staphylococcus
foreign matter. When confronted with overwhelming num- aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa.
bers of virulent microorganisms, however, this protective A common, serious viral source of pneumonia is the Cyto-
mechanism fails. The invading organism irritates the walls megalovirus, which affects clients with compromised immune
of the alveoli. In response to this irritation, the alveolar walls status, such as those taking immunosuppressant medications

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80 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Medical–Surgical
CLIENTTEACHING Management
Pneumonia Medical
• Discuss pertinent information about medications Clearing the airways of exudate and maintaining adequate
being taken. oxygenation are the goals of treatment for clients with pneu-
• Instruct in measures to prevent spread of infec- monia. Postural drainage and percussion may be ordered to
tion (covering the mouth and nose with a tissue
aid the client in mobilizing secretions. Aerosol or nebulization
treatments may also be utilized, often with added medications.
when coughing or sneezing).
The client is encouraged to cough and deep breathe, particu-
• Encourage disposal of tissues in a closed paper larly following respiratory treatments. Incentive spirometry,
sack. which measures the amount of air inspired in one inhalation,
• Outline individual’s specific risk factors (age, is ordered to aid the client when coughing and deep breathing
chronic respiratory condition, cardiac condition). are inadequate (e.g., after surgery) (Figure 4-6). If the client
is unable to mobilize secretions, suctioning of the respiratory
• Instruct in methods to prevent future infection
tract is indicated. When secretions are overwhelming, the
(avoiding crowds and obtaining vaccine).
physician may perform a bronchoscopy in order to remove
• Encourage increase in oral fluid intake, if appro- them. Intravenous fluids are utilized to maintain adequate
priate for client. hydration, especially in the presence of fever. Adequate hydra-
tion promotes liquefaction of respiratory secretions and thus
aids in their removal. Pulse oximetry or ABGs are done to
assess the level of oxygenation. Supplemental oxygen is used
when oxygenation is inadequate.
or those infected with human immunodeficiency virus (HIV).
Pneumocystis carinii pneumonia can also occur in the immu- Pharmacological
nosuppressed client. The invading organism associated with
The treatment of choice for bacterial pneumonia is specific
Pneumocystis carinii pneumonia is thought to be a protozoan.
based on a sputum specimen for culture and sensitivity. It
The infecting microorganisms that cause pneumonia are
should be obtained before initiating antibiotic therapy. After a
spread by airborne droplets or direct contact with infected
specimen has been obtained, the physician may start therapy
individuals or carriers.
with a broad-spectrum antibiotic. If laboratory data indicate
Chemical pneumonia is caused by entry of irritating sub-
stances into the pulmonary passageways. A common source of
chemical pneumonia is the aspiration of gastric contents. Inhala-
tion of irritating substances can also result in a chemical pneu-
monia. Pneumonia is now classified according to the causative
factor rather than the area of the lung affected (e.g., aspiration
pneumonia). The right middle and lower lobes are affected by
pneumonia more frequently than the right upper and left lobes

COURTESY OF DELMAR CENGAGE LEARNING

because of the anatomy of the right bronchus and the effects of
gravity.
A high fever of sudden onset is often the presenting
complaint of the client. The elderly client, however, may be
seriously ill and have only a low-grade fever. A productive
cough yielding abnormally thick and discolored sputum
may be present. Associated respiratory symptoms include
dyspnea, coarse crackles, and diminished breath sounds.
Most clients complain of pleuritic chest pain, which is stab-
bing in nature and increases on inspiration. Pain occurs Figure 4-6 An Incentive Spirometer
as a result of irritation of the pleura lying adjacent to the
affected alveoli.
In the case of bacterial pneumonia, white blood cell
count increases and may go as high as 40,000/mm3. Pneu-
monia caused by viruses or mycoplasms may produce a COLLABORATIVECARE
normal or a lowered white blood cell count. Chest x-ray
reveals consolidation in the affected areas. Bacterial pneu- Postural Drainage, Medications
monia is likely to produce isolated areas of consolidation on
a chest x-ray, whereas viral and chemical pneumonia appear Respiratory therapists work together with nurses
as more diffuse areas of consolidation. Arterial blood gases in providing postural drainage for clients with
(ABGs) may reveal a decrease in PaO2 or oxygen saturation pneumonia or other respiratory problems when
caused by interference with gas exchange. Pulmonary func- exudate drainage from the lungs is desired. They
tion tests (PFTs) are usually within normal limits unless also collaborate on administering aerosol or
the client has an underlying pulmonary disorder such as nebulized medications.
emphysema.

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 CHAPTER 4 Respiratory System 81

LIFE SPAN CONSIDERATIONS PROFESSIONALTIP

Respiratory Status in the Older Client Assessment and Respiratory Assistive
• Respiratory effort increases because muscles
Devices
atrophy, the diaphragm flattens out, costo- When caring for clients with respiratory assistive
chondral cartilage calcifies, ligaments and joints devices in place, assess the following:
stiffen, and intervertebral discs degenerate. • Oxygen
• Alveolar gas exchange diminishes because of a – Mode of delivery (e.g., nasal cannula, face
decrease in the lung’s elastic recoil, which causes mask)
air to be trapped, especially in the lower lobes, – Percentage of oxygen that is being delivered
for a portion of the respiratory cycle. (e.g., 25%, 40%)
• The medulla becomes less sensitive to changes – Flow rate of the oxygen (e.g., 2 L/min,
in carbon dioxide and oxygen levels, thereby 4 L/min)
rendering the respiration triggering mechanism
– Humidification provided and oxygen
less active.
warmed
• Ciliary activity diminishes, thereby increasing • Incentive spirometer
susceptibility to infection.
– Frequency of use
• Cough reflex decreases.
– Volume achieved
• Aspiration risk increases because of the decrease
– Number of times client reaches goal with each
in the cough reflex.
use

resistant microorganisms, a specific antibiotic will be started. nutritionally balanced meals are preferred. Respiratory treat-
Antiviral agents, such as acyclovir sodium (Zovirax), are ments that promote coughing should be avoided immediately
utilized for clients with chronic respiratory problems related before and after meals to prevent nausea and vomiting associ-
to viral pneumonia. Prophylactic antibiotic therapy is often ated with vigorous coughing.
utilized for viral pneumonia to prevent a secondary bacterial
infection. To promote opening and clearing of the airways,
bronchodilators, and mucolytic agents are administered via
Activity
aerosol or nebulization by the respiratory therapist or nurse. Bed rest or limited activity promotes optimal tissue oxygen-
Expectorants may be given orally. Cough suppressants and ation; however, range-of-motion exercises and progressive
pain relievers, especially those containing narcotics such ambulation prevent immobility complications.
as codeine sulfate, are administered only with discretion,
because they may further inhibit the client’s ability to clear Health Promotion
the airways.
Pneumococcal vaccine (Pneumovax 23), a vaccine that pre-
vents infection caused by Streptococcus pneumonia, should
Diet be given to clients at risk of developing pneumonia, such as
The client with pneumonia is encouraged to drink fluids to aid those with chronic respiratory or cardiac conditions, and the
in the liquefaction of respiratory secretions. Small, frequent, older adult. Usually only one dose of vaccine is needed, but
under certain circumstances a second dose may be given. A
second dose is recommended for clients who have: a dam-
aged or removed spleen, sickle-cell disease, HIV infection
LIFE SPAN CONSIDERATIONS or AIDS, cancer, leukemia, lymphoma, multiple myeloma,
nephrotic syndrome, organ or bone transplant, or are taking
Oxygen Therapy in Children medication that lowers immunity (chemotherapy, long-term
• Any child receiving oxygen therapy should not steroids). When a second dose is given, it should be given
play with friction toys or use a nylon or wool five years after the first dose. Medicare pays for this vaccine
(ALA, 2009).
blanket.
• Oxygen concentration must be measured near
the child’s head with an oxygen analyzer. Pro- Nursing Management
longed exposure to a high concentration can be Auscultation of lungs for breath sounds, assessment of vital
toxic to certain tissues (retina in preterm babies signs, and monitoring pulse oximetry and/or ABGs are nurs-
and lungs in all children), especially in children ing responsibilities. Encourage deep breathing, use of incen-
with asthma or cystic fibrosis. tive spirometer, and the intake of fluids. Reposition clients
who are on bed rest at least every 2 hours. Assist with range-
of-motion exercises and ambulation when able.

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82 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

NURSING PROCESS Objective Data

The client’s level of consciousness should be noted. Evidence
Assessment of dyspnea, orthopnea, tachypnea, and cyanosis may be pres-
ent. On auscultation of the lung fields, moist crackles or dimin-
Subjective Data ished breath sounds may be heard. In the event of obstruction
Data gathered in the history include the onset, duration, and of the airways, sibilant wheezes occur. All vital signs are taken
severity of cough; the color, amount, and odor of sputum if before and after drug therapy to provide information regarding
present; the onset and duration of elevated temperature; and the severity of the illness and the efficacy of treatment. The
the presence or absence of night sweats. color, amount, viscosity, and odor of sputum are noted.

Nursing diagnoses for a client with pneumonia include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Airway Clear- The client will have clear Encourage client to breathe deeply and cough a minimum of
ance related to inability to breath sounds upon auscul- every 2 hours.
remove airway secretions tation. Teach use of the incentive spirometer to encourage lung
expansion.
Administer aerosol and nebulizer treatments as ordered.
Assess breath sounds and respiratory rate prior to and
following respiratory procedures to evaluate their
effectiveness.
Encourage fluids to liquefy thickened secretions.
For clients who are able, assist in sitting up or ambulating
three to four times daily; those on bed rest, turn every
2 hours.
Administer medications as ordered.
Provide oral care several times a day.

Impaired Gas Exchange The client will have an Monitor pulse oximetry and/or ABGs.
related to inflammatory oxygen saturation of 92% or Administer supplemental oxygen as ordered.
changes in alveolar capil- greater.
lary membrane

Activity Intolerance related The client will be able to Encourage client to complete ADL according to ability and
to hypoxia secondary to complete activities of daily the physician’s orders.
pneumonia living (ADL) and activity as To prevent client fatigue, alternate periods of activity and
ordered and without com- care with periods of rest.
plaints of fatigue.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

<■ TUBERCULOSIS
A A > the bacilli and do not develop the disease. Those at risk for

P
tuberculosis include persons suffering from malnutrition,
ulmonary tuberculosis (TB) is an infection of the lung those living in crowded conditions, persons with compro-
tissue by Mycobacterium tuberculosis. Infection by tubercle mised immune status, and health care workers providing care
bacilli can occur in other parts of the body, but with less fre- to high-risk individuals.
quency. In pulmonary tuberculosis, the tubercle bacilli are Once inhaled in sufficient numbers, the tubercle bacilli
inhaled into the lungs. Whether infection occurs depends on cause an inflammatory response within the alveoli of the
the host’s susceptibility, the virulence of the tubercle bacilli, lung. A small nodule called a primary tubercle, contain-
and the number of bacilli inhaled. Tuberculosis is not as ing tubercle bacilli, forms in the lung tissue. In an attempt to
highly contagious as once thought. Prolonged exposure to the isolate the primary tubercles, the body forms a fibrous outer
bacilli is required to produce infection. In addition, persons coating around each tubercle. This fibrous surface interferes
with uncompromised immune systems are able to combat with the blood and nutritional supplies to the tubercle. In

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 CHAPTER 4 Respiratory System 83

time, the interior of the tubercle becomes soft and cheese- indicates only that the client has been infected with and
like as a result of decreased perfusion, a process known as developed antibodies against the tubercle bacillus (Table
caseation. Then the tubercle may become calcified and is 4-6). It is important for clients to know that the test will
called a Ghon’s tubercle. thereafter always be positive throughout the individual’s
Liquefaction necrosis, where the tissue dies and lifetime. The Food and Drug Administration recently
changes to a liquid or semi-liquid state, may occur; this fluid approved a new TB blood test called QuantoFERON-TB
may then be coughed up. A cavity is formed at the site where that is used for detecting TB and latent TB infection.
the primary tubercle liquefied and ruptured. This is called The client receives the results from this test in less than
cavitation. 24 hours (ALA, 2008a).
Following the advent of antitubercular medications in The bacteria can remain alive but inactive in the body,
the 1950s, the incidence of TB decreased dramatically until often for a lifetime, so a client is given prophylactic treat-
1985. From 1985 to 1992, TB cases increased 20%, but from ment, usually isoniazid (INH), for 6 to 12 months. Other
1992 have decreased 39%. In 2007, the total number of cases medications used against tuberculosis are outlined in Table
of TB (13,293 persons) in the United States was the lowest it 4-7. If INH has not been given and the person later in
has been since the study started in 1953 (ALA, 2009). New life is under physical or emotional stress, which weakens
forms of TB, resistant to conventional drug therapy, have the immune system, the bacteria may become active and
surfaced. Some of the factors that may be responsible for cause TB disease.
the increase in TB cases are increased numbers of persons A negative reaction does not rule out the possibility
with compromised immune systems (e.g., many AIDS clients of TB exposure. Individuals at high risk, such as those who
also have TB); increased mobility of the world’s population are infected with HIV or who have compromised immune
(persons from areas of high TB incidence moving to areas of status, may have a negative reaction because they are unable
low incidence); widespread IV drug abuse; increased numbers to develop antibodies. Immediately following exposure to
of those with poor access to health care; and increased num- TB, a skin test may reveal a false-negative result because it
bers of those living in impoverished conditions. Direct health can take up to 10 weeks for an infected individual to develop
care costs for TB are $703.1 million each year (ALA, 2008a). the antibodies. An additional skin test may be done in 10 to
Symptoms of TB develop gradually following infection 12 weeks. If the second TB test is positive, the client’s history
and include the following: low-grade fever that recurs in a is reviewed for the presence of symptoms suggesting TB,
specific pattern, persistent cough, hemoptysis, hoarseness, and further evaluation is indicated.
dyspnea on exertion, night sweats, fatigue, weight loss, and Chest x-ray and sputum specimens are utilized to confirm
enlarged lymph nodes. a diagnosis of TB. Inpatient clients are placed in airborne
The Mantoux skin test is the preferred screening respiratory isolation until cultures are completed with results.
method for TB. Purified protein derivative (PPD) of killed Sputum is tested for the presence of acid-fast bacilli (AFB).
tubercle bacilli 0.1 mL is injected intradermally in the inner The sputum specimen is collected when the client arises in the
forearm. The test is evaluated by measuring the area of morning to prevent specimen contamination with ingested
induration (palpable swelling) that occurs 48 and 72 hours food and liquids. In most instances, three specimens collected
following injection. A reddened area with no induration on consecutive days and testing positive for AFB indicate a
is not considered positive. A positive skin test, however, positive diagnosis of TB. The TB diagnosis is confirmed if

Table 4-6 Classification of the Tuberculin Reaction

CLASSIFIED AS POSITIVE POPULATION
Induration of 5 mm or more • HIV-positive persons
• Recent contacts of TB case
• Persons with chest x-rays consistent with old, healed TB
• Clients with organ transplants or other immunosuppressed persons

Induration of 10 mm or more • Injection drug users

• Recent arrivals (<5 years) from high-prevalence countries
• Residents and employees of high-risk congregate settings (prisons, nursing
homes, mental institutions, residential facilities for AIDS patients, and homeless
shelters)
• Persons with medical conditions that have been shown to increase the risk of TB,
such as silicosis; persons who are 10% or more below ideal body weight; and
COURTESY OF DELMAR CENGAGE LEARNING

persons with some hematologic disorders (leukemias and lymphomas) and other
malignancies
• Mycobacteriology laboratory personnel
• Children < 4 years of age, or children and adolescents exposed to adults in high-risk
categories

Induration of 15 mm or more Persons with no risk factors for TB

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84 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Table 4-7 Tuberculosis Medications

DRUG MEDICATION PRECAUTIONS AND INFORMATION
First-Line Drugs
ethambutol hydrochloride (Myambutol) Monthly vision checks are important for acuity and distinc-
tion of red and green colors. Take medication with food.

isoniazid (INH) (Laniazid) Alcohol ingestion interferes with metabolism and may cause
hepatitis. Check baseline and monthly hepatic enzymes.
Report signs of neuropathy and hepatitis. Have client take
pyridoxine (vitamin B6 ) to decrease side effects.

pyrazinamide (PMS Pyrazinamide) Take medication with food and drink 2 liters of liquids daily.
Check baseline and monthly uric acid and liver enzymes.

Rifamate A combination of isoniazid and rifampin.

rifampin (Rifadin) Body secretions (urine, sweat, tears) turn orange while tak-
ing the medication.

rifapentine (Priftin) As effective as rifampin but taken less frequently. Body

secretions (urine, sweat, tears) turn orange. Drug must be
given with at least one other tuberculosis drug.

Rifater A combination of isoniazid, rifampin, and pyrazinamide.

streptomycin sulfate Have monthly audiograms to check auditory function.

Check baseline and monthly renal function.

Second-Line Drugs
cycloserine (Seromycin) Observe for mental alertness. While taking the medication,
monitor renal and liver function, drink 2 to 3 liters of fluid

COURTESY OF DELMAR CENGAGE LEARNING

daily, and avoid alcohol.

ethionamide (Trecator-SC) Given with other antitubercular drugs to prevent resistant

organisms from developing.

kanamycin sulfate (Kantrex) Drug may cause steatorrhea and electrolyte imbalance.

para-amino-salicylate (Sodium P.A.S.) Must be taken with other antitubercular drugs; taken with meals.

the TB bacilli grow in a culture. Individuals who are unable through (Figure 4-7). The Centers for Disease Control and
to produce sputum, including children and older adults, may Prevention recommend periodic TB skin testing for health
have stomach contents aspirated for AFB testing. Chest x-ray care personnel.
may reveal the presence of primary tubercles, calcified lesions,
and cavitation in the lung. Surgical
In the past, surgical intervention involving the removal of
Medical–Surgical Management affected lung tissues was common. With the advent of effec-
tive chemotherapy (treatment with drugs), however, surgical
Medical intervention is now rarely utilized.
Most clients are treated briefly in the hospital, with long-term
treatment continuing at home. In the hospital, follow Air- Pharmacological
borne Precautions in addition to Standard Precautions. The Multidrug-resistant TB (MDR TB) can develop when a
precautions include placing the client in an isolation room client does not complete the full therapy or is inadequately
with negative air pressure (air inflow is controlled through treated. A new strain of TB called extensively-drug resistant
one vent and air outflow is exhausted through another vent tuberculosis (XDR TB) is a strain with extensive resistance
directly to the outside and is not recirculated to other rooms.). to second-line drugs. XDR TB is a public threat worldwide
The doors and windows of the client’s room must be kept and is raising concerns of a future epidemic of TB that is
closed to maintain control of air flow. Caregivers should wear virtually untreatable (ALA, 2008b). Active TB is treated
N95 particulate respirator masks because standard isolation with a combination of medications. Three medications—
masks do not prevent Mycobacterium tuberculosis from passing isoniazid (Laniazid, which is most effective), rifampin

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 CHAPTER 4 Respiratory System 85

MEMORYTRICK
MASK
A memory trick for the nurse to use to remember
how to correctly wear and use an N95 particulate
respirator mask when providing care for a TB client
is the term MASK:
M = Make sure you are using the correct size
mask.
A = Always wear an N95 particulate respirator
mask (NOT a surgical mask).
S = Seal between face and respirator must be
tightly fitted and intact.
K = Keep N95 particulate respirator mask on
until after you leave the client’s room.

INFECTION CONTROL
Figure 4-7 A particulate respirator fits tightly around Use of a Particulate Respirator
the nose and face. (Photo courtesy of Moldex Metric Inc; • Follow facility’s procedure for fit-testing.
www.moldex.smugmug.com)
• Use the correct size mask.
(Rifadin), and pyrazinamide (PMS Pyrazinamide)—are
given for several months. This is followed by a regimen of • Put on respirator before entering client’s
rifampin and isoniazid for an additional time. The combi- room and remove after leaving client’s room.
nation of three drugs is given initially to rapidly decrease
the number of active bacilli in the body and to prevent the • Ensure that the respirator is free of holes.
development of MDR TB. Long-term therapy is required • Check that the seal between face and
because TB bacilli have long periods of metabolic inactivity. respirator is intact.
Those clients with bone and joint infections, meningitis, or
resistant forms of TB are treated for longer periods. Clients • Discard soiled or damaged respirators.
who are HIV positive require a longer regimen of isoni-
azid and pyrazinamide; prophylactic treatment with isoni- • Have client wear N95 respirator when leaving
azid is indicated from then on. Ethambutol hydrochloride the room.
(Myambutol) and streptomycin sulfate are added to the
treatment regimen if the infecting organism is resistant to
one of the three normally used medications. Infection with
MDR TB requires the use of kanamycin sulfate (Kantrex),
capreomycin sulfate (Capastat Sulfate), and cycloserine
INFECTION CONTROL
SAFETY Tuberculosis
Caregivers in Health Care Institutions • Instruct client to cover mouth and nose when
• Be aware of risks when caring for a client with TB. coughing or sneezing.
• Follow Standard Precautions and Airborne
• Double-bag secretions and dispose of them as
Precautions.
infectious waste.
• Use face and/or eye shield in addition to
particulate mask when performing sputum- • Use disposable items for care when possible.
induction procedure.
• Thoroughly clean and disinfect nondisposable
• Plan care to limit prolonged exposure to client.
items.
• Wash hands frequently and thoroughly.

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86 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

CRITICAL THINKING
CLIENTTEACHING Tuberculosis Precautions
Side Effects of Rifampin
A nurse is working in a medical clinic when a
• Urine, saliva, or tears may turn orange. client comes to the desk and informs her that one
• May permanently discolor contact lenses. of his friends has TB, and that he was told to come
• Birth control pills and implants become less to the clinic to get checked. The client is coughing
effective. Use alternative methods of birth continuously. The nurse knows that it will be
control. 45 minutes before she can get him in to see the
physician. What should the nurse do?

(Seromycin). The client is considered noninfectious fol-

whose condition permits it may ambulate in the hallways, as
lowing three negative AFB sputum specimens. At that
long as a particulate respirator mask is worn by the client while
point, the client may return to work and other normal
outside of the room.
activities. Prophylactic treatment of high-risk individuals
is recommended to reduce their chances of developing the
disease following their exposure. Health Promotion
Taking multiple drugs can be confusing and lead to non- Prevention of TB is preferred to treatment. In areas where the
compliance. The development of two new drugs has been disease remains endemic (seldom in the United States), a vac-
valuable. These drugs are Rifater, a combination of isoniazid, cine containing attenuated tubercle bacilli, bacillus Calmette-
rifampin, and pyrazinamide, and Rifamate, a combination of Guérin (BCG), may be given, but its effectiveness has not
isoniazid and rifampin. been proven. Individuals receiving it will test positive to the
tuberculin skin test.
Diet Any person who has had close contact with a client with
The client with TB often has nutritional deficits. Correcting TB without practicing appropriate protective measures should
these deficits assists the client in overcoming the disease pro- be tested. Other measures that decrease the likelihood of TB
cess. Dietary management is based on the type of deficiency include adequate nutrition, housing, and health care access,
present. A well-balanced diet is encouraged for all clients with and treatment of individuals who have or are at risk for devel-
TB. Fluids are encouraged to aid in the liquefaction of respira- oping TB.
tory secretions.

Activity Nursing Management

Activity is restricted based on the client’s tolerance. The client Assess client for low-grade fever, night sweats, and persistent
who is severely compromised from a respiratory standpoint cough. Teach client and family about the disease process and
may be placed on bed rest. If the client’s condition allows, stress the importance of absolute compliance with the treat-
activity is encouraged because it promotes lung expansion and ment plan.
aids in the removal of static secretions. The client in isolation

NURSING PROCESS
Assessment
The Client with Tuberculosis Subjective Data
Advise the client of the following: The history includes questions about the presence of signs
• Keep all clinic appointments. and symptoms of TB, such as night sweats, dyspnea on
exertion or at rest in late disease, anorexia, loss of muscle
• Take all medications exactly as directed for
strength, and fatigue. Pleuritic pain occurs when the pleura
duration of treatment.
is involved.
• Until tested and noninfectious:
– Put used tissues in a closed paper sack and Objective Data
throw away.
Objective data include weight loss; persistent, low-grade
– Avoid close contact with anyone; wear a
fever; and persistent cough. The cough may be nonpro-
mask. ductive early in the disease. Later, the cough is productive
– Sleep alone in bedroom. and yields thick, purulent sputum. Eventually, hemoptysis
– Air out bedroom often, using a fan in the (blood spitting) occurs. Auscultation of breath sounds
window to blow air outside. reveals coarse crackles. In the presence of cavitary disease,
– Thoroughly clean articles such as eating breath sounds are diminished or absent in the affected
utensils. areas. Sputum is observed as to amount, color, odor, and
consistency.

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 CHAPTER 4 Respiratory System 87

Nursing diagnoses for a client with TB include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing Pat- The client will have color and Assess client’s color, respiratory rate, and respiratory effort
tern related to pulmonary respiratory rate within normal and auscultate the breath sounds.
infectious process limits and will not complain Plan care activities to allow client uninterrupted periods of
of dyspnea. rest.
Assist client in assuming the position that most aids respira-
tory effort.
Administer medications as ordered.
Encourage fluids if not otherwise contraindicated.

Deficient Knowledge The client will verbalize an Teach client and family about the basic pathophysiology of
related to disease process understanding of the disease TB, how the infection is contracted, who is at risk of devel-
and its treatment process and its treatment. oping an infection, the signs and symptoms of TB infection,
and complications that may arise.
Present information regarding the actions, side effects, and
untoward effects of the drugs being administered.
Teach client signs and symptoms of adverse drug reactions
to report to the physician.
Emphasize the necessity of long-term therapy to cure TB.
Inform client and family that symptoms decrease and are
often gone long before the organism is eliminated from the
body.

Ineffective Therapeutic The client will continue Include client and family in making decisions about care,
Regimen Management medication regimen for the when appropriate.
related to client value prescribed length of time. Allow client to be an active participant in care decisions, to
system increase personal responsibility and accountability. Visits
from public health or home care nurses may be necessary to
monitor client for compliance.
Explore reasons for noncompliance with client and family,
and identify strategies to increase compliance.
Refer client who is unable to afford the cost of medications
to agencies such as the local health department for
assistance.
Begin directly observed therapy if the client continues to be
noncompliant. Directly observed therapy involves send-
ing the nurse or another health care worker to the client to
administer the medications and verify that they are taken.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with TB

R.D. is an 87-year-old man who is admitted to the hospital with a chief complaint of productive cough
and fatigue. Four months ago, R.D. was placed in a long-term care facility because of his inability to care
for himself at home after his wife’s death 1 year previously. Since admission to the long-term care facility,

(Continues)

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88 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

SAMPLE NURSING CARE PLAN (Continued)

R.D. has lost 15 pounds. The nurses at the facility report that R.D. has experienced progressive fatigue,
dyspnea on exertion, cough, night sweats, and anorexia. Initially, his cough was nonproductive, but it is
now productive of moderate amounts of thick, purulent sputum that is occasionally streaked with blood.
Vital signs are temperature 99.8°F, pulse 108 beats/min, respirations 26 breaths/min, and blood pressure
138/86 mm Hg. A TB skin test done at the long-term care facility 1 week ago was evaluated as negative
at 6 mm. Sputum specimens for AFB reveal the presence of active tubercle bacilli, and chest x-ray is posi-
tive for TB. Auscultation of breath sounds reveals crackles in the right lower half of the lung. R.D. says,
“I don’t understand why I can’t breathe good and what all this fuss is about.”
NURSING DIAGNOSIS 1 Ineffective Breathing Pattern related to infectious pulmonary process as
evidenced by dyspnea on exertion and productive cough
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Respiratory Status: Airway Patency Airway Management
Respiratory Status: Ventilation Ventilation Assistance
Energy Conservation Energy Management

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.D. will have respiratory rate, Initially and periodically assess Provides a database from which the
oxygen saturation, and color R.D.’s respiratory status, including plan of care can be formulated and
within desired ranges and will not color, respiratory rate, respiratory against which the effectiveness of
complain of dyspnea. effort, oxygen saturation, breath treatment is evaluated. Subsequent
sounds, level of consciousness, assessments evaluate the effec-
cough, and sputum. tiveness of interventions and may
modify the care plan.
Assist R.D. in assuming a position Allows for greater ease of respira-
that most aids respiratory effort. tion and lung expansion.
Alternate care activities with peri- Allows R.D. to compensate for
ods of rest. the increased oxygen demand
required by activity.
Encourage activity within R.D.’s Promotes expansion of the lungs.
tolerance.
Encourage fluids. Promotes liquefaction of respira-
tory secretions.
Administer medications for fever Persistent fever leads to dehydra-
as ordered. tion, which hinders the removal
of respiratory secretions.
Administer oxygen as ordered Necessary for optimal cellular
to maintain an SaO2 of 95% or function.
greater.
Administer antitubercular drugs Decreases the number of viable
as ordered. tubercle bacilli.

EVALUATION
R.D. verbalizes a decrease in dyspnea and cough. R.D.’s color, respiratory rate, and oxygen saturation are
within normal limits.

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 CHAPTER 4 Respiratory System 89

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 2 Risk for Infection spread related to viable bacilli in secretions as evidenced
by AFB in sputum
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Infection Control Health Education

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.D. will verbalize both those situ- Place R.D. in a negative air pres- Prevents transmission of the
ations that allow for the transmis- sure, private room; keep door tubercle bacilli in air that has
sion of the tubercle bacilli and the closed at all times. On the door, been circulated into and out of
means to prevent their transmis- place Airborne Precaution signs R.D.’s room. Prevents inadvertent
sion. indicating that R.D. has an infec- contact and exposure. The nature
tious process and asking visitors to of the infection is not revealed
see nursing personnel before visit- publicly to maintain client confi-
ing. Instruct visitors to wear N95 dentiality. Visitors are informed
respirators when in R.D.’s room, of precautions to take to prevent
to limit the length of their visits, exposure.
to avoid intimate contact, and to
wash their hands when leaving
the room.
Instruct R.D. to cover his mouth Aids in the containment of the
and nose when coughing and tubercle bacilli.
sneezing.
Instruct R.D. to cough up secre- Aids in preventing the spread of
tions in tissues and to place the the tubercle bacilli.
tissues in a plastic bag. Dispose of
contained secretions as infectious
waste.
Inform the long-term care Known exposure to active tuber-
facility and family/significant oth- cle bacilli necessitates testing to
ers of the positive results of the identify individuals who may have
AFB studies. Instruct those persons become infected.
who have been exposed to R.D. to
have a TB skin test.
Observe Standard Precautions and Decreases the likelihood of trans-
Airborne Precautions. mitting the tubercle bacilli (and
other infectious diseases) to staff
and other clients.
Wear a fitted N95 respirator when Prevents the inhalation of
in R.D.’s room. tubercle bacilli, which are able
to pass through a simple surgical
mask.

EVALUATION
Persons exposed to R.D. have been tested for TB. Those with TB are being treated.

(Continues)

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90 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 3 Deficient Knowledge related to disease process and its treatment as evi-
denced by client statement: “I don’t understand why I can’t breathe good and what all this fuss is about.”
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Disease Process Teaching: Disease Process
Knowledge: Treatment Regimen Teaching: Individual

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.D. will verbalize an under- Assess R.D.’s present level of Provides a database regarding
standing of the disease process knowledge regarding TB and its R.D.’s present level of knowledge
and the required medication treatment. regarding TB and its treatment.
regimen. Client education can then be in-
dividualized to build and expand
on that knowledge base. Misin-
formation can also be corrected.
Provide information in small Increases the likelihood of learn-
amounts and use a variety of ap- ing and stimulates the various
proaches (e.g., verbal, written, senses.
video).
Encourage and allow time for R.D. Provides a means to clarify
to ask questions. information and for the nurse
to evaluate learning and correct
misconceptions.
Have R.D. verbalize signs and Provides a means to clarify
symptoms of adverse medication information and for the nurse
effects to report to the staff. to evaluate learning and correct
misconceptions.

EVALUATION
R.D. verbalizes individual treatment regimen and its purpose. R.D. reports adverse effects of medication to
health care personnel to allow for early intervention.

(MRI) or computerized tomography (CT) studies are useful

■ PLEURISY/PLEURAL EFFUSION in detecting pleural effusions, particularly small ones. A chest

P
x-ray will show pleural effusions of 250 mL of fluid or more.
leurisy is a painful condition that arises from inflammation If empyema is suspected, culture and sensitivity studies will
of the pleura, or sac that encases the lung. This pleuritic pain identify the presence and type of infection. The client with
is sharp and stabbing in nature. Pain increases on inspiration as the empyema will also have an elevated temperature and white
irritated pleura rub over each other. Inflammation of the pleura blood cell count.
occurs with many disorders, such as viral infections, cancer of the
lung, trauma, tuberculosis, congestive heart failure, and pulmo- Contralateral mediastinal shift
nary embolism. The inflamed pleura secrete increased amounts of
pleural fluid into the pleural cavity, creating a pleural effusion. As Pleural
effusion
fluid accumulates within the pleural space (cavity), it compresses and
the lung tissue (Figure 4-8). Collapse, or atelectasis, results if the thickening
effusion is left untreated. Those areas of collapsed lung tissue are
COURTESY OF DELMAR CENGAGE LEARNING

unable to take part in gas exchange, thereby decreasing oxygen-

ation. Empyema is the term to describe infected pleural exudate.
The primary manifestation of pleurisy is pain on inspira- Fluid in
pleural
tion. Signs and symptoms of pleural effusion depend on the No breath space
sounds
amount of lung tissue compressed and the source of the effu-
sion. With large pleural effusions, the mediastinum (heart,
great vessels, and trachea) shifts toward the unaffected side;
this can be detected by inspection, and heart sounds will
move toward the unaffected side. Magnetic resonance imaging Figure 4-8 Pleural Effusion
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 CHAPTER 4 Respiratory System 91

From
PROFESSIONALTIP From air vent client
Suction

Assessment of Client with a Chest

Tube
• Obtain vital signs as ordered.
• Be alert for dyspnea.
• Record and describe amount of drainage.
• Look for loops of tubing containing drainage.
• Monitor water level in the water seal. Fluctua-

COURTESY OF DELMAR CENGAGE LEARNING

tion (called tidaling) should occur with respira-
Water
tions and will stop when lung is reexpanded,
seal
tubing is kinked, connections are not tight, or
chest tube becomes dislodged.
• Keep chest drainage system below the level of Chest
Suction Drainage
the client’s chest. control collection drainage
• Every 2 hours, monitor client’s response to chambers
coughing and deep breathing.
Figure 4-9 Underwater Seal Chest Drainage Device
• If the chest tube is accidentally dislodged, cover
opening with petrolatum gauze and tape only
three sides of the dressing to create a one-way allows for the drainage of accumulated fluid or air. Most chest
valve in which air can exit the pleural space on tube devices have a chamber to which suction may be applied to
exhalation to prevent a tension pneumothorax assist in the removal of fluid or air from the pleural space. It can
also be sealed with a Heimlich (one-way) valve. A chest x-ray is
from occurring (Daniels, Nosek, Nicoll, 2007).
done to evaluate the chest tube’s placement and effectiveness.
• Assess for pain and discomfort.
• Ensure chest tube patency. Pharmacological
• Auscultate breath sounds in each lung lobe. If a pleural effusion is small and does not interfere greatly with
• Assess chest tube insertion site for signs of infection. respiratory function, diuretics are used to promote removal of
fluid from the pleural space. Furosemide (Lasix) and bumetanide
• Assess and palpate skin at chest tube insertion
(Bumex) may be given for this purpose. If empyema is present,
site for puffiness and crepitus (crackling). specific therapy is used once the causative agent is identified.
• Observe for signs of subcutaneous emphysema. Pain relief is a high priority. Analgesia that also decreases
inflammation is preferred. Ketorolac tromethamine (Toradol)
Medical–Surgical
or other nonsteroidal anti-inflammatory drugs are often used.
Severe pain may require narcotics. For extensive inflamma-
Management tion, corticosteroids may be utilized.

Medical Activity
Treatment is aimed at eliminating the underlying cause, main- The client’s activity is limited to prevent fatigue. High Fowler’s
taining adequate oxygenation to the tissues, and preventing position assists respirations.
complications such as atelectasis and pneumonia. Oxygen-
ation is evaluated by ABGs and/or pulse oximetry. Supple- Nursing Management
mental oxygen is given to maintain an oxygen saturation of Assess the client’s color, respiratory rate and effort, and level of
95% or greater. Respiratory treatments to aid lung expansion consciousness. Monitor vital signs and breath sounds. If a chest
such as incentive spirometry are used. tube is in place, watch that all tubes are in place and the drainage
device is working properly. A variety of closed-drainage chest tube
Surgical systems are available. Empty drainage per agency policy. Encour-
Larger pleural effusions require that a thoracentesis be age the client to use the incentive spirometer.
performed by the physician to remove accumulated fluid. After
the overlying tissues are anesthetized, a large-bore needle is
placed into the pleural space. Fluid is removed (no more than NURSING PROCESS
1500 mL) and may be sent to the laboratory for diagnostic pur-
poses (e.g., culture, cytology). If fluid accumulation continues, Assessment
a thoracotomy tube is placed into the pleural space to drain fluid
continuously. Following administration of local anesthetics, the Subjective Data
physician places a large-bore catheter into the pleural space. A nursing history is obtained from the client regarding
This catheter is attached to an underwater seal chest tube drain- onset, duration, and severity of symptoms. The client usually
age device (Figure 4-9). It prevents the negative pressure within describes both chest pain that increases with each inspiration
the pleural space from pulling air into the pleural space, and and difficulty breathing.
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92 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Objective Data ment are diminished or absent. A pleural friction rub may be
audible. Dyspnea, cyanosis, and hypoxia occur in proportion
The client’s color, respiratory rate, and effort are evaluated to the severity of the condition. If a chest tube is in place, the
along with the level of consciousness. Abnormalities in vital amount and color of drainage are assessed.
signs are noted. Breath sounds over the areas of involve-

Nursing diagnoses for a client with a pleural effusion include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to Using a scale of 0 to 10, the Administer pain medications as ordered. Assist the client in
inflammation of the pleura client will verbalize a attaining the position that allows for greatest comfort.
decrease in the level of pain. Elevate the head of the bed. Provide diversional activities.

Impaired Gas Exchange The client will maintain an Monitor vital signs and pulse oximetry. Provide supplemental
related to compressed oxygen saturation of 95% oxygen as ordered.
lung or greater and a respiratory Encourage client to breathe deeply or use the incentive
rate of 14 to 22 bpm and will spirometer as ordered.
have clear breath sounds.
Administer diuretics and anti-inflammatory medications as
ordered.
Assist physician with the thoracentesis or the placement of a
thoracotomy tube.
Collect specimen for culture and sensitivity and other stud-
ies as ordered.

Risk for Activity Intolerance The client will increase activ- Stagger periods of activity with periods of rest. To prevent
related to hypoxia second- ity without complaining of fatigue, plan activities around therapies.
ary to pleural effusion fatigue.

Bathing/Hygiene Self-care The client will increase self- Assist client with hygiene and self-care needs, but
Deficit related to mobility care activities as mobility encourage participation in self-care activities within the limits
restriction increases. of the physician’s orders.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ SEVERE ACUTE RESPIRATORY Nursing Management

SYNDROME Follow Standard Precautions (hand hygiene and eye protection),

S
Contact Precautions (gown and gloves), and Airborne Precau-
evere acute respiratory syndrome (SARS) is a viral tions (isolation room with negative pressure and use of N-95 respi-
respiratory illness with flu-like symptoms that is caused rators). Monitor client’s vital signs. Assess breath sounds. Provide
by the SARS associated coronovirus (SARS-CoV). It was routine care with uninterrupted rest periods.
identified in China in late 2002, and first reported in Asia
in February 2003 (CDC, 2008). A total of 8,098 people
became sick with SARS, and 773 died worldwide during the ACUTE RESPIRATORY TRACT
outbreak (CDC, 2005a). SARS spread worldwide over sev- DISORDERS
A
eral months before the outbreak ended (National Institutes
of Health, 2009c). cute respiratory tract disorders include atelectasis, pul-
It appears that SARS spreads by close personal contact or monary embolism, pulmonary edema, acute respiratory
contact with infectious material (respiratory secretions). This distress syndrome, and acute respiratory failure.
happens when a client with SARS coughs or sneezes droplets
onto themselves, others, or nearby surfaces. ■ ATELECTASIS

A
The incubation period is generally 2 to 7 days. Then an
elevated temperature of > 100.4°F (>38°C) occurs and may telectasis refers to the collapse of a lung or a portion of
be associated with chills, headache, malaise, body aches, respi- a lung. The most common cause of atelectasis is airway
ratory symptoms, pneumonia, and even respiratory failure. obstruction. A bronchiole becomes blocked with secretions,
After 2 to 7 days, clients may develop a dry, nonproductive and the alveoli distal to it collapse (Figure 4-10). Airway
cough and dyspnea. obstruction of this nature is common after surgery and with
There is no specific treatment for SARS. Support treat- immobility problems. Anesthesia, pain, narcotics, and immo-
ment is provided based on the symptoms. bility can cause hypoventilation and retention of secretions.

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 CHAPTER 4 Respiratory System 93

Ipsilateral the sections on pleural effusion and pneumothorax). Atelecta-

mediastinal shift sis resulting from the growth of a tumor requires removal of
Obstruction
(secretions or tumor) the tumor.
Lung not
totally Pharmacological
inflated
Adequate pain control aids the client, particularly the surgi-
Breath cal client, to breathe deeply and cough. Client-controlled
sounds analgesia or a routine schedule of pain medication may be
decreased
used to provide effective pain management. Bronchodila-
tors may be used to open the airways. Mucolytic agents are
used to liquefy secretions. Bronchodilators, such as albuterol
sulfate (Ventolin), and mucolytics, such as acetylcysteine
(Mucomyst), may also be administered via updraft or nebu-

COURTESY OF DELMAR CENGAGE LEARNING

lizer treatments. The client with an infection requires treat-
ment with an appropriate antibiotic.

Diet
Unless otherwise contraindicated, fluids are encouraged to
promote liquefaction of trapped respiratory secretions.

Figure 4-10 Atelectasis (Collapsed Lung)

Activity
Activity promotes lung expansion. Immobile clients are turned
a minimum of every 2 hours and assisted to do range-of-
motion exercises. Surgical clients may do leg exercises as well
Hypoventilation can cause atelectasis, which increases as deep breathing and coughing. Ambulation is recommended
hypoventilation. Atelectasis can occur with compression of if the client’s condition allows. If the client is unable to walk,
lung tissue, as in pleural effusion or pneumothorax. Insuf- sitting up in a chair is encouraged. To prevent fatigue, rest
ficient surfactant results in increased recoil properties of the periods are planned between activities.
lungs, leading to atelectasis.
Signs of respiratory distress are proportional to the
amount of lung tissue involved. When large areas of the lung Nursing Management
are involved, orthopnea or cyanosis may develop. Breath Monitor for pain, shortness of breath, fatigue, dyspnea, cyanosis,
sounds are diminished or absent over collapsed areas. Chest anxiety, and level of consciousness. Assess for Homans’ sign.
wall movement may decrease on the affected side. Oxygen- Teach client how to cough, deep breathe, and use the incentive
ation decreases as shown by ABGs or pulse oximetry. Pulse spirometer. Encourage ambulation as client’s condition allows.
and respiratory rate increase as the heart and lungs work harder Turn immobile clients at least every 2 hours.
to meet the body’s oxygen needs. Trapped secretions are a
growth medium for microorganisms. An elevated temperature
indicates secondary infection (pneumonia). Chest x-ray shows
the areas of collapse. Bronchoscopy (insertion of a broncho- NURSING PROCESS
scope into the trachea) is used to directly visualize the area of
obstruction and obtain a specimen for diagnostic purposes. Assessment
Subjective Data
Medical–Surgical Clients who smoke, those who are immunocompromised, and
those who have known chronic respiratory or cardiovascular dis-
Management eases are at increased risk of developing atelectasis. The client is
asked about the onset, duration, and severity of symptoms such as
Medical pain, cough, and dyspnea. The client may complain or show signs
The physician orders incentive spirometry and deep breath- of air hunger, shortness of breath, fatigue, and anxiety.
ing and coughing exercises to promote expansion of the lungs.
Postural drainage and percussion aids in the removal of any Objective Data
static secretions. If the client is unable to cough up secretions, Assess the client for changes in level of consciousness, an
suctioning of the respiratory tract is performed. Bronchos- early sign of decreased oxygenation. Periodically evaluate for
copy may be done to remove secretions and obtain specimens. dyspnea, tachypnea, cyanosis, and restlessness. Measure vital
Arterial blood gases and pulse oximetry are utilized to evaluate signs frequently, with particular attention to respiratory rate
the need for supplemental oxygen. Oxygen is administered to and effort. Auscultation reveals diminished or absent breath
maintain an oxygen saturation of 95% or greater. sounds over the areas of atelectasis. Crackles (rales) or sonorous
wheezes may be heard if pneumonia develops. Note objec-
Surgical tive indicators of pain such as facial grimacing, and validate by
Clients with pneumothorax or pleural effusion as the underly- subjective questioning. Assess the effectiveness of the client’s
ing cause of atelectasis require removal of trapped air or fluid cough. A productive cough is evaluated for amount, color, con-
via thoracentesis or placement of a thoracotomy tube (refer to sistency, and odor of secretions.

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94 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with atelectasis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client will have an Establish a schedule for coughing and deep
related to decreased oxygen saturation of 95% breathing.
alveolar–capillary surface or greater, a respiratory rate Encourage client to ambulate and/or sit up in a chair three to
of 14 to 22 bpm, and clear four times daily.
breath sounds.
Turn the immobile client every 2 hours or more
frequently.
Assess client’s vital signs and breath sounds every
4 hours or more frequently as situation warrants.
Encourage fluids if client’s condition allows. Administer
respiratory treatments and medications as ordered.
Assess secretions (sputum) for color, amount, consistency,
and odor.

Risk for Activity Intolerance The client will complete Encourage some activity, such as walking, to promote lung
related to hypoxia second- activity without complaints expansion, and alternate with periods of rest to avoid client
ary to atelectasis of shortness of breath, fatigue.
dyspnea, or fatigue. Provide assistance with ADL as client’s condition
requires.
Place client in a high or semi-Fowler’s position to aid lung
expansion.
Position client on the unaffected side.

Deficient Knowledge The client will verbalize the Teach all preoperative and immobile clients to cough
related to the complica- purpose of deep breath- and breathe deeply at least every 2 hours and have the
tions of surgery and/or ing, coughing, and activity client demonstrate to ensure that learning has occurred.
immobility following surgery, and will Teach the surgical client to splint the surgical incision to
demonstrate deep breathing minimize discomfort that might occur with coughing and
and coughing. deep breathing.
Instruct clients at risk for developing atelectasis in the use of
incentive spirometry.
Emphasize the importance of early ambulation and activity
to promote lung expansion.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ PULMONARY EMBOLISM factors increasing the risk for PE are heredity, smoking,

P
peripheral vascular disease, diabetes mellitus, and oral
ulmonary embolism (PE) develops when a bloodborne contraceptive use.
substance lodges in a branch of a pulmonary artery and Emboli interfere with gas exchange to the pulmonary
obstructs flow. A common source of PE is deep vein throm- circulation distal to the emboli, resulting in hypoxemia. The
bosis. Other sources are air from intravenous infusions; fat client describes breathlessness and dyspnea. Pulse oximetry
from long-bone fractures; and amniotic fluid. The size and or ABGs will show the degree to which oxygenation has been
location of the emboli determine the severity and outcome of affected. Obstruction of a main branch of a pulmonary artery
the condition. can result in lung infarction, necrosis, and may even lead to
Pulmonary emboli rarely develop before adulthood. As death.
age increases, the risk for pulmonary embolism becomes All clients at risk for PE are observed for signs and symp-
greater because of the development of arteriosclerosis toms of deep vein thrombosis, such as localized calf tender-
and other vascular changes associated with aging. Other ness or swelling. Measures to prevent thrombus formation are

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 CHAPTER 4 Respiratory System 95

taken for these individuals. Any signs of thrombophlebitis are

immediately reported to the physician.
Signs and symptoms of PE are abrupt in onset. The
CLIENTTEACHING
client becomes anxious and restless. Sudden, sharp chest Anticoagulant Therapy (Coumadin)
pains or back pain of a pleuritic nature (worse on inspira-
tion) develop. Dyspnea and cough, along with hemoptysis, Stress the importance of:
occur. Venous return is diminished, resulting in jugular • Follow-up laboratory testing
venous distention. The client becomes diaphoretic. A low- • Using a soft toothbrush to prevent trauma to
grade fever develops in response to inflammation. A high the gums (bleeding)
temperature indicates lung infarction. Diagnosis of PE is
• Inspecting the skin for bruises or petechiae
often done by a ventilation/perfusion lung scan, but the
gold standard is pulmonary angiography. Arterial blood • Using an electric razor to avoid scratching skin
gases show hypoxia and respiratory alkalosis. A spiral CT • Reporting nosebleeds, tarry stool, hematuria, or
scan of the lungs may be ordered, and can be performed hematemesis to the physician
within a few seconds. • Eating a consistent amount of green, leafy veg-
etables daily (differing amounts alter anticoagu-

Medical–Surgical lant effects)

Management • Avoiding other medications including aspirin (it

has an anticoagulant effect) without approval
Medical from physician
Preventive measures are instituted for the client at risk • In the female client, monitor menstrual flow for
of developing deep vein thrombosis. Following surgery, excessive amount
antiembolism stockings, sequential compression devices
(SCDs), intermittent pneumatic compression devices (e.g.,
PlexiPulse), and early ambulation are indicated. When
hypoxia occurs, supplemental oxygen is given to increase
oxygenation. The underlying cause of the PE is treated when LIFE SPAN CONSIDERATIONS
identified.
Older Adults at Risk for Pulmonary
Embolism
Surgical
In severe cases, the physician may remove the clot via an The risk of developing a pulmonary embolism
embolectomy. This procedure is usually done at the time increases with age. For each 10 years after age
of angiography. Clients who experience successive episodes 60, the risk of developing a pulmonary embolism
of PE may require a venacaval plication or filter. This sur- doubles (NHLBI, 2009c).
gical procedure involves placing a sieve-like device in the
inferior vena cava to catch emboli before they enter pulmo-
nary circulation (National Heart Lung and Blood Institute,
2009b).
Diet
Pharmacological Fluids are encouraged to prevent hemoconcentration leading
to clot formation. Unless contraindicated, fluids are encour-
The client at risk of developing deep vein thrombosis and/ aged for the client at risk of developing PE.
or PE may be treated with enoxaparin (Lovenox). Lovenox
is often used in the postoperative client to prevent clot for-
mation. After PE has developed, anticoagulation is ordered Activity
to prevent the formation of further clots. Heparin sodium
is initially used to establish anticoagulation and is adminis- To prevent the formation of clots, activity is encouraged. After
tered parenterally by either the intravenous or subcutaneous a clot has formed, however, the client’s activity is restricted
route. After adequate anticoagulation is established, warfarin to prevent the clot from moving and becoming an embolus.
sodium (Coumadin) therapy is initiated and may be given Activities such as sitting, crossing the knees, or prolonged
concurrently with heparin while the client is hospitalized bending at the hips are to be avoided because they promote
until Coumadin level is therapeutic. Coumadin alone is given venous stasis.
orally when the client is discharged. If the clot is large or lies
in a branch of a main pulmonary artery, fibrinolytic therapy
may be used. Fibrinolytics lyse, or dissolve, the clot versus
inhibiting the formation of new clots. Examples of fibrinolytic Nursing Management
agents are alteplase recombinant (Activase) and streptokinase Assess the abrupt onset of pleuritic chest pain for location,
(Streptase). These agents may be administered intra-arterially duration, severity, and character. Assess lung sounds, monitor
at the site of the clot or intravenously to achieve a systemic pulse oximetry, vital signs, jugular veins for distension, periph-
effect. Narcotic analgesics such as morphine are used to con- eral pulses, and capillary refill. Encourage deep breathing and
trol pain. provide supplemental oxygen as ordered. Monitor results of

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96 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

APTT, INR, PT, hemoglobin, and hematocrit. Do not mas- Objective Data
sage site if deep vein thrombosis (DVT) has occurred.
Pulse oximetry measurements are monitored. The client’s
respirations are rapid and shallow. Pallor progressing to
NURSING PROCESS cyanosis develops as oxygenation decreases. The client
becomes diaphoretic. Increased anxiety or a change in level
Assessment of consciousness may be the first indication of PE. The
pulse increases in response to anxiety and in an attempt
Subjective Data to supply oxygen to the body’s cells. Blood pressure may
The client’s history is obtained to identify potential risk factors increase or decrease in response to hypoxia, anxiety, and
for the development of PE. Ask the client about the onset, dura- pain. Temperature may elevate in response to inflamma-
tion, and severity of symptoms. Shortness of breath, dyspnea, tion and tissue necrosis. On auscultation, breath sounds
and severe pleuritic chest pain are abrupt in onset. Pain is evalu- may or may not be decreased. The jugular veins may be
ated as to onset, location, duration, severity, and character. distended.

Nursing diagnoses for a client with pulmonary embolism include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client will maintain an Assess client for indications of decreasing oxygenation.
related to alteration in oxygen saturation of 95% Auscultate breath sounds every 4 hours or more often.
pulmonary circulation or greater, have a respira-
tory rate of 14 to 22 bpm, Assess peripheral pulses and capillary refill.
and have color within normal Encourage deep breathing and coughing.
limits. Provide supplemental oxygen to maintain oxygen saturation
at greater than 95% or as ordered.
Administer anticoagulants (Heparin, Lovenox,
Coumadin) as ordered.
Encourage fluids, unless contraindicated, to prevent hemo-
concentration.

Acute Pain related to de- Using a scale of 0 to 10, the Administer pain medication as ordered and monitor for
creased perfusion of lung client will indicate decreased relief.
tissue pain. Assist client in assuming a position of comfort. If possible,
place client in a high Fowler’s position to aid respiratory
effort.

Risk for Injury related to The client will be free of Assess for evidence of bleeding. Monitor lab reports for
anticoagulation/fibrinolytic abnormal bleeding and activated partial thromboplastin time (APTT), international
therapy maintain hemoglobin and normalized ratio (INR), prothrombin time (PT), decrease in
hematocrit within normal platelet count, and hemoglobin and hematocrit levels.
limits. Evaluate blood pressure and pulse for signs of bleeding (i.e.,
rapid pulse and low blood pressure). Check stool for occult
blood. Assess gums for bleeding.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ PULMONARY EDEMA The hallmark of acute pulmonary edema is a cough

A
producing a copious amount of frothy, blood-tinged sputum
cute pulmonary edema is a life-threatening condition (hemoptysis), often appearing pinkish. The client rapidly
characterized by a rapid shift of fluid from plasma into becomes dyspneic, orthopneic, and cyanotic. Anxiety rang-
the pulmonary interstitial tissue and the alveoli (Figure 4-11). ing from restlessness to panic occurs. Heart and respiratory
As a result, gas exchange is markedly impaired. Pulmonary rate increase. Progressive crackles (rales) are heard in the lung
edema generally has a cardiac cause such as left ventricular fields on auscultation. Initially, fine crackles (rales) are pres-
failure or myocardial infarction, or a noncardiac cause such as ent in the posterior bases of the lung. As pulmonary edema
fluid overload, inhalation of noxious gases, opiate overdose, progresses, the crackles (rales) become increasingly coarser,
aspiration, sepsis, or radiation injury. louder, and more diffuse. Wheezes are heard in the presence

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 CHAPTER 4 Respiratory System 97

Extravascular Bronchodilators are administered to dilate airways obstructed

accumulation
of fluid in the with fluid.
pulmonary
tissues and
air spaces Diet

COURTESY OF DELMAR CENGAGE LEARNING

A sodium-restricted diet may be ordered to prevent fluid
retention. Intake and output as well as daily weight are mea-
sured to monitor fluid balance.

Activity
Bed rest reduces the workload on the heart and lungs. High
Fowler’s position aids respiratory effort and enhances venous
pooling. Activities are increased slowly according to the physi-
Figure 4-11 Pulmonary Edema cian’s orders and the client’s ability to tolerate activity.
of significant airway obstruction by fluid. Left untreated, the
client deteriorates rapidly as oxygenation decreases. The cli- Nursing Management
ent’s history is crucial to identify the cause. Noncardiogenic Monitor ABGs and pulse oximetry and administer oxygen as
pulmonary edema can quickly become respiratory failure. ordered. Assess breath sounds, vital signs, and level of con-
sciousness. Keep client in high Fowler’s position. Keep an accu-
Medical–Surgical rate intake and output record. Monitor client’s weight daily.
Management
Medical NURSING PROCESS
The goals of medical management are to remove fluid from
the alveoli and pulmonary interstitial space, prevent further Assessment
influx of fluid, improve oxygenation, and decrease workload
of left ventricle. Arterial blood gases and pulse oximetry values Subjective Data
are used to assess oxygenation. Oxygen is administered per The nurse must be aware of the conditions that predispose the
physician’s order when hypoxia is present. Noncardiogenic client to pulmonary edema. The client may describe feeling
pulmonary edema often requires ventilation support and anxious, breathless, and fatigued.
treatment of the cause.
Objective Data
Pharmacological Breath sounds are auscultated for the presence of crackles
A diuretic such as furosemide (Lasix) is the primary treat- (rales). Report increasingly coarse and diffuse crackles (rales)
ment for cardiogenic pulmonary edema. When the pumping to the physician. Assess the client’s level of consciousness, respi-
force of the left ventricle is impaired, a digitalis preparation is ratory rate and effort, and color. Dyspnea, tachypnea, cyanosis
given to improve the contractile force of the myocardium. To and/or pallor may be present. Assess oxygenation via pulse
prevent further influx of fluid into the lungs, venous pooling oximetry or ABGs. A productive cough may be present, as may
is enhanced. This also decreases the workload on the heart symptoms of CHF, such as rapid weight gain and peripheral
by limiting venous return. Morphine is used to promote edema. Pulse may be rapid and weak. Blood pressure may
vasodilation and, thus, venous pooling and to relieve anxiety. increase in response to anxiety and decreased oxygenation.

Second Third
Restlessness Course Crackles
Anxiety Wheeze
Panic Airway obstructed F
st O
Fir Heart Rate↑ by fluid Re xyge inal
s
Lif pi a n
ic Respiratory Rate↑ e r t
ne ic th ator ion↓
y sp pne tum Fine Crackles re
D tho ic S pu at y fa
r t en ilu
O ano with ing re
Cy ugh
Co rothy h ed
COURTESY OF DELMAR CENGAGE LEARNING

f
i n kis –ting
p od
blo

Concept Map 4-1 Progression of Pulmonary Edema

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98 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with pulmonary edema include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client will maintain an Place client in high Fowler’s or orthopneic position (sitting
related to fluid in the lung oxygen saturation of 95% or upright leaning forward).
tissue greater and will have respira- Continually assess oxygenation with ABG or pulse oximetry
tory rate, color, and blood measurements and provide supplemental oxygen to
gases within normal limits maintain an oxygen saturation of 95% or greater or per
and clear breath sounds. physician’s order.
Frequently assess respiratory rate, breath sounds, apical
heart rate, and blood pressure. Administer respiratory treat-
ments as ordered.
Assist client with activities to reduce the workload on the
heart and lungs, and alternate periods of activity with peri-
ods of rest to prevent client fatigue.
Administer medications as ordered and evaluate the effec-
tiveness of each. Monitor lab reports for electrolyte values.

Excess Fluid Volume The client’s weight will return Weigh client daily. Monitor I&O.
related to altered tissue to normal. Frequently assess the client for peripheral edema.
permeability
Provide client with a low-sodium diet as ordered.
Administer diuretics per order and evaluate their
effectiveness.
Monitor lab reports for electrolyte values.
Monitor the rate at which intravenous fluids are given.
Teach client and family symptoms of fluid excess, medica-
tion information, and dietary modifications.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

The ABGs and pulse oximetry reveal severe hypoxemia and

■ ACUTE RESPIRATORY progressive respiratory and metabolic acidosis. On ausculta-
DISTRESS SYNDROME tion, the lung fields are filled with diffuse coarse crackles (rales)

A
and sonorous wheezes. The client will have a productive cough
cute respiratory distress syndrome (ARDS; formerly
yielding blood-tinged sputum. Chest x-ray shows widely scat-
called adult respiratory distress syndrome) is a life-
tered infiltrates, often referred to as a “white out.”
threatening condition characterized by severe dyspnea,
Medical–Surgical Management
hypoxemia, and diffuse pulmonary edema. The condition
usually follows a major assault on multiple body systems
or severe lung trauma. Underlying causes include trauma, Medical
sepsis, coronary artery bypass surgery, major thoracic or
vascular surgery, renal failure, severe pulmonary infections, The client with ARDS is cared for in the intensive care unit. The
inhalation lung injuries, and acute drug poisoning. ARDS is a underlying cause of ARDS is ascertained and treated; until that
noncardiogenic pulmonary edema, caused by damage to the time, supportive care is given. Mechanical ventilatory support
alveolocapillary membranes allowing fluid to leak into the is necessary, with multiple other systems often also being sup-
lungs under normal pressure. ported. A mechanical ventilator allows the oxygen percentage,
Gas exchange is severely impaired by the damage to the pulmonary pressure, and lung volume to be controlled. Oxy-
pulmonary capillary membrane and the presence of fluid in genation is monitored with ABGs and pulse oximetry. Respira-
the alveoli. The surfactant is rendered inactive, resulting in the tory secretions are removed by frequent bronchial suctioning.
collapse of the alveoli, further reducing gas exchange. Hypox-
emia, resistant to conventional oxygen therapy, develops. Pharmacological
The client with ARDS is critically ill, as reflected by severe Pharmacological therapy includes high doses of corticosteri-
dyspnea, tachypnea, and cyanosis. Arterial blood gases will ods such as hydrocortisone sodium succinate (Solu-Cortef) or
show PaO2 < 70 mm Hg, PaCO2 > 35 mm Hg, bicarbonate ion methylprednisolone sodium succinate (Solu-Medrol). Furo-
< 22 mEq/L, and initially elevated then steadily decreasing pH. semide (Lasix) and other diuretics are given to remove fluids

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 CHAPTER 4 Respiratory System 99

and increase urinary output. Aminophylline (Aminophyllin) excess secretions. Provide frequent oral care. Plan for uninter-
is administered to open the bronchi. While the client is on rupted rest periods. Assess for restlessness and anxiety.
the mechanical ventilator, pancuronium bromide (Pavulon)
is given to suppress the client’s own respiratory effort. Blood
pressure can fall dangerously low, and vasopressors such as NURSING PROCESS
dopamine hydrochloride (Intropin) may be required to main-
tain the blood pressure within an acceptable range. Assessment
Diet Subjective Data
Total parenteral nutrition (TPN) may be given to the client, The client history is typically gathered from family members
especially during the acute phase of the illness. When possible, or significant others because the client is usually too ill to
enteral feedings are preferred. communicate.

Activity Objective Data

The client with ARDS will be on bed rest. Special beds that The client’s level of consciousness and response to stimuli are
provide movement and pressure adjustment prevent the assessed, and the client is observed for restlessness and anxi-
complications associated with immobility. According to the ety. Vital signs are measured every 15 minutes or more often.
ARDS Support Center (2009a), prone positioning improves Heart rate is increased, and arrhythmias may be present. Blood
oxygenation and may prevent further lung damage. pressure is usually low. Respiratory rate, rhythm, and effort
are assessed for signs of dyspnea, nasal flaring, cyanosis, tac-
Nursing Management hypnea, and other indications of respiratory distress. Arterial
blood gases and pulse oximetry values are assessed to evaluate
Monitor client’s level of consciousness, response to stimuli, oxygenation and acid–base balance. Diffuse, coarse crackles
vital signs, ABGs, pulse oximetry, and breath sounds. Suction (rales) and wheezes are heard throughout the lung fields.

Nursing diagnoses for a client with ARDS include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client will have an Provide adequate oxygenation and ventilation as ordered.
related to pulmonary capil- oxygen saturation of 95% or Monitor ABGs and pulse oximetry to evaluate oxygenation
lary membrane damage greater, ABGs within normal and acid–base balance.
limits, and respiratory rate
and effort within normal Assess the client’s respiratory rate and effort and auscultate
limits. the lungs frequently.
Suction the respiratory tract as necessary to remove excess
secretions, and provide oral care frequently.

Anxiety related to difficulty The client, if able, will verbal- Describe care and purposes to the client.
breathing and mechanical ize a decrease in anxiety Allow rest periods between periods of activity to avoid over-
ventilation or will exhibit fewer objec- whelming the client with stimuli.
tive signs of anxiety, such
as restlessness and facial Plan care to allow for uninterrupted rest.
grimacing. Allow family and significant others to visit and participate in
care, as appropriate.
Assess client for signs of sensory overload/deprivation.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

respiratory tract infections are at risk for developing acute

■ ACUTE RESPIRATORY FAILURE respiratory failure.

A cute respiratory failure is not a disease entity in and

of itself; rather, the term is used to refer to conditions
wherein there is a failure of the respiratory system as a whole.
CHRONIC RESPIRATORY
TRACT DISORDERS
A
This condition occurs as a result of the client literally becom-
ing too tired to continue the “work” of breathing. Mechanical sthma, chronic obstructive pulmonary disease (COPD),
ventilatory support is required during the acute phase. Clients chronic bronchitis, emphysema, and bronchiectasis are
with preexisting pulmonary conditions coupled with acute discussed following.

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100 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

as the respiratory secretions become thick and block the airways.

LIFE SPAN CONSIDERATIONS Cyanosis and a decrease in oxygen saturation occur. Heart rate
elevates, as may blood pressure. The client becomes anxious and
Asthma and Age may complain of a sense of impending doom. These responses
are thought to be caused by a release of catecholamines. Values
In children: of ABGs indicate hypoxia and respiratory acidosis. Chest x-ray
• Asthma attacks often become less severe and shows hyperinflation of the lungs. Pulmonary function tests
less frequent as the child ages. reveal an abnormal flow rate and lung volume. With a severe
• Asthma attacks are usually associated with asthma attack, apnea and sudden death can occur in minutes.
definite allergens.
• Oral bronchodilators should be taken 30 to
Medical–Surgical Management
60 minutes before exercise, inhaled broncho- Medical
dilators 15 to 20 minutes before exercise. The client with allergies should avoid specific antigens that
In adults: might bring on an attack. Some clients with asthma are aided
by controlling psychological stressors. Routine physical exer-
• Asthma attacks usually become more severe and
cise is beneficial in treating exercise-induced asthma. The
more frequent as the individual ages. client with asthma should avoid other respiratory irritants
• Asthma attacks are usually not associated with such as cigarette smoke and air pollution. Clients who develop
definite allergens. asthma later in life show more symptoms as they age.
Pharmacological
The primary treatment for an acute asthma attack is pharmaco-
■ ASTHMA logical. A combination of medications is used to open the nar-

A sthma is a condition characterized by intermittent air-

way obstruction in response to a variety of stimuli.
The epithelial lining of the airways responds by becoming
rowed airways. Medications used to dilate the bronchi include
bronchodilators such as aminophylline (Aminophyllin) and
terbutaline sulfate (Brethine, Bricanyl); beta agonists such as
inflamed and edematous. Bronchospasm occurs in the smooth epinephrine (Primatene Mist) and albuterol sulfate (Vento-
muscles of the bronchi and bronchioles. Secretions increase in lin); and anticholinergics such as atropine sulfate and ipratro-
viscosity. Elastic recoil decreases. All of these changes result in pium bromide (Atrovent). Corticosteroids such as prednisone
a reduction of the diameter of the airways, making breathing (Delatsone) are utilized to decrease inflammation. Mucolytic
more difficult. Some clients who develop asthma in childhood agents such as acetylcysteine (Mucomyst) aid in liquefying
experience spontaneous recovery. secretions. Supplemental oxygen is given when indicated.
Asthma is classified as extrinsic or intrinsic. Extrinsic asthma is
caused by substances outside the body that precipitate the asthma Diet
response, such as pollen, house dust, or food additives. Intrinsic Adequate fluid intake is maintained to promote liquefaction of
asthma is diagnosed when no extrinsic factor can be identified secretions. Foods, such as dairy products, which contribute to
and the asthma is the result of internal factors such as emotional mucous production, should be avoided during or immediately
stress, exercise, or fatigue. An asthma attack that does not respond following an asthma attack.
to treatment and persists is known as status asthmaticus.
The hallmark of an asthma attack is sudden onset of wheez-
Activity
ing, increasing dyspnea, and chest tightness. Mild asthma usu- Incorporate several rest periods for the client. Use relaxation tech-
ally is controlled by routine medication. Severe asthma attacks niques to manage anxiety. The client should not overexert to the
usually occur at night and require extra medication. With severe point of dyspnea, wheezing, or fatigue. If overexertion occurs, the
attacks, wheezing may be audible to the unaided ear. Expiratory client should sit down and sip warm water. This promotes slower,
wheezes are common as air attempts to escape through the nar- regular breathing; bronchodilation; and loosens secretions.
rowed airways. Both inspiratory and expiratory wheezes may be
heard. Absence of wheezing could indicate complete closure of the Nursing Management
airway. The respiratory rate rises initially, but as the client tires, Obtain history about previous asthma attacks. Evaluate
the rate may decrease. Nasal flaring and costal and sternal retrac- wheezes for location, duration, and phase of respiration when
tions may be present, particularly in the young client. The client they occur. Monitor pulse oximetry and ABGs for oxygen-
uses accessory muscles to assist respiratory effort. Cough occurs ation and acid–base balance.

COLLABORATIVECARE
Assessment and Teaching for Asthma Asthma
Respiratory therapists and nurses work together • Prohibit smoking in the home, especially if a
in assessing breath sounds and respiratory effort. child has asthma.
Teaching the client how to use a nebulizer or • Use a humidifier, especially in the bedroom of
inhalers and aerosol treatment is a collaborative the person with asthma.
effort of nurses and respiratory therapists.
• Use fans to circulate air.

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 CHAPTER 4 Respiratory System 101

NURSING PROCESS Objective Data

Note the effectiveness of ventilation. Wheezes are evaluated as
Assessment to their duration, location, and the phase of respiration during
which they occur (e.g., inspiration). Wheezes heard without the
Subjective Data aid of a stethoscope are called audible wheezes. Respiratory
A detailed history is taken regarding exposure to triggering rate, depth, rhythm and effort; position assumed; and client
stimuli before past asthma attacks. Also, the onset, duration, color are evaluated. Monitor pulse oximetry or lab reports of
and severity of symptoms such as dyspnea are noted. ABG values to determine oxygenation and acid–base balance. If
sputum is produced, note its color, amount, viscosity, and odor.

Nursing diagnoses for a client with asthma include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Inefficient Breathing Pat- The client will have respira- Assist client in assuming a position that facilitates ventilation.
tern related to narrowed tory rate and color within Administer medication as ordered. Assist client in the use of
airways normal limits, clear breath inhalers and aerosol treatments.
sounds on auscultation,
and ABG or pulse oximetry Assess oxygenation by ABG or pulse oximetry values and
values within normal limits. administer supplemental oxygen, as ordered.
Frequently assess respiratory rate and effort as well as color
as client’s condition dictates and auscultate the lung fields for
presence of wheezes.
If sputum is produced, note its color, amount, viscosity, and odor.
Frequently assess vital signs as client’s condition dictates.
Unless otherwise contraindicated, encourage fluid intake to
promote liquefaction of respiratory secretions.

Deficient Knowledge The client will verbalize an Teach client and family about the disease process; the purpose,
related to asthma, asthma understanding of both the effect, adverse effects, side effects, and use of all prescribed med-
treatment, and individual pathophysiology and treat- ications, especially inhalers and respiratory aerosol equipment.
triggers for asthma attacks ment of asthma, including Assist client in establishing a medication schedule that will
the medications taken and facilitate regular and timely taking of medications.
their purposes and side
effects. The client will also Instruct client to use the inhaler prior to meals to aid in breath-
identify individual triggers ing while eating.
and means of avoiding If client is taking steroids, teach to rinse mouth after using the
these triggers. inhaler so as to prevent fungal infection.
Encourage exercise because it increases respiratory reserve
and improves overall physical condition.
Assist client in identifying triggering stimuli and ways to avoid
them.
Teach client and family signs and symptoms of asthma attacks
and respiratory tract infections.
Teach client to avoid crowded areas and close contact with
persons with infections.

Anxiety related to per- The client will verbalize a Provide client with explanations for all care.
ceived threat of dying decrease in anxiety. Provide care in a calm, unhurried manner.
Plan care to allow client uninterrupted periods of rest.
Allow client to make decisions regarding care, if possible.
Provide client with opportunities to discuss anxiety with staff,
family, or significant others.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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102 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

CNS. When supplemental oxygen is necessary, it is maintained

■ CHRONIC OBSTRUCTIVE at the lowest possible flow rate to maintain oxygenation and
PULMONARY DISEASE prevent depression of the client’s respiratory drive. Evaluate

C
the client with chronic bronchitis and CHF for signs of fluid
hronic obstructive pulmonary disease (COPD), also called overload. Daily weight, intake, and output are monitored.
chronic obstructive lung disease (COLD), is a term used for
two closely related respiratory diseases: chronic bronchitis and Pharmacological
emphysema. These two diseases often occur together. Most clients Current medications used include beta-adrenergic agonists, cho-
have a long history of heavy cigarette smoking (NHLBI, 2009a). linergic antagonists, methylxanthines, corticosteroids, cromolyn
First signs are chronic cough, sputum production, or shortness of sodium/nedocromil, and leukotriene modifiers. Bronchodilators
breath. It gradually gets worse over time. There is no known cure. such as theophylline (Theo-dur) given orally, and ipratropium
In the United States, about 12 million adults have COPD. It is the bromide (Atrovent) given as an inhalation aerosol (metered
fourth leading cause of death. In 2007, the national cost for COPD dose inhaler [MDI]) or inhalation solution (nebulizer) are used
was approximately $42.6 billion (ALA, 2007a). to open airways. Tiotropium bromide (Spiriva) is a once-daily
inhalation powder administered using a HandiHaler device.
Salmeterol (Serevent), given by a dry powder inhaler (DPI) is
■ CHRONIC BRONCHITIS a long-acting beta2-selective agonist used for chronic mainte-

B
nance therapy. Inhalation aerosol (MDI) or inhalation solution
ronchitis is an inflammation of the bronchial tree (nebulizer) treatments with bronchodilators such as albuterol
accompanied by hypersecretion of mucus. The condi- (Proventil, Ventolin) or metaproterenol sulfate (Alupent) are
tion becomes chronic if cough and sputum are present on often used in conjunction with oral medications. Prednisone
most days for 3 months a year for 2 consecutive years or for (Meticorten), a corticosteroid, is given as short-term therapy
6 months in 1 year (NHLBI, 2001b). Constant irritation of the for acute exacerbations. If steroids are required on a long-term
bronchi results in hypertrophy of the mucus-secreting glands. basis, they may be given by inhalation to prevent some adverse
The bronchioles fill with exudate, and subsequent infections systemic effects. Mucolytic medications such as acetylcysteine
are common. There may be narrowing of large and small air- (Mucomyst) are given to reduce the viscosity of purulent and
ways. Environmental factors, especially cigarette smoke, play nonpurulent pulmonary secretions. Guaifenesin (Robitussin,
an important role in the development of chronic bronchitis. Naldecon Senior EX, Mucinex) are expectorants given to loosen
The client usually has a history of recurrent respiratory phlegm and thin bronchial secretions. If infection occurs, broad-
infections, dyspnea, cyanosis, and chronic or recurrent cough spectrum antibiotics are given. Immunization against influenza
yielding copious amounts of sputum. Often, the sputum is viruses and Streptococcus pneumoniae is recommended.
purulent or green in color. Over the course of time, the chest The client with chronic bronchitis who also has CHF will
wall configuration becomes slightly distended. Coarse crack- receive medications to aid the function of the weakened heart.
les (rales) are present throughout the lung fields. Breath Digoxin (Lanoxin) strengthens the force of the contraction
sounds may be diminished or absent over the periphery of of the heart muscle. Diuretics such as furosemide (Lasix) are
the lung fields. Elevation of pulmonary artery pressure results given to remove fluid by increasing urinary output. Supplemen-
in increased workload for the right ventricle and in signs and tal potassium chloride (K-Dur, Kay-Ciel elixir) is given if the
symptoms of right-sided congestive heart failure (CHF), such client’s potassium level decreases from effect of the diuretic.
as peripheral edema and fatigue. Arterial blood gases reveal
increased PaCO2 and decreased PaO2. The red blood cell count Diet
elevates, as do hemoglobin and hematocrit. The increases in
Encourage the client to eat a well-balanced diet. If the client
the amounts of red blood cells and hemoglobin represent an
also has CHF, sodium intake is restricted. Unless contraindi-
attempt by the body to compensate for the lower oxygen level.
cated, fluids are encouraged. Offer small, frequent meals to
Chest x-ray shows hyperexpansion of the lungs. When CHF
clients experiencing shortness of breath.
occurs, the chest x-ray also shows an enlarged heart.
Activity
Medical–Surgical Management Activity is restricted to decrease the workload on the heart and
lungs. With acute exacerbations, the client is placed on bed
Medical rest. The level of activity is then slowly increased based on the
The goals of medical treatment are to decrease symptoms of air- client’s tolerance.
way irritation, decrease airway obstruction related to secretions Programs of breathing exercises and graded (easy to diffi-
and inflammation, prevent infection, maintain oxygenation, cult) exercise regimes assist the client to achieve the maximum
and increase the client’s exercise tolerance. Respiratory therapy level of activity tolerance. Breath-retaining exercises such as
includes the use of updraft (nebulizer) and aerosol treatments, coughing techniques, pursed-lip breathing, and diaphragmatic
along with percussion and postural drainage. Humidification or abdominal breathing are taught. The client is monitored
of inspired air helps liquefy secretions. Supplemental oxygen is from a respiratory standpoint while exercising. The goal is to
administered based on ABG or pulse oximetry values. The neu- increase the client’s capacity for all ADLs.
rological stimulus to breathe becomes altered in some clients
with chronic bronchitis so that breathing is initiated when the Nursing Management
blood level of oxygen falls instead of when the level of carbon Obtain history of onset, duration, and severity of symptoms.
dioxide rises. Consequently, when the level of oxygen in the Note changes in level of consciousness, mental status, respi-
blood is relatively high in relation to the level of carbon dioxide, ratory rate and effort, color, and use of accessory muscles.
the stimulus to breathe is reduced and further depresses the Obtain sputum specimen for culture and sensitivity. Monitor

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 CHAPTER 4 Respiratory System 103

vital signs. Assess for weight gain, peripheral edema, and neck Objective Data
vein distention.
Note changes in level of consciousness or mental status, color,
respiratory rate and effort, the position the client assumes to
NURSING PROCESS aid respiratory effort, and the use of accessory muscles. Review
ABGs or pulse oximetry values. Auscultate lung fields for crack-
Assessment les (rales) and diminished breath sounds. Note color, amount,
viscosity, and odor of sputum. Obtain specimens for culture and
Subjective Data sensitivity, if indicated. Frequently measure vital signs. The pulse
A thorough past medical history is obtained, including infor- may be elevated and irregular. Blood pressure may be elevated or
mation about the onset, duration, and severity of symptoms. low. An elevated temperature may indicate infection. Assess for
The client may describe fatigue and difficult breathing. peripheral edema, neck vein distention, and rapid weight gain.

Nursing diagnoses for a client with chronic bronchitis include the following:
NURSING DIAGNOSES PLANNING/ OUTCOMES NURSING INTERVENTIONS
Ineffective Airway Clear- The client’s color, respiratory Frequently assess level of consciousness, mental status,
ance related to thicker rate, and ABG values will be vital signs, respiratory effort, and color, and auscultate breath
and increased amounts of within normal limits. sounds at least every 4 hours.
respiratory secretions Obtain sputum specimens as ordered, and assess sputum for
amount, viscosity, color, and odor.
Assist client in assuming the position that most aids respira-
tory effort, usually an upright position.
Administer oxygen and respiratory treatments as ordered and
assess their effectiveness.
Evaluate results of diagnostic and laboratory tests (ABGs) and
notify the physician of abnormalities.
Alternate care with periods of uninterrupted rest.
Administer antibiotics and bronchodilators as ordered and
evaluate their effectiveness.
Provide client with a well-balanced diet and, unless otherwise
contraindicated, encourage fluids.
Assess client for signs and symptoms of CHF (i.e., fine crack-
les heard on auscultation, peripheral edema, weight gain, and
fatigue).
Report any signs and symptoms of CHF to the physician.

Deficient Knowledge re- The client will verbalize Teach client to avoid respiratory infections, maintain adequate
lated to chronic bronchitis signs and symptoms to re- nutrition, increase fluid intake, and obtain adequate rest; the
and its treatment and port to the physician, safety purpose, expected effects, and side effects of medications;
prevention precautions to take with and to administer respiratory treatments and medications
medication and equipment, prior to eating to aid in breathing.
medication and respiratory Instruct client to rinse mouth following use of inhaler.
treatment regimen, and
techniques for facilitating Teach client to self-administer oxygen.
breathing. Provide information regarding both the use of equipment and
safety measures for the equipment.
Refer client to an established respiratory rehabilitation
program. If such a program is not available, instruct client in
breathing techniques.
Encourage regular exercise within the client’s limitations.
Encourage client to obtain immunization against influenza
viruses and Streptococcus pneumoniae.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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104 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

A B
■ EMPHYSEMA

E mphysema is a complex and destructive lung disease

wherein air accumulates in the tissues of the lungs. The

COURTESY OF DELMAR CENGAGE LEARNING

airways lose their elasticity and the walls thicken, resulting in
narrower lumens. Airflow is impeded as it leaves the lungs (i.e.,
during expiration). The alveoli distal to these airways become
x x
overdistended with trapped air (Figure 4-12). Rupture of the
alveolar wall may occur. The alveolar capillary membrane is
2x x
destroyed, resulting in a loss of available area for gas exchange.
Cigarette smoking is the most common cause of emphysema. 1:2 ratio 1:1 ratio
Deficiency in alpha-1-antitrypsin is a familial disorder that
leads to the development of emphysema. Alpha-1-antitrypsin Figure 4-13 Changes in Chest Configuration and Posture;
is an enzyme that inhibits the activity of the enzyme elactase, A, The normal ratio of the anterior posterior diameter to the
which breaks down lung tissue. lateral diameter is 1:2; B, With a barrel chest, the ratio between
Emphysema develops slowly over a period of years. The the diameters is 1:1.
earliest symptom is a daily morning cough with clear spu-
tum. Later, the client notes increasing dyspnea in response been displaced by distended lung tissues. Pulmonary function
to activity. The degree of dyspnea corresponds to the degree studies reveal a decrease in expiratory volume. Polycythemia
of hypoxia, which is usually mild at rest but becomes increas- and elevation of hemoglobin and hematocrit occur in response
ingly severe in response to activity. In advanced stages of the to prolonged hypoxia.
disease, hypoxia is evident even at rest. With infection, a cough
yielding purulent sputum occurs. The client’s complexion
appears ruddy, or reddish in color. The chest becomes barrel
shaped (Figure 4-13) as the chest cage enlarges to accommo- Medical–Surgical
date distended lung tissues. The respiratory rate elevates. The Management
expiratory phase of respiration becomes increasingly difficult.
Accessory muscles are used to aid respiratory effort. Because Medical
of destruction of the alveoli, bronchial breath sounds are heard The goals of treatment are to prevent further damage to
in the periphery of the lungs. As the disease progresses, breath the lung tissues, maintain adequate oxygenation, prevent
sounds diminish and eventually disappear over the periphery infection, and improve the client’s activity tolerance. The
of the lungs. Arterial blood gases reveal the degree of hypoxia client who smokes should stop or, at least, decrease the
depending on the severity of the disease. Hypercapnia, or number of cigarettes smoked daily. Supplemental oxygen
retention of carbon dioxide, is not as likely as with chronic is given to maintain oxygenation. The client with advanced
bronchitis. The extra effort required to breathe increases emphysema and severe, chronic hypoxia may be maintained
metabolic need, resulting in weight loss. Chest x-ray reveals at PaO2 of 55 to 59 mm Hg and/or oxygen saturation of
hyperinflated lung tissue and a flattened diaphragm, which has 90% or greater. As with chronic bronchitis, the client with
emphysema is given supplemental oxygen at the lowest pos-
Increased
sible flow rate, usually 2 to 3 L/min, to prevent respiratory
Trachea and CNS depression.
thoracic midline Prolonged
volume
breath
sounds Pharmacological
Trapped The client with emphysema receives many of the same
air medications used to treat chronic bronchitis. To open air-
ways that have become fibrotic, theophylline and similar
preparations are used. Steroids may be required for exacer-
bations. The client with emphysema usually does not need
mucolytic agents, unless infection is present. Antibiotics
are used to treat and prevent respiratory tract infections.
The client should receive immunizations against influenza
and Streptococcus pneumoniae. The client who smokes may
use nicotine gum or transdermal patches to aid in smoking
cessation.
COURTESY OF DELMAR CENGAGE LEARNING

Diet
The client with emphysema requires a diet high in carbohy-
drates to supply the energy necessary for breathing. If a nega-
Flattened
Normal tive nitrogen balance exists because of the client’s using muscle
diaphragm
placement of tissue to provide energy, a diet high in protein is ordered.
diaphragm Dietary supplements such as Ensure may be needed to supply
the necessary calories and nutrients. Unless contraindicated,
Figure 4-12 Emphysema fluids and small, frequent meals are encouraged.

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 CHAPTER 4 Respiratory System 105

Nursing Management
Review factors that increase client’s dyspnea and those that
CULTURAL CONSIDERATIONS relieve dyspnea. Evaluate client’s nutritional status, vital
signs, ABGs, pulse oximetry, color, and level of conscious-
ness. Assist with ADL. Plan for uninterrupted periods of
Skin Color/Cyanosis rest.
• For a client with highly pigmented skin, estab-
lish a baseline skin color.
• Observe skin surfaces that have the least NURSING PROCESS
amount of pigmentation, such as the palms, the
soles of the feet, the abdomen, mucous mem- Assessment
branes, or the inner aspect of forearms. Subjective Data
Included in the history is information regarding the timing
Activity of dyspnea, those factors that exacerbate dyspnea, and those
The client is placed on bed rest. Level of activity is increased factors that relieve dyspnea.
based on the client’s oxygenation. Oxygen saturation is evalu-
ated periodically as the activity level is increased to determine Objective Data
the effect of activity on oxygenation. Assess sputum for color, amount, viscosity, odor, and vital
signs. An elevated pulse may indicate hypoxia and/or infec-
Health Promotion tion. Auscultation of the lungs will reveal the presence of
The client with emphysema benefits from a respiratory reha- adventitious, diminished, or absent breath sounds. Note the
bilitation program. The client is taught breathing exercises client’s position to aid respiratory effort, color, respiratory
similar to those taught to the client with chronic bronchitis. rate and effort, and use of accessory muscles to aid breathing.
A graded exercise program is also used for the client with Evaluate the client’s nutritional status by weighing the client
emphysema. Group programs that aid in smoking cessation and measuring nutrient and caloric intake. Review results of
are useful for the client who smokes. laboratory and diagnostic tests.

Nursing diagnoses for a client with emphysema include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client’s respiratory rate, Assess the client’s level of consciousness and mental status.
related to destruction of color, and ABG values will Frequently evaluate client’s respiratory rate, respiratory effort,
the alveoli be within normal limits. color, and oxygenation with ABG and/or pulse oximetry.
Assess the effect of activity on oxygenation, particularly when
activity is being increased and provide supplemental oxygen
as ordered.
Auscultate the lungs and report abnormalities to the physician.
Assess client’s vital signs: heart rate and temperature eleva-
tions may indicate infection, an elevated pulse may indicate
hypoxia.
Review results of diagnostic and laboratory tests and report
abnormalities.
Administer medications and respiratory treatments as ordered.
Assist client in assuming the position that offers the most
comfort and most aids respiratory effort. Instruct client in
breathing techniques, such as pursed-lip breathing.

Risk for Activity Intolerance The client will complete Assist client with ADL and hygiene needs.
related to hypoxia activity without experienc- Plan care and treatments to allow client uninterrupted periods
ing fatigue or dyspnea. of rest. Allow rest before and after meals.
As activity increases, assess the effects on oxygenation.

(Continues)

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106 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with emphysema include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: Less The client will achieve or Assess client’s weight and evaluate in relation to the client’s
than Body Requirements maintain a weight within height.
related to increased energy normal limits for height. Evaluate client’s diet for nutritional adequacy and review
requirements to maintain client’s food likes and dislikes.
respiration
Provide a well-balanced diet based on client’s likes and
dislikes. Provide nutritional supplements as ordered.
Avoid activities or procedures prior to meals that might
reduce appetite (e.g., enemas).
Administer medications and respiratory treatments prior to
meals to aid in breathing.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

oxygenation. Percussion and postural drainage are used to aid in

■ BRONCHIECTASIS the removal of secretions. Aerosol and updraft respiratory treat-

B
ments may be ordered before percussion and drainage. If the cli-
ronchiectasis is chronic dilation of the bronchi. The ent is unable to expectorate secretions, bronchial suctioning is
main causes of this disorder are pulmonary TB infection, performed. The physician performs a bronchoscopy to remove
chronic upper respiratory tract infections, and complications especially tenacious and copious secretions. Arterial blood
of other respiratory disorders of childhood, particularly cys- gases and/or pulse oximetry values are evaluated to assess
tic fibrosis. The bronchi become distended and eventually the need for supplemental oxygen. Daily weight and I&O are
lose their elastic recoil property. The mucociliary blanket’s performed to detect signs of CHF. Pulmonary function studies
function is impaired, and secretions thicken. Secretions accu- evaluate the severity of lung damage.
mulate in the bronchi, resulting in a medium for infection.
Airflow is hindered, reducing gas exchange.
The client with bronchiectasis describes a frequent or Pharmacological
chronic productive cough, dyspnea, weight loss, and fatigue. Mucolytic agents are given to promote liquefaction of respira-
Sputum is thick and sometimes purulent when infection is tory secretions. Antibiotics are ordered to treat and prevent
present. Crackles, which clear on coughing, are heard scat- infection. The client is immunized against influenza and
tered throughout the lungs and are more prominent early against Streptococcus pneumoniae with the pneumococcal vac-
in the morning. Accessory muscles are used to aid respira- cine (Pneumovax 23). Bronchodilators are indicated to open
tion. Over a period of time, right-sided CHF and peripheral the fibrotic airways. Inflammation is treated with oral steroids
edema develop. Arterial blood gases reveal elevated PaCO2, such as prednisone (Meticorten) and/or by inhalation with
decreased PaO2, and respiratory acidosis. Polycythemia and beclomethasone dipropionate (Beclovent). The client with
elevated hemoglobin and hematocrit levels are present. Chest cystic fibrosis is required to take pancreatic enzymes, pancreli-
x-ray shows slight hyperinflation of lung tissue and, in the pres- pase (Pancrease capsules, Cotazym capsules), to replace those
ence of CHF, cardiomegaly. Respiratory flow rate decreases, that are missing with this disorder. If CHF occurs, the client
and lung volume increases, as demonstrated by pulmonary is treated with digoxin (Lanoxin), furosemide (Lasix), and
function studies. Table 4-8 compares asthma, chronic bron- potassium supplements, as indicated.
chitis, emphysema, and bronchiectasis.
Diet
Medical–Surgical To provide energy for breathing, the diet should be high in
Management carbohydrates and calories. Protein is supplemented if nec-
essary. Dietary supplements such as Ensure may be needed.
Medical Fluids are encouraged, unless otherwise contraindicated.
Medical treatment is aimed at removing respiratory secretions, Sodium is restricted in the diet of the client with CHF to
preventing or eliminating infection, and maintaining adequate prevent fluid retention. The diet for the client with cystic
fibrosis is restricted in fats because fats are not properly
CRITICAL THINKING absorbed.
COPD Disorders
Activity
What are the differences and the similarities of the
During acute exacerbations or in the presence of serious
two disorders classified as COPD? infection, activity is limited. The client is placed on bed rest.
Activity is progressively increased depending on the client’s

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 CHAPTER 4 Respiratory System 107

Table 4-8 Signs and Symptoms of Asthma, Chronic Bronchitis,

Emphysema, and Bronchiectasis
CHRONIC
ASTHMA BRONCHITIS EMPHYSEMA BRONCHIECTASIS
History Intermittent attacks Recurrent respiratory Insidious onset, dys- Cystic fibrosis, recur-
of dyspnea and infections, chronic pnea on exertion to rent respiratory infec-
wheezing cough dyspnea at rest tions, TB

Cough Present during attack Chronic or recurrent Present with Frequent or chronic
productive cough infections productive cough

Sputum Thick Copious, purulent, Scanty mucoid, Thick, tenacious,

green unless infection sometimes purulent
present secretions

Weight No weight loss Slight or no weight Weight loss common Commonly, weight
loss loss or failure to gain

Appearance Flushed then Commonly cyanosis Ruddy complexion Clubbing of finger-

cyanotic (“blue bloater”) (“pink puffer”) nails

Chest Configuration Slight overdistention Slight overdistention Overdistention promi- Slight overdistention
nent (“barrel chest”)

Breath Sounds Audible wheezing Coarse crackles Bronchial breath Crackles

Prolonged expiration (rales) sounds in peripheral
lung fields
Diminished or absent
in late disease

Edema Infrequent Peripheral edema Infrequent Peripheral edema in

common, especially late disease
in ankles

Right-sided CHF Infrequent Frequent Infrequent Frequent late in

(Cor Pulmonale) disease

CO Retention Sometimes Common Unlikely Common in late

(Hypercapnia) disease

Hypoxemia Depends on severity Possibly severe Usually mild, espe- Possibly severe in
of attack cially at rest late disease and with
infection

Dyspnea Increases during Progressive Dyspnea on exertion With respiratory

attack to dyspnea at rest infection and late
usually presenting disease
symptom
COURTESY OF DELMAR CENGAGE LEARNING

Accessory Muscles Yes Yes Yes Yes

Used for Respiration

Poly cythemia Uncommon Late in disease Yes In late disease

Respiratory Failure Possible Common Possible Common

tolerance. Respiratory rehabilitation and graded exercise pro- Nursing Management

grams are useful in the treatment of bronchiectasis. Regular Review client’s history for recent and past respiratory infec-
exercise is encouraged, particularly for the pediatric client tions, TB, and cystic fibrosis. Monitor vital signs. An increased
with cystic fibrosis. heart rate may indicate hypoxia and/or infection, and an

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108 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

without an obvious underlying cause. A tension pneumotho-

PROFESSIONALTIP rax is a life-threatening condition wherein air enters the pleu-
ral space on inspiration but is unable to exit on expiration.
The air thus continues to accumulate in the pleural space,
Cystic Fibrosis compressing the underlying structures. If left untreated, a
tension pneumothorax collapses the lung and encroaches
Cystic fibrosis (CF) is an inherited life-threatening
on the structures on the opposite side. The structures of the
disorder that causes severe lung damage and
mediastinum shift to the unaffected side as more and more
nutritional deficiencies. Improvements in the air accumulates in the pleural space. Without intervention,
treatment of CF have increased the life expectancy tension pneumothorax will result in cardiopulmonary arrest.
of a client with CF from 10 years of age in 1962 Tension pneumothorax is often associated with mechanical
to 37 years of age in 2009 (National Institutes ventilation. The pressure exerted by the ventilator on com-
of Health, 2009a). Treatment for CF is aimed promised lung tissue interrupts the integrity of the pleura.
at relieving symptoms and complications. New Air continues to enter the pleural space but is unable to exit
antibiotics such as inhaled tobramycin sulfate as mechanical ventilation continues. In the case of a pneu-
(TOBI) are more effective in treating infections, mothorax associated with trauma or surgery, bleeding of
and other drugs, such as dornase alfa recombinant adjacent vessels into the pleural cavity often occurs. Blood
(Pulmozyme) and azithromycin (Zithromax, Zmax)
within the pleural space is referred to as a hemothorax.
When accompanied by air, the condition is called a hemo-
slow the progression of the lung disease. Mechanical
pneumothorax.
chest physical therapy devices used daily, such as The severity of injury and the amount of lung tissue
electric chest clappers and inflatable vibrating vests affected determine the signs and symptoms the client exhibits.
help loosen and remove thick mucus from the lungs. The client with a small pneumothorax may be asymptomatic
Lung transplantation may be an option for clients or may complain of minor dyspnea, whereas the client with a
with severe lung damage. Respiratory failure is the significant pneumothorax may exhibit signs of severe respira-
most dangerous consequence of CF (Mayo Clinic, tory distress. Dyspnea, tachypnea, orthopnea, and cyanosis may
2009). For more information about CF visit the Cystic be present. Oxygenation is impaired. Pleuritic pain is common.
Fibrosis Foundation at http://www.cff.org Breath sounds are absent in the area of the pneumothorax. The
client with an accompanying hemothorax exhibits signs and
symptoms of shock associated with blood loss.
elevated temperature may indicate infection. Note weight
loss and muscle wasting. Monitor breath sounds and suction Medical–Surgical
mucous as necessary.
Management
CHEST TRAUMA Medical
P neumothorax/hemothorax is discussed following. For the affected lung to reexpand, the air and/or blood must
be removed from the pleural space. When the blood loss

■ PNEUMOTHORAX/ Contralateral
HEMOTHORAX mediastinal shift

N ormally, the pleural space between the visceral and pari-

etal pleura contains pleural fluid and is held together by
surface tension. The pleural space is a closed compartment
No breath
sounds

with a negative pressure compared to the lungs or the atmo-

sphere. When the integrity of the pleura is interrupted, air
from the atmosphere or from the lungs moves between the B
pleura, creating a space. This air in the pleural space is known
as a pneumothorax (Figure 4-14). The lung tissue under-
lying the pneumothorax is compressed and unable to fully
expand. If the pneumothorax is large enough, the entire lung A
may collapse from the compression.
COURTESY OF DELMAR CENGAGE LEARNING

A pneumothorax may be referred to as traumatic (closed Air

or open), spontaneous, tension, or a hemopneumothorax.
A closed pneumothorax occurs when there is no commu-
nication between the pleura and the external environment.
An example of a closed pneumothorax is when blunt trauma
to the chest causes a broken rib that pierces the pleura and
lung, allowing air to enter between the pleura. An open
pneumothorax exists when there is direct communication
between the external environment and the pleural space as Figure 4-14 Pneumothorax; A, Penetrating Wound;
in a gunshot wound. A spontaneous pneumothorax occurs B, Ruptured Bleb on the Lung

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 CHAPTER 4 Respiratory System 109

associated with a hemothorax is significant, fluid and blood Activity

replacement may be necessary.
If hypoxia is present, activity restrictions are necessary. The
presence of other injuries or conditions may also necessitate
Surgical activity restrictions. After the client is adequately oxygenated
A thoracotomy tube, or chest tube, is inserted by the physi- and stable, activity is encouraged to promote expansion of the
cian into the pleural space to drain fluid and air and allow the lungs.
lung to reexpand. The tube is placed in the midaxillary line at
approximately the fifth intercostal space. To drain air alone, Nursing Management
the tube is placed in the anterior chest at the midclavicular Gather information about recent chest injuries or falls. Assess
line and the fourth intercostal space. The thoracotomy tube is level of consciousness, mental status, color, respiratory effort,
connected to an underwater seal drainage device (refer back to and chest wall movement. Monitor vital signs. Auscultate for
Figure 4-9). The underlying cause of the hemopneumothorax breath sounds. When a chest tube is in place, assess function,
then must be treated. patency, and amount and character of drainage.
A recurrent spontaneous pneumothorax may require a
pleural cortication to prevent further episodes. This involves
roughing the adjacent surfaces of the visceral and parietal NURSING PROCESS
pleura so the resulting scar tissue will improve adhesion
between the two surfaces. Emergency treatment for a tension Assessment
pneumothorax that is severely compromising the function
of the heart and lungs is placing a large-bore needle into the Subjective Data
anterior chest at the fourth intercostal space. A thoracotomy Gather information about the source of the pneumothorax.
tube is then inserted until the lung(s) are fully reexpanded and Ask the client about previous pneumothoraces, recent chest
to prevent a recurrence. injury, falls, and severe coughing. The client often describes
being very anxious.
Pharmacological
To control pleuritic pain, narcotic analgesics such as morphine Objective Data
sulfate or meperidine (Demerol) are prescribed. Analgesics Assess the client’s level of consciousness and mental status and
may be given orally or parenterally depending on the severity the client’s color, respiratory effort, and chest wall movement.
of the pain. Before insertion of a thoracotomy tube, intrave- Chest wall movement is decreased on the affected side. When
nous narcotics may be given prophylactically. Tissues adjacent a large pneumothorax is present, the trachea shifts toward the
to the area of the pneumothorax are injected with local anes- unaffected side. Dyspnea and cyanosis may occur. The cough
thetics before insertion of a thoracotomy tube. is forceful and nonproductive. Respiratory rate and heart rate
are elevated. Blood pressure may be elevated because of the
presence of pain and anxiety or may be low because of blood
Diet loss. Breath sounds are diminished or absent over the affected
A well-balanced diet with sufficient amounts of protein is areas. Note the location, duration, and severity of pain. When
encouraged for healing. The client with other injuries and a chest tube is inflated, assess for function, patency, and
conditions may require TPN or enteral feedings. amount and character of drainage.

Nursing diagnoses for a client with a pneumothorax include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing Pat- The client’s respiratory rate Monitor the amount and character of drainage from the
tern related to decreased and color will be within nor- chest tube and note chest tube drainage as output.
lung expansion mal limits, and the client will Observe fluctuations (tidaling) in the water seal chamber,
have clear breath sounds in which indicates that the tube is in the pleural space.
affected area.
Investigate the absence of tidaling because this may
indicate that the lung is fully reexpanded or that the tube is
occluded or kinked.
Observe for bubbling in the water seal chamber, which
indicates an air leak. Assess the connections and chest tube
to determine if leaks are present. If no air leaks are present,
notify the physician because the air leak may be within the
client’s lungs.
Encourage client to cough and deep breathe to prevent
further respiratory complications.

(Continues)

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110 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with a pneumothorax include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize a Assist client in assuming the position that most aids respira-
pleural space irritation decrease in pain on a scale tion. Most clients find this to be the orthopneic position.
of 0 to 10. Assess vital signs and respiratory status.
Administer pain medications as ordered. Remember that
respiratory depression is possible with narcotic medications.
Provide diversional activities.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Family members and significant others often need assis-

NEOPLASMS OF THE tance in coping with their feelings.
RESPIRATORY TRACT
Medical–Surgical
N eoplasms discussed following include benign neoplasms,
lung cancer, and laryngeal cancer. Management
Medical
■ BENIGN NEOPLASMS Treatment of lung cancer depends on the type and stage of

A
the cancer.
benign tumor or cyst in the lung has sharply defined
edges, as revealed on an x-ray. Peripheral tumors usually
have no symptoms. Bronchial tumors may cause obstruction,
infection, or atelectasis.

■ LUNG CANCER

M alignant tumors (carcinomas) of the lung may origi-

nate within the lung or may result from metastasis
from other tumor sites (e.g., breast, colon, or kidney). Men, A B
especially those older than 40 years of age, are more likely to
have lung cancer than are women. The number of deaths is
still rising among women, but has reached a plateau for men
(ALA, 2007c). Cigarette smoking is the most important risk
factor for lung cancer. Air pollution and exposure to carcino-
gens such as asbestos are also risk factors, especially among
smokers, for developing lung cancer. Exposure to radiation or
radon is also known to cause lung cancer. Prognosis depends
on the size of the tumor when diagnosed and the specific cell
type (Figure 4-15).
Symptoms develop late in the course of lung cancers.
Peripheral lesions generally have few symptoms. Initially, the
client may complain of a chronic cough or wheezing. Central
lesions cause obstruction and erosion of the bronchi. As the
tumor grows and occludes the air passages, the client may C D
experience shortness of breath, dyspnea, and blood-tinged
COURTESY OF DELMAR CENGAGE LEARNING

sputum. Pain occurs relatively late in the course of the disease

and indicates that the tumor has grown to a significant size to
put pressure on adjacent nerves and other structures. Although
some tumors can be seen on chest x-ray, many cannot. Low-
dose helical CT scans and MRI scans are more reliable studies
when assessing soft-tissue structures. To confirm a diagnosis,
cytology studies are performed on specimens collected via
bronchoscopy, needle biopsy, or mediastinoscopy. Lung scans
are occasionally useful for diagnosis. Before initiating treat- Figure 4-15 Lung Cancers; A, Small-Cell Carcinoma;
ment, the client is evaluated for metastatic disease using bone B, Epidermoid (Squamous-Cell) Carcinoma; C, Adenocarcinoma;
and total body scans. D, Large Cell (Undifferentiated) Carcinoma

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 CHAPTER 4 Respiratory System 111

Health Promotion
The foremost method of preventing lung cancer is to avoid
smoking or to cease smoking. Avoid the secondhand smoke
Client with Laryngeal Stoma of others.
• Humidify home, especially in winter.
• The client and family must know how to suction Nursing Management
the respiratory tract and care for the respiratory Review client’s history for smoking, exposure to carcinogens,
equipment. and other risk factors. Gather information about onset and
• Use warm water to clean around the stoma. severity of symptoms. Assess for pain. Monitor breath sounds,
vital signs, and drainage from chest tube. Assist to semi-Fowl-
• Do not use tissues, linty cotton, or soap for er’s position or lying on the affected side. Monitor ABGs and
cleansing. provide oxygen as indicated. When pain medication is given,
• Wear a bib or dressing over the stoma to filter monitor for respiratory depression. Aid client to express feel-
and warm incoming air. ings of grief about diagnosis.
• Do not swim or splash water in the stoma when
showering or bathing. NURSING PROCESS
• Notify the physician if any signs of respiratory
infection develop, such as fever, cough, yellow Assessment
or green mucus, or redness around the stoma.
Subjective Data
• Keep follow-up appointments with physician.
Review the client’s history for smoking, exposure to carcino-
gens, and other risk factors. Gather information regarding the
onset, duration, and severity of symptoms. The client may
report hoarseness, chronic cough, pain, and shortness of breath.
Surgical Assess pain for location, character, duration, and severity.
Surgical intervention involves the removal of the tumor and
adjacent lung tissue. Pneumonectomy is the removal of an Objective Data
entire lung. Lobectomy is the removal of a lobe of a lung. Note the color, amount, consistency, and odor of sputum.
Segmental resection is the removal of a segment of a lung. Before surgery, wheezing or decreased breath sounds may be
The client will have a thoracotomy tube on the operative side. heard on the affected side. Following surgery, breath sounds
Radiation and chemotherapy are often used in conjunction are diminished or absent on the affected side. Monitor the
with surgery. The incidence of lung tumor recurrence follow- amount and color of drainage from the thoracotomy tube.
ing surgery is high. Surgery is often indicated for early non– Assess the wound for hemorrhage and infection. Respiratory
small-cell carcinomas. rate and effort may be increased. Pulse rate may be elevated
as a result of a variety of factors including decreased oxy-
genation, hemorrhage, and infection. Hypotension occurs
Pharmacological with significant blood loss. High blood pressure may indicate
The specific type of chemotherapy used depends on the cell pain, anxiety, or other underlying pathology such as essential
type and the extent of tumor growth. hypertension.

Nursing diagnoses for a client with lung cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing The client’s respiratory rate Frequently monitor client’s level of consciousness, vital
Pattern related to disease and color will be within nor- signs, color, and respiratory effort. Auscultate breath sounds.
process mal limits. Assess oxygenation and provide supplemental oxygen as
indicated.
Stagger activities with periods of rest to prevent overtaxing
client’s reserves.
Assist client in assuming the position that maximizes respi-
ratory effort by positioning client in semi-Fowler’s position or
lying on the affected side.
Monitor lab reports for blood gas levels.

(Continues)

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112 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with lung cancer include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to The client will state pain is Administer pain medication and monitor for respiratory
Lung cancer decreased on a scale of depression.
0 to 10. Provide diversional activities. Assist client in assuming a
position of comfort.

Anticipatory Grieving The client will be able to Aid the client in expressing feelings of grief related to the
related to prognosis and express to significant others diagnosis.
perceived separation from and/or staff feelings related Hope should not be eliminated, but false hope should not be
significant others to diagnosis and prognosis. encouraged.
Allow the client and family time to express their feelings.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

nerve may be removed (National Cancer Institute, 2009).

■ LARYNGEAL CANCER Radiation may be used as an adjunct to surgery or as primary

T
treatment if the tumor is detected in the early stages. Follow-
he American Cancer Society (2007) estimated that in 2008 ing surgery, a permanent tracheostomy is necessary to allow
approximately 12,250 Americans would be diagnosed with air to enter the respiratory tract. A small incision is made
laryngeal cancer, and about 3,670 persons would die from it. Risk into the trachea and below the Adam’s apple, and a plastic
factors for cancer of the larynx include smoking, chronic alcohol tracheostomy tube is inserted.
abuse, chronic laryngitis, and overuse of the voice. Laryngeal
cancer is relatively asymptomatic. The client may experience
hoarseness or difficulty speaking above a whisper. If either per- Nursing Management
sists for more than 2 weeks, medical care should be sought. Dif- Monitor respiratory status. Suction secretions and provide
ficulty swallowing is sometimes present. Laryngeal pain radiating tracheostomy care. Teach client stoma protection. Keep head
to the ear or a lump in the throat are often signs of metastasis. of bed elevated and provide extra humidity. Refer client to the
American Cancer Society for support at www.cancer.org.
Medical–Surgical Management
Treatment is determined by the extent of tumor growth. NURSING PROCESS
Surgical Assessment
Surgical removal of the larynx, a laryngectomy, is used to treat Subjective Data
laryngeal cancer. A radical or modified radical neck dissection
may be performed if the cancer has spread to surrounding tis- Obtain a history of the onset, duration, and severity of symp-
sues and lymph nodes. Radical neck dissection operations have toms, such as hoarseness or laryngitis and alcohol and tobacco
been performed for almost 100 years and include the removal use. The client may describe ear pain and difficulty breathing
of lateral neck lymph nodes and tissues, the submandibular and swallowing.
gland, the sternocleidomastoid muscle, the jugular vein and
the spinal accessory nerve (Georgetown University Hospital, Objective Data
2009). A modified radical neck dissection removes all the Evaluate the client’s respiratory status for other respiratory
lymph nodes in one or both sides of the neck without remov- problems that may accompany laryngeal cancer, such as
ing neck muscles. The jugular vein and spinal accessory COPD. Examine sputum for the presence of blood.

Nursing diagnoses for a client with laryngeal cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Airway Clear- The client’s respiratory rate Suction frequently following surgery to remove static secre-
ance related to tracheos- and color will be within de- tions and provide routine tracheostomy care.
tomy tube sired ranges, and the client Provide small, frequent feedings of liquid or pureed food to
will have clear breath sounds prevent choking.
to auscultation.
Assist client to turn, cough, and deep breathe two to four
times an hour.

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 CHAPTER 4 Respiratory System 113

Nursing diagnoses for a client with laryngeal cancer include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Teach client stoma protection.
Assess respirations two to four times an hour, if secretions
are copious. Auscultate lung sounds.
Keep head of bed elevated. Provide extra humidity.

Impaired Verbal Commu- The client will be able to Before surgery, establish a means of communication to be
nication related to removal communicate needs. used afterward. If available, a manual or computer word/pic-
of the larynx ture board works well.
Keep call light by client’s bed.
Avoid mouthing communications, as this is frustrating to the
client and is time consuming.
As possible, ask questions that require only a “yes” or “no”
answer.
Refer client to the local support group (Lost Chord Club) or
the American Cancer Society.
Provide written information and materials.

Deficient Knowledge The client will verbalize Teach client and family how to suction the respiratory tract,
related to tracheostomy precautions and safety mea- care for the tracheostomy, and use respiratory equipment.
care sures for a tracheostomy; Instruct client and family in what to do in case of an emergen-
how to use equipment; how cy, such as secretions clogging the tracheostomy tube.
to suction the respiratory
tract; how to change a tra- Advise client not to swim and to avoid aspirating water when
cheostomy tube; and actions showering or bathing.
to take in an emergency. Advise client to avoid extremely cold temperatures. Cover
tracheostomy site for warming or cosmetic purposes with a
porous material without frayed or loose threads.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

stop the bleeding. Signs of airway obstruction or aspira-

DISORDERS OF THE NOSE tion require immediate attention. The goals of treatment

T
are to maintain airway, stop bleeding, identify the cause,
he most common disorder of the nose is epistaxis, or
and prevent recurrence. Nosebleeds are usually responsive
nose bleed.
to compression of the nares. Maintain firm pressure for
5 minutes. If bleeding persists, the client should blow the
■ EPISTAXIS nose and clear the nasal passages. Resume pressure for a full

E
10 minutes. Epistaxis that continues following these mea-
pistaxis is hemorrhage of the nares or nostrils. It is either sures requires more aggressive treatment. Bleeding sites that
unilateral, which is most common, or bilateral. Epistaxis may
cannot be visualized require a sterile nasal packing inserted
be primary in nature, stemming from drying of the nasal mucosa,
after application of a local anesthetic. In severe cases, a
local irritation, or trauma, or may occur secondary to uncon-
nasostat is inserted. This device resembles a Foley catheter
trolled hypertension or coagulopathies (e.g., thrombocytopenia,
and provides direct compression to the site of bleeding via
anticoagulant therapy). The diffuse vascularity and proximity of
blood vessels to the surface of the nasal mucosa make the nares a
susceptible avenue for hemorrhage. Blood loss can be minimal to
severe. With significant blood loss, hypovolemic shock occurs. INFECTION CONTROL

Medical–Surgical Epistaxis

Management Wear gloves, goggles or a face mask, and a

gown when caring for a client with epistaxis. A
Medical cough or sneeze can splatter blood.
The client with epistaxis usually arrives at an urgent care
facility or emergency room after unsuccessful attempts to

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114 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

a balloon. Clients with severe nosebleeds may require fluid

and blood replacement to prevent hypovolemic shock. Per- NURSING PROCESS
sistent or recurrent epistaxis may require surgical ligation of
the artery supplying the area. Assessment
Subjective Data
Pharmacological Ask about the onset, precipitating events, duration, and fre-
quency of epistaxis, as well as associated symptoms such as
Sites of bleeding that can be visualized are cauterized by nausea, vomiting, headache, and lightheadedness. The client
the physician using silver nitrate sticks. Hemostasis also is with an occult bleeding in the back of the throat may complain
accomplished by packing the affected nostril with epinephrine of needing to swallow frequently.
1:1000 on cotton packing.
Objective Data
Nursing Management Evaluate blood flow for amount, consistency, color, and rate (or
severity). Overt bleeding from the nose may be present. This
Evaluate overt blood flow and visually examine the poste- bleeding can vary in flow, from a continuous drip to a pulsat-
rior oropharynx for hidden bleeding. Monitor vital signs. ing stream of blood. Visually examine the posterior orophar-
Have client sit up with head bent slightly forward, breathe ynx of the client with an occult epistaxis to assess blood flow.
through the mouth, and allow blood to run freely from Vomiting may be present. Lowered blood pressure and rapid
the nose into a container. Avoid tipping the head back as heart rate are signs of hypovolemic shock. Conversely, the cli-
blood will flow down the esophagus causing nausea and ent with uncontrolled hypertension has an abnormally high
vomiting. Then, wearing gloves, compress the nares for systolic blood pressure. Prothrombin time (PT), APTT, INR,
5 minutes. Suction through the mouth to prevent aspira- and other clotting studies will be abnormal with underlying
tion. Monitor for nausea and vomiting caused by swal- coagulopathies. Decreased red blood cell count, hemoglobin,
lowed blood. and hematocrit are evidence of significant bleeding.

Nursing diagnoses for a client with epistaxis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange relat- The client’s respiratory rate, color, Place client in a high Fowler’s position, with the head
ed to airway obstruction and blood gases will be within bent slightly forward.
normal limits. Instruct client to breathe through the mouth and al-
low the blood to escape freely from the nose and into
a container. This aids in preventing obstruction of the
airway and swallowing of blood.
Monitor client for signs and symptoms of airway
obstruction.
Assess client’s color, respiratory rate and effort, and
breath sounds.
Monitor pulse oximetry and lab reports of ABGs and
administer supplemental oxygen as indicated.

Risk for Aspiration related to The client will develop no compli- Place client in the position previously described
epistaxis cations related to aspiration. to aid in preventing aspiration of blood. Assess
client for signs of aspiration, such as choking, coarse
crackles (rales) on auscultation, or elevated
temperature.
Suction the respiratory tract through the mouth to
remove secretions and blood.

Deficient Fluid Volume The client will maintain With a gloved hand, compress the nares for 5 min-
related to blood loss adequate fluid volume. utes. If bleeding persists, have client blow nose to
clear passages, then compress nares for 10 minutes.
If bleeding continues following compression at-
tempts, prepare to assist the physician with proce-
dures such as cautery or insertion of nasal packing.

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 CHAPTER 4 Respiratory System 115

Nursing diagnoses for a client with epistaxis include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Administer medications to control blood pressure, as or-
dered.
After hemostasis has been established, the clots formed
should not be removed or dislodged, as this will lead to
recurrence of bleeding.
Every 30 minutes, evaluate the blood pressure and pulse of
the client who shows signs of volume depletion.
Assess for orthostatic hypotension as a means of measuring
volume depletion. A decrease in systolic blood pressure of
greater than 10 mm Hg when the position is changed from
lying to sitting or standing indicates hypovolemia.
Administer intravenous fluids, as ordered.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CASE STUDY
P.W. is a 77-year-old woman with a history of smoking two to three packs of cigarettes per day for the past
60 years. P.W. has been diagnosed with COPD for the past 4 years. She has required supplemental oxygen at 2 L/min
for the last 18 months. Three days ago, P.W. was admitted with chief complaints of increasing dyspnea on exertion
and a productive cough yielding thick, green-yellow sputum. She states that she does “not know why she is cough-
ing up this awful stuff.”
Physical examination of P.W. this morning revealed vital signs of T = 101.5°F, P = 124 beats/min, R = 38 breaths/min,
BP = 168/74 mm Hg, and sonorous and sibilant wheezes on expiration and in the posterior lung fields, with super-
imposed coarse crackles heard in the right posterior lower lung field. She is unable to ambulate to the bathroom
or complete other ADL because of the dyspnea. Chest x-ray showed a large area of consolidation in the right lower
lobe. Sputum culture is still pending.

The following questions will guide your development of a nursing care plan for the case study.
1. List the clinical manifestations that indicate P.W. is experiencing an infection concomitant with her COPD.
2. Explain why COPD predisposes a client to respiratory infection.
3. Explain why the physician will increase P.W.’s oxygen flow to 3 to 4 L/min.
4. List the subjective and objective data the nurse should obtain during the nursing assessment.
5. Identify three nursing diagnoses and client goals that would be pertinent to P.W.’s care.
6. List the above diagnoses in order of priority, with number one being the highest.
7. Describe client outcomes indicating that P.W.’s treatment and nursing care regimen have been successful.

SUMMARY

• The primary function of the respiratory system is delivery problems of immobility are at increased risk of developing
of oxygen to the lungs and removal of carbon dioxide from pneumonia.
the lungs. • Pulmonary TB is an infection of the lung tissue
• Pneumonia is a lung infection wherein infectious caused by the Mycobacterium tuberculosis. Treatment
secretions accumulate in the air passages and interfere with of TB requires the long-term administration of
gas exchange. Clients with chronic pulmonary disorders or pharmacological agents.

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116 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

• A common respiratory tract disorder associated with • Traumatic disorders of the respiratory tract include
immobility and the administration of anesthetic agents pneumothorax and hemothorax, wherein the
is atelectasis. Clients at risk are encouraged to cough and underlying lung tissue is compressed and eventually
breathe deeply to aid in preventing atelectasis. collapses.
• Obstruction of a pulmonary artery by a bloodborne • Cigarette smoking is indicated as a major causative factor
substance is known as pulmonary embolism. Deep vein in the development of respiratory disorders, such as lung
thrombosis is a common cause of pulmonary emboli. cancer, cancer of the larynx, emphysema, and chronic
• Chronic obstructive pulmonary disease is a collective term bronchitis.
used to refer to chronic bronchitis and emphysema, which
often occur together.

REVIEW QUESTIONS

1. The physician orders 2 to 3 L/min of oxygen to be 3. altered tissue perfusion.

delivered to the client with COPD because: 4. acute pain.
1. no client ever requires more than 2 to 3 L/min of 6. A client needs to be tested for tuberculosis when
oxygen. the nurse takes a medical history that includes
2. the client requests it. complaints of:
3. a higher flow rate may suppress the client’s drive 1. cough, night sweats, hemoptysis.
to breathe. 2. weight gain, diarrhea, vomiting.
4. 2 to 3 L/min is the maximum flow that a 3. fever > 102°F, fatigue, dry mouth.
nasal cannula can effectively deliver. 4. weight loss, stridor, chills.
2. A particulate respirator mask is used by the nurse 7. The health care provider has prescribed furosemide
caring for a client with TB because: (Lasix) for a client with a pleural effusion as part
1. regular masks allow the tubercle bacilli to pass of the treatment plan. Which of the following
through. statements made by the client regarding furosemide
2. this mask is more comfortable for long-term use. (Lasix) indicates that further teaching is needed by
3. this type of mask allows the nurse to be in close the nurse?
contact with the client for prolonged periods of 1. “I will probably need to urinate more frequently.”
time. 2. “This medication will help remove fluid from my
4. there is no need for this type of mask when caring pleural space.”
for clients with TB. 3. “The nurse will monitor my intake and output
3. The nurse is teaching a client about lung cancer. each shift.”
Which statement best demonstrates the client 4. “I should take this medication at bedtime.”
correctly understands the risk factors for lung cancer? 8. Parents of a newly diagnosed 14-year-old asthmatic
1. “I work with asbestos everyday and it is safe now.” client ask the nurse what medications will be
2. “Having asthma does not make me more at risk prescribed for their child. The nurse informs the
for getting lung cancer.” parents that common medications for asthma
3. “I should stop chewing tobacco and drinking include: (Select all that apply.)
alcohol.” 1. bronchodilators.
4. “My wife smokes and I do not, so I do not have to 2. antibiotics.
worry.” 3. corticosteroids.
4. A client with severe epistaxis arrives at an urgent 4. diuretics.
care clinic. When assessing this client, the nurse’s 5. mucolytic agents.
initial action should be to: 6. beta agonists.
1. identify the cause of the bleeding. 9. A client with a pneumothorax is brought to the
2. stop the bleeding. emergency department. Which of the following
3. assess for a patent airway. assessments will the nurse be able to make?
4. teach the client how to prevent recurrence. 1. Decreased respirations, low blood pressure,
5. The nurse’s assessment of a client with pulmonary constricted pupils.
edema indicates the following: thick frothy sputum, 2. Cyanosis, dyspnea, tracheal shift, and tachycardia
cough, and dyspnea. On the basis of these findings, 3. Clammy skin, dilated pupils, slow pulse, and low
the most appropriate nursing diagnosis is: blood pressure.
1. ineffective airway clearance. 4. Dyspnea, agitation, visual hallucinations, and
2. activity Intolerance. elevated blood pressure.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 4 Respiratory System 117

10. A client informs the nurse that she is not sure how to 3. “Would this be a good time for me to teach you
use her incentive spirometer. The most appropriate and demonstrate?”
response from the nurse would be: 4. “Did someone from the respiratory department
1. “The incentive spirometer measures the amount teach you?”
of air inspired in one inhalation.”
2. “The incentive spirometer is a device that a client
will use after surgery.”

REFERENCES/SUGGESTED READINGS
American Cancer Society (ACS). (2003). Cancer facts and figures 2003. Centers for Disease Control and Prevention (CDC). (2008). NIOSH
Atlanta, GA: Author. topic area: Severe acute respiratory syndrome (SARS). Retrieved
American Cancer Society (ACS). (2007). Overview: laryngeal and July 17, 2009 from http://www.cdc.gov/niosh/topics/SARS/
hypopharyngeal cancer. How many people get laryngeal and Centers for Disease Control and Prevention(CDC). (2009). Influenza:
hypopharyngeal cancers? Retrieved April 1, 2009 from http://www The disease. Retrieved July 20, 2009 from http://www.cdc.gov/flu/
.cancer.org/docroot/CRI/content/CRI_2_2_1X_How_many_ about/disease/index.htm
people_get_these_cancers_23.asp?sitearea= Chan, S., & Goldrick, B. (2003). Emerging infections. AJN, 103(6), 60–62.
American Cancer Society (ACS). (2009). Lung cancer. Retrieved April Daniels, R., Nosek, L., & Nicoll, L. (2007). Contemporary medical-
11, 2009 from http://www.cancer.org/docroot/PRO/content/ surgical nursing. Clifton Park, NY: Delmar Cengage Learning.
PRO_1_1x_Lung_Cancer.pdf.asp?sitearea=PRO Davies, P. (2002). Guarding your patient against ARDS. Nursing2002,
American Lung Association (ALA). (2007a). Chronic obstructive 32(3), 36–41.
pulmonary disease fact sheet. Retrieved April 11, 2009 from http:// Diehl-Oplinger, L., & Kaminski, M. F. (2002). Flash pulmonary edema.
www.lungusa.org/site/apps/nlnet/content3.aspx?c=dvLUK9O Nursing2002, 32(7), 96.
0E&b=2058829&content_id={EE451F66-996B-4C23-874D- Dirkes, S., & Winklerprins, A. (2002). Help for ARDS patients. RN,
BF66586196FF}&notoc=1 65(8), 52–58.
American Lung Association (ALA). (2007b). HIV and tuberculosis fact Dunn, N. (2001). Keeping COPD patients out of the ED. RN, 64(2),
sheet. Retrieved April 10, 2009 from http://www.lungusa.org/site/ 33–37.
apps/nlnet/content3.aspx?c=dvLUK9O0E&b=2060731&conten Eckler, J. (2002). Keeping pulmonary tuberculosis at bay. Nursing2002,
t_id={A3132347-3F7C-4ED7-AB4C-34FBEE5B0D4C}&notoc=1 32(12), 70.
American Lung Association (ALA). (2007c). Lung cancer fact sheet. Ellmers, K., & Criddle, L. (2002). Cystic fibrosis. RN, 65(9), 60–66.
Retrieved April 11, 2009 from http://www.lungusa.org/site/apps/ Estes, M. E. Z. (2010). Health assessment & physical examination (4th
nlnet/content3.aspx?c=dvLUK9O0E&b=4294229&ct=3232839 ed.). Clifton Park, NY: Delmar Cengage Learning.
American Lung Association (ALA). (2008a). Trends in tuberculosis Finesilver, C. (2001). Perfecting your skills: Respiratory assessment.
morbidity and mortality. Retrieved April 10, 2009 from http://www Travel Nurse Today supplement to RN (April) 16–26.
.lungusa.org/atf/cf/{7a8d42c2-fcca-4604-8ade-7f5d5e762256}/ Georgetown University Hospital. (2009). Neck dissection patient
TB_TRENDS_AUG_2008.PDF information. Retrieved July 17, 2009 from http://www
American Lung Association (ALA). (2008b). Tuberculosis fact sheet. .georgetownuniversityhospital.org/body.cfm?id=1016#3
Retrieved April 10, 2009 from http://www.lungusa.org/site/apps/ Goodfellow, L., & Jones, M. (2002). Bronchial hygiene therapy. AJN,
nlnet/content3.aspx?c=dvLUK9O0E&b=4294229&ct=3052619 102(1), 37–43.
American Lung Association (ALA). (2009). Influenza and pneumonia. Hayes, D. (2001). Stemming the tide of pleural effusions. Nursing2001,
Retrieved April 10, 2009 from http://www.lungusa.org/site/ 31(5), 49–52.
pp.asp?c=dvLUK9O0E&b=4074717 Lazzara, D. (2001). Respiratory distress. Nursing2001, 31(6), 58–63.
Andrews, C., & Kearney, K. (2002). Preventing air embolism. AJN, Lazzara, D. (2002). Eliminate the air of mystery from chest tubes.
102(1), 34–36. Nursing2002, 32(6), 36–43.
ARDS Support Center. (2009a). Frequently asked questions about Lindell, K., & Jacobs, S. (2003). Idiopathic pulmonary fibrosis. AJN,
ARDS. Retrieved April 11, 2009 from http://www.ards.org/ 103(4), 32–41.
learnaboutards/whatisards/faq/ Little, C. (2002). Chronic bronchitis. Nursing2001, 32(9), 52–55.
ARDS Support Center. (2009b). Learn about ARDS. Retrieved April Marion, B. (2001). A turn for the better: “Prone positioning” of
11, 2009 from http://ards.org/learnaboutards/ patients with ARDS. AJN, 101(5), 26–33.
Avalos-Bock, S. (2001). The hard truth about the PPD skin test. Marthaler, M., Keresztes, P., & Tazbir, J. (2003). SARS: What have we
Nursing2001, 31(6), 56–57. learned? RN, 66(8), 58–66.
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. Mayo Clinic. (2009). Cystic fibrosis. Retrieved July 20, 2009 from
(2008). Nursing Interventions Classification (NIC) (5th ed.). http://www.mayoclinic.com/health/cystic-fibrosis/DS00287
St. Louis, MO: Mosby/Elsevier. McConnell, E. (2002). Providing tracheostomy care. Nursing2002,
Carroll, P. (2001). How to intervene before asthma turns deadly. RN, 32(1), 17.
64(5), 52–58. Miracle, V. (2002). Asthma attack. Nursing2002, 32(11), 104.
Centers for Disease Control and Prevention (CDC). (2005a). Basic Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
information about SARS. Retrieved April 11, 2009 from http:// Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby.
www.cdc.gov/ncidod/sars/factsheet.htm National Cancer Institute. (2009). Metastatic squamous neck cancer
Centers for Disease Control and Prevention (CDC). (2005b). Current with occult primary treatment (PDQ). Retrieved July 17, 2009 from
SARS situation. Retrieved April 11, 2009 from http://www.cdc http://www.cancer.gov/cancertopics/pdq/treatment/metastatic-
.gov/ncidod/sars/situation.htm squamous-neck/Patient/page4
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
118 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

National Heart Lung and Blood Institute (NHLBI). (2009a). Phipps, W., Monahan, P., Sands, J., Marek, J., & Neighbors, M. (2003).
COPD: what causes COPD? Retrieved April 11, 2009 from Medical–surgical nursing: Health and illness perspectives (7th ed.). St.
http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd Louis, MO: Mosby.
_Causes.html Pope, B. (2002). Asthma. Nursing2002, 32(5), 44–45.
National Heart Lung and Blood Institute (NHLBI). (2009b). How is Pullen, R. (2003). Teaching bedside incentive spirometry. Nursing2003,
pulmonary embolism treated? Retrieved April 11, 2009 from http:// 33(8), 24.
www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_treatments.html Schultz, T. (2002). Community-acquired pneumonia. Nursing2002,
National Heart Lung and Blood Institute (NHLBI). (2009c). Who is 32(1), 46–49.
at risk for pulmonary embolism? Retrieved April 11, 2009 from Shortall, S., & Perkins, L. (1999). Interpreting the ins and outs of
http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_risk.html pulmonary function tests. Nursing99, 29(12), 41–47.
National Institute of Allergy and Infectious Diseases. (2009). Spratto, G., & Woods, A. (2010). 2010 Delmar nurse’s drug handbook.
Flu (influenza). Retrieved July 20, 2009 from http://www3.niaid Clifton Park, NY: Delmar Cengage Learning.
.nih.gov/topics/Flu/understandingFlu/DefinitionsOverview.htm Tasota, F., & Davies, P. (2001). Diagnosing pulmonary embolism with
National Institutes of Health(NIH). (2009a). Fact sheet: Cystic spiral CT. Nursing2001, 31(5), 75.
fibrosis. Retrieved July 20, 2009 from http://www.nih.gov/about/ Togger, D., & Brenner, P. (2001). Metered dose inhalers. AJN, 101(10),
researchresultsforthepublic/CysticFibrosis.pdf 26–32.
National Institutes of Health (NIH). (2009b). Pleural disorders. Wisniewski, A. (2003). Chronic bronchitis and emphysema: Clearing
Retrieved April 11, 2009 from http://www.nlm.nih.gov/ the air. Nursing2003, 33(5), 46–49.
medlineplus/pleuraldisorders.html Woods, A. (2002). Pneumonia. Nursing2002, 32(11), 56–57.
National Institutes of Health (NIH). (2009c). Severe acute respiratory World Health Organization (WHO). (2009). Severe acute respiratory
syndrome. Retrieved April 11, 2009 from http://www.nlm.nih.gov/ Syndrome. Retrieved April 11, 2009 from www.who.int/csr/sars/
medlineplus/severeacuterespiratorysyndrome.html travel/en/index.html
Perkins, L., & Shortall, S. (2000). Ventilation without intubation. RN, Zorb, S. (2002). Transplantation offers hope. RN, 65(9), 66–68.
63(1), 34–38.

RESOURCES

American Cancer Society (ACS), Centers for Disease Control and Prevention (CDC),
http://www.cancer.org http://www.cdc.gov
American Lung Association, Cystic Fibrosis Foundation,
http://www.lungusa.org http://www.cff.org
American Thoracic Society, International Association of Laryngectomees,
http://www.thoracic.org http://www.theial.com/ial/

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 5
Cardiovascular System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the cardiovascular system:
Adult Health Nursing Delmar’s Heart & Lung Sounds on
• Respiratory System StudyWareTM: Heart Sounds
• Hematologic and Lymphatic Systems
• Endocrine System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe the anatomy and physiology of the cardiovascular system.
• Relate laboratory results to each disorder.
• Describe basic heart dysrhythmias.
• Explain the pathophysiology of each disorder.
• Describe nursing interventions in caring for clients with cardiovascular
conditions.

KEY TERMS
aneurysm cardiac output (CO) hypertrophy
angina pectoris cardiac tamponade implantable cardioverter-
annulus depolarization defibrillator (ICD)
arteriosclerosis dyspnea myocardial infarction
ascites dysrhythmia myocarditis
atherosclerosis embolus necrosis
baseline level heart sound orthopnea
bradycardia hemolysis palpitation
cardiac cycle Homans’ sign

119

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120 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

paroxysmal nocturnal sclerotherapy transesophageal echocardiography

dyspnea secondary hypertension (TEE)
pericardial friction rub stasis dermatitis varicosities
pericardiocentesis stent vasoconstrict
pericarditis stroke volume (SV) vasodilate
peripheral resistance tachycardia vein ligation
phlebitis thrombectomy vein stripping
phlebothrombosis thrombophlebitis Virchow’s triad
primary hypertension thrombosis
repolarization thrombus

endothelium cells that line the inside of the heart, the four
INTRODUCTION heart valves, and is continuous with the endothelial lining
Since 1900, heart disease has been the leading cause of death of the arteries, capillaries, and veins making the circulatory
in the United States every year except in 1918 during the flu system a closed system. Therefore, if a person has a systemic
epidemic (AHA, 2007a). In 2003, 911,163 deaths were attrib- blood infection the heart lining and valves are also affected.
uted to cardiovascular disease (CVD) compared to 869,724 The myocardium consists of striated muscle and varies in
deaths in 2007 (AHA, 2007a). The death rate for cardiovascu- thickness depending on the heart chamber. The left ven-
lar disease is declining because of public education in modifying tricle pumps blood to the body and is, therefore, the thickest
and decreasing risk factors such as smoking, high-fat diets, and chamber. The outside of the heart is surrounded by the epi-
minimal exercise. cardium. The pericardium consists of two layers: the parietal
This chapter reviews the anatomy and physiology of the pericardium and visceral pericardium. The parietal layer
cardiovascular system. Pathophysiology, medical manage- (outer layer) is a fibrous loose sac that surrounds the heart
ment, and nursing interventions related to cardiovascular and the visceral layer lines the great vessels and is also called
conditions are discussed with an emphasis on decreasing risk the epicardium when it lines the heart. The pericardial space
factors and improving lifestyles. is between the two pericardium layers and is filled with fluid
(see Figure 5-1).
The heart is a hollow muscular organ containing four
ANATOMY AND PHYSIOLOGY chambers that fill and empty of blood with each contraction
(depolarization) and recovery phase (repolarization) of
REVIEW the cardiac muscle. The upper chambers are the atria and the
lower chambers are the ventricles (Figure 5-1). When the
The cardiovascular system consists of the heart and its vascu- atria contract, blood is forced into the ventricles. Contrac-
lature and the peripheral vascular system. The heart is located tion of the right ventricle pumps blood into the pulmonary
in the lower anterior area of the mediastinum with the apex arteries and on to the lungs (pulmonary circulatory system).
near the diaphragm. The heart apex tips forward and to the left Contraction of the left ventricle pumps blood into the aorta
of the client’s chest cavity. In an average lifetime, the heart will and out to the entire body (systemic circulatory system).
pump 80 million gallons of blood. The myocardium of the left ventricle is thicker than the
The peripheral vascular system consists of arteries, arteri- right ventricle because more force is needed to pump blood
oles, capillaries, venules, and veins. The arteries carry oxygen- throughout the body.
ated blood away from the left side of the heart to the body There are four valves in the heart: tricuspid, bicuspid
tissues, and the veins carry deoxygenated blood back to the (mitral), pulmonic, and aortic. One end of fibrous cords
right side of the heart. The capillaries connect the arterioles to called chordae tendineae is attached to the cusps of the tricus-
the venules. The venules and veins contain 60% to 70% of the pid and mitral valves, and the other end is attached to papil-
body’s total blood volume. lary muscles on the ventricular walls. The chordae tendineae
The cardiovascular system provides oxygen, nutrients, keep the valves from inverting when the ventricles contract,
and hormones to the cells and removes carbon dioxide and thus preventing blood from flowing back into the atrium.
waste products of cellular metabolism from body cells. Body The pulmonic and aortic valves prevent blood from flowing
temperature is maintained by the distribution of heat through- back into the ventricles from the pulmonary artery and aorta
out the body produced by the metabolic activity of muscles during repolarization.
and other body organs.
Circulation of Blood
Structure of the Heart Blood enters the heart through veins and leaves the heart
The heart is encapsulated by a protective sac called the through arteries. With the contraction of the right ventricle,
pericardium and consists of three layers: endocardium, blood is forced through the pulmonic valve into the pulmonary
myocardium, and epicardium. The endocardium is made of artery. Blood circulates through the pulmonary circulatory

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 CHAPTER 5 Cardiovascular System 121

Superior vena Coronary Arteries

cava Aorta Coronary arteries supply nutrients and oxygen to the muscle
Right tissue of the heart. The two coronary arteries, which branch
Left pulmonary off the aorta, are the right coronary artery and the left coro-
pulmonary artery
artery nary artery (Figure 5-2). The right coronary artery divides
Left
pulmonary
into the posterior descending artery (interventricular artery)
Right
pulmonary veins and the marginal artery and supplies blood to the anterior
veins Left atrium area of the right and left ventricles, the posterior area of the
Pulmonic Aortic right ventricle, the AV node, and the posterior section of the
(semilunar) (semilunar) interventricular septum. The left coronary artery divides
valve valve into the anterior descending artery and the circumflex artery.
Endocardium The left anterior descending (LAD) artery supplies blood to
Right atrium Pericardium
Parietal the anterior section of the interventricular septum, anterior
Tricuspid valve pericardium area of the left ventricle, and the lateral aspect of the left
Bicuspid (mitral) ventricle. The circumflex artery nourishes the left atrium and
Right ventricle valve ventricle.
Myocardium

Conduction System
Epicardium
Inferior vena Left ventricle
Endocardium Septum
cava The specialized cardiac muscle cells are capable of conducting
Pericardial
Space
electrical impulses from one part of the heart to another. For
Epicardium
the heart to beat regularly in a rhythmic sequence, electrical
Pericardial
impulses follow a set pattern through the conduction system
Unoxygenated blood space COURTESY OF DELMAR CENGAGE LEARNING of the heart. The conduction system, consisting of the sinoatrial
Parietal node (SA node), atrioventricular node (AV node), bundle of
Oxygenated blood pericardium His, bundle branches, and Purkinje fibers, controls the heartbeat
Pericardium (Figure 5-3).
Endocardium The SA node located in the superior aspect of the
Myocardium right atrium initiates electrical impulses that cause the heart
to beat. It is called the pacemaker of the heart. Electrical
impulses from the SA node pass through the muscle fibers
of the right and left atria, causing the atria to contract almost
Figure 5-1 Internal View of the Heart with Aorta, Vena simultaneously. Atrial impulses are transmitted to the AV
Cava, and Pulmonary Arteries and Veins node located in the lower part of the right atrium. There is a
short delay in the impulse at the AV node that allows the atria

system, where carbon dioxide is exchanged for oxygen in the

lungs. The blood then returns to the left atrium through the
pulmonary veins, providing oxygenated blood for systemic
circulation. When the left ventricle contracts, blood is forced
through the aortic valve into the aorta, beginning systemic
circulation. Blood is then distributed throughout the body and
returns to the right atrium of the heart through the inferior
Left
and superior vena cava. coronary
artery
Stroke Volume and Right
Cardiac Output coronary
artery Circumflex
Heart rate (HR) is the number of ventricular contractions artery
per minute as determined by auscultation of the heart or
palpation of a pulse. Each time the heart beats, the ventricle
pumps 60 to 80 mL of blood. The volume of blood ejected
COURTESY OF DELMAR CENGAGE LEARNING

from the left ventricle with each contraction or systole is Posterior Anterior
known as the stroke volume (SV). Normal stroke volume descending descending
is approximately 70 mL. The amount of blood ejected in 1 artery or artery
minute is known as the cardiac output (CO). Therefore, interventricular
CO is determined by multiplying HR for 1 minute by the artery
stroke volume (CO = HR × SV) (Bender, 2008). If the heart
has a strong ventricular contraction, more blood is pumped Marginal artery
by the heart into the systemic circulatory system. Therefore,
CO has a direct effect on the circulating volume of arterial Figure 5-2 Coronary Arteries that Supply Blood to the
blood. Heart Tissue

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122 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

reading of at least 80 mm Hg is needed to palpate a radial pulse

(Bender, 2008).

Heart Sounds
There are two normal heart sounds heard on auscultation;
S1 and S2. They yield a sound like “lubb-dubb.” S1, or the
“lubb,” is the sound of the mitral and tricuspid valves closing
Sinoatrial simultaneously. The S1 sound is heard on the left fifth inter-
(SA) node costal space. S2, or the “dubb,” is the simultaneous closing of

COURTESY OF DELMAR CENGAGE LEARNING

Atrioventricular
(AV) node Bundle of His the pulmonic and aortic valves, heard on the right second
(AV) Bundle Right and intercostal space. There is a slight pause after the “lubb-
left bundle dubb” is heard. Clients with congestive heart failure (CHF)
branches may have a third sound known as S3. The low-pitched sound
Purkinje fibers occurs after the S2 sound, or the “dubb,” making the heart
sound like the word “Kentucky” (“lubb-dubb-by”). The S3
sound also is described as a gallop because of the similarity in
sound to a horse’s gallop.
Figure 5-3 Conduction System of the Heart

Arterioles and Arteries

to complete their contraction and empty the blood into the The arteries are thick-walled tubes consisting of three layers or
ventricles. The electrical impulse is transmitted from the AV tunics (Figure 5-4). The inner layer is called the tunica intima
node into a group of specialized conduction fibers called the and consists of a single layer of smooth endothelial cells. The
AV bundle or the bundle of His. Once the impulse leaves the middle layer is the tunica media and is composed of smooth
AV node, it travels down the fibers of the bundle of His into muscle cells. The smooth muscle layer of the artery receives
the interventricular septum. The fibers separate into right nerve stimulation from the sympathetic nervous system. The
and left bundle branches dividing into smaller and smaller suppleness of the smooth muscle allows the vessel to vaso-
branches, called Purkinje fibers. These terminate in the ven- constrict (decrease in diameter) and vasodilate (increase
tricular muscle, causing the ventricles to contract. When an in diameter). The outer layer, the tunica adventitia or tunica
impulse has completely gone through the conduction system externa, consists of a connective tissue sheath with some of its
of the heart and the ventricles have contracted, a cardiac collagen fibers fusing with those of the surrounding tissue to
cycle is completed. hold the vessels in place. The elastic connective tissue allows
The end-diastolic volume (EDV) is the amount of blood the artery to expand and recoil with each contraction of the
in the ventricles after the ventricular rest and filling phase ventricle as an increased volume of blood is pumped through
of the cardiac cycle. In the healthy heart, the EDV is usually the vessel. The arteries have thick walls, so they can withstand
around 120 mL. The end-systolic volume (ESV) is the amount the increased pressure from the left ventricle pumping blood
of blood in the ventricles after the ventricular contraction and through the body.
ejection phase of the cardiac cycle. In the healthy heart, the The arteries divide and branch into smaller vessels called
ESV is usually around 50 mL. arterioles. The same three layers are present in the walls, but
Ejection fraction (EF) is an indicator of ventricle func- as the arterioles approach the capillaries their walls become
tioning and is reduced in patients with myocardial infarc- thinner. The outer layer is reduced to a very thin layer of
tion and diagnostic for heart failure (HF). To determine connective tissue.
the EF, stroke volume is divided by end-diastolic volume
(EF = SV/EDV). In healthy hearts, the EF is between
50% and 70% of the EDV. The EF is determined through Endothelial
echocardiography. cells
Valve
Four factors influence stroke volume and CO: preload,
afterload, contractility, and HR. Preload refers to the amount Tunica
of pressure within the ventricles. This is determined by the intima
amount of stretch or tension derived from the ventricular
filling and the pressure exerted by fluid volume on the myo-
cardium at the end of diastole (ventricular end-diastolic pres- Tunica
sure), or just before contraction. Afterload is the force that media
resists ejection of blood from the ventricles, or the force that
COURTESY OF DELMAR CENGAGE LEARNING

is needed to open the semilunar valve and eject blood during

systole. This resistance arises from the pulmonary circulation
Tunica
for the right ventricle, and from the systemic circulation for
adventitia
the left ventricle. Contractility refers to the strength of car-
diac contraction. Systolic pressure is the force exerted against
arterial walls during ventricular contraction. Diastolic pressure
is the force exerted against arterial walls during ventricular Artery Vein Capillary
relaxation. Blood pressure is expressed as systolic pressure/
diastolic pressure (e.g., 120/80). A systolic blood pressure Figure 5-4 Tunic Layers of Each Type of Vessel

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 CHAPTER 5 Cardiovascular System 123

To heart To heart To heart Advancing age, male gender, diabetes, heredity, and family
history of chest pain or myocardial infarctions are risk factors
Blood that cannot be altered. Alterable risk factors are physical inac-
flow tivity, smoking, contraceptive method, dyslipidemia, overweight,
obesity, and triglyceride level. A change in diet may alter the

COURTESY OF DELMAR CENGAGE LEARNING

Contracted
skeletal last four factors.
muscles Back
flow
There are two objectives in assisting the client toward
a healthier lifestyle: (1) to educate the client about the risk
Relaxed
skeletal
factors; and (2) to determine what risk factors the client
muscles would like to modify. Once this is determined, assist the
client to establish goals and determine actions to achieve
A B C
the goals.
Figure 5-5 Valves in the veins hold the blood at a certain
level in the vein. A, Contracted skeletal muscles apply pressure to
veins and assist with the circulation of blood. B, Valves prevent ASSESSMENT
the backflow of blood. C, Incompetent valves allow a backflow Assessment includes clients’ self-report of symptoms as well as
of blood. physical findings and confirming lab data.

Capillaries Subjective Data

The typical concerns expressed by a client with a cardiac dis-
Capillaries are very tiny thin vessels that connect the smallest order are chest pain, dyspnea (difficulty breathing), edema,
arterioles with the smallest venules. They have only one layer fainting, palpitations, diaphoresis, and fatigue. When a client
of endothelial cells whose cell membranes are the semiperme- talks about having chest pain, ascertain the time of onset, situ-
able membrane that allows the exchange of oxygen, nutrients, ation occurring at the onset of pain, location and radiation of
carbon dioxide, and waste products between the tissues of the pain, severity of chest pain, duration, past episodes of chest
body and the blood. pain, and methods used to alleviate pain. Using the Memory
Trick: Pain Assessment PQRST is an ideal way for a nurse to
Venules and Veins assess a client’s pain. This method is described in the Memory
Trick: Pain Assessment PQRST. Women are more likely to
Venules are small vessels that emerge from the capillaries and experience shortness of breath, fatigue, back or jaw pain, and
gradually increase in size to eventually form veins. Veins have atypical discomfort such as a feeling of indigestion or nausea
three layers or tunics like the arteries, but the middle layer of a and vomiting (Nagle & Nee, 2002; AHA, 2007b).
vein is thinner with less smooth muscle and elastic tissue. The The client may be experiencing several types of dyspnea.
elasticity of the smooth muscles allow the walls of the veins Exertional dyspnea occurs when a person participates in
to dilate more easily. Endothelial flaps, called valves, are on moderate activity and becomes short of breath. This occurs
the inside lining of veins. The valves open and close with each in the early stages of HF and indicates that the heart is not
contraction of the surrounding skeletal muscles. The valves able to meet the demands of the body during moderate activ-
assist the blood in returning to the heart. Blood is held by ity. Orthopnea is when a client has difficulty breathing
the valves until skeletal muscle contractions move the blood while lying down and must sit upright or stand to relieve the
toward the heart against gravity (Figure 5-5).

HEALTH HISTORY
There are three goals when obtaining a health history from
MEMORYTRICK
a client: (1) identify present and potential health problems, Pain Assessment PQRST
(2) identify possible familial and lifestyle risk factors, and
(3) involve the client in planning long-term health care. P = Provoker of pain (aggravating factors) and
Ascertain the onset of the symptoms, the predisposing palliative measures (alleviating factors)
factors that cause the symptoms, and the client’s treatment Q = Quality of pain (gnawing, pounding, burning,
of the symptoms. Ask about the client’s activity level or stabbing, pinching, aching, throbbing, and
limitations in activity. Determine if appetite has increased or crushing)
decreased. Evaluate the client’s ability to sleep, the need for the
trunk of the body to be supported with pillows when sleeping, R = Region (location) and radiation to other body
or the need to sleep in a chair. sites
Major risk factors associated with cardiovascular diseases S = Severity (quantity of pain on 0–10 scale, 0 =
are age, gender, heredity (including race), smoking, dyslipidemia no pain and 10 = worst pain experienced) and
(presence of increased total serum cholesterol and low-density
setting (what causes the pain)
lipoprotein [LDL]), high blood pressure, physical inactivity,
overweight, obesity, and diabetes mellitus. An individual’s T = Timing (onset, duration, and frequency)
response to stress may be a contributing factor. Additional
contributing factors for women include menopause, use of (Adapted from Estes, 2010)
birth control pills, and high triglyceride level.

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124 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

dyspnea. This occurs in a more advanced stage of HF. Parox- and pale when elevated. As the ischemia progresses, the leg
ysmal nocturnal dyspnea usually occurs 2 to 5 hours after and/or foot skin becomes mottled, smooth, and shiny. If the
an individual falls asleep. The person suddenly awakens, is veins are occluded, the foot and/or leg become cyanotic when
sweating, and has difficulty breathing. in a dependent position, and has a normal coloration when
A client has fainting spells for various physical and psy- elevated. The anterior area of the lower leg and ankle has a
chological reasons. Cardiac clients faint because of decreased brown pigmentation with venous involvement.
CO causing decreased blood flow to the brain. Clients with decreased circulation to the extremities have
A client may describe a “fluttering” or “pounding” sen- hardened and brittle nails and less hair distribution. The leg
sation in the chest. This is known as palpitations. If these will be cool if there is an arterial circulatory problem but warm
sensations occur during exercise, it is a sign that the heart has if there is a venous circulatory problem. Skin ulcerations may
to work harder to meet the demands of the body. Palpitations be found around the ankles and toes.
may also be caused by anxiety, ingestion of a large meal, lack Check the client’s ankles for stasis dermatitis, an inflam-
of adequate rest, or a large intake of caffeine. mation of the skin caused by decreased circulation. Waste
A cardiac client will usually experience fatigue increasing products that normally are carried away by the circulatory
throughout the day because the heart is not able to keep up system remain in the tissues, causing pruritus and irritation of
with the demands of the body. Frequent rest periods will help the skin. At first, the ankle area is reddened and edematous,
alleviate some of the fatigue. then vesicles form and start oozing. The skin becomes crusted,
The typical concerns expressed by the client with a periph- thickened, and brown.
eral vascular disorder are pain, paresthesia (decreased sensation A positive Homans’ sign is present in some cases of
in an area), and/or paralysis in the hands, thigh, calf, ankles, foot, deep vein thrombosis (DVT). To test for Homans’ sign, dor-
abdomen, or lower back. The quality of pain (aching, cramping, siflex the client’s foot. If there is pain in the calf of the leg or
sharp, or throbbing) and any numbness or tingling is noted. behind the knee, the Homans’ sign is positive and may indi-
cate the presence of a venous clot. Do not do a Homans’ sign
Objective Data if there is a diagnosis of a thrombus, because the clot may be
dislodged with the procedure.
In a head-to-toe assessment on a cardiac client, the skin, neck Refer to Box 5-1, “Questions to Ask and Observations to
veins, respirations, heart sounds, abdomen, and extremities are Make When Collecting Data” for guidance in completing cli-
carefully assessed. Observe the skin for cyanosis in the earlobes, ent cardiac assessments.
lips, mucous membranes, and finger-and toenails. Assessment
of skin turgor may indicate fluid volume. If the skin is dry and
has poor turgor, the client may be dehydrated from diuretics. If
a client has distended internal and external jugular veins when
the head of the bed is gradually elevated to a 45-degree angle or
higher, there may be right-sided HF. Assess the quality of respira-
tions for rate and ease of breathing, signs of dyspnea, and cough-
ing. Heart sounds are assessed for the normal S1 and S2 sounds. If
the typical lubb-dubb is heard, the valves are closing properly.
While listening to the heart, the radial pulse should be
palpated to account for every heartbeat. If a heartbeat is heard
through the stethoscope but not felt in the radial pulse, the
heart has decreased CO to the extremities. If the abdomen
is distended, the client may have ascites, which is excess
fluid in the abdomen. After assessing the heart and lung
sounds, check the peripheral pulses. Pulses on both sides of 1+ = disappears rapidly 2+ = lasts 10 to 15 seconds
the body should be checked at the same time to determine
adequate bilateral perfusion. It is important to check pedal
pulses in both feet to determine blood flow to each foot. Pulse
amplitude can be described as absent, diminished, normal,
increased, and bounding (Gehring, 2002).
If the hands and feet are cold or have mottling, this indicates
decreased CO. Capillary refill should be less than 3 seconds in
the fingers and toes.
Note if the feet, ankles, or legs are edematous (Figure
5-6). A client may gain 10 pounds before edema is detected.
COURTESY OF DELMAR CENGAGE LEARNING

Weigh cardiac clients with edema daily. The weight must be

taken on the same scale, at the same time of day, with the client
wearing the same amount of clothing.
Decreased circulation to an area results in coolness in the
ischemic area, pallor, paresthesia, and paralysis. Paresthesia
and paralysis result from a lack of oxygenated blood and 3+ = lasts more than 4+ = lasts 2 to 5 minutes
nourishment to the nerves. Symptoms of paresthesia are 1 minute
numbness and tingling.
If an artery in the leg is occluded, the foot and/or leg Figure 5-6 Edema Rating Scale: Press down for
become reddish in color when the leg is in a dependent position, 5 seconds, then time how long indentation remains.

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 CHAPTER 5 Cardiovascular System 125

BOX 5-1 QUESTIONS TO ASK AND COMMON DIAGNOSTIC TESTS

OBSERVATIONS TO MAKE WHEN Commonly used diagnostic tests for clients with symp-
COLLECTING DATA toms of cardiovascular system disorders are listed in Table
5-1. Cardiac biomarkers that diagnose, evaluate, and moni-
SUBJECTIVE DATA
tor clients with possible acute coronary syndrome (ACS)
Have you experienced chest pain? Radiating pain? are troponin I, troponin T, CK, CK-MB, and myoglobin.
Nausea? Indigestion? Fatigue? AST and LDH are not specific for heart damage and are
What activities cause chest pain? not recommended for clients suspected with ACS (Ameri-
can Association for Clinical Chemistry, 2008). Troponins
Have you felt palpitations or your heart flutter?
are replacing CK and CK-MB in some settings because
Do you ever feel dizzy or lightheaded? they are more specific for heart injury (versus skeletal
Tell me about your memory. muscle injury) and are elevated for a longer period of time.
On how many pillows do you sleep? Troponins elevate within 3–4 hours after injury and may
remain elevated for 10−14 days (see Table 5-2 for eleva-
Do you awaken short of breath? tion times of biomarkers). The greater the tissue damage
List prescription and over the counter medications the greater the elevation. Muscular injection, strenuous
you are taking. exercise and drugs that affect muscles do not elevate tro-
Do you use any herbal supplements? ponin levels as they do with CK (Bender, 2008). Other
general tests ordered with cardiac biomarkers are ABGs,
Describe your daily exercise habits.
comprehensive metabolic panel, basic metabolic panel,
Are you on any specific type of diet? electrolytes, and CBC.
Do you weigh yourself at regular intervals? Have A newer cardiac biomarker test used with troponin and an
you noticed a weight gain of 5 pounds or more ECG to identify clients at a greater risk of an MI is ischemia
from one day to the next? modified albumin (IMA). If IMA is not present in a client who
has experienced chest pain for a few minutes to a few hours, it
How often do you urinate during the daytime? is not likely that the client has ischemia. IMA is not as valuable
During the night? with a client who has experienced chest pain for several hours
Are you sexually active? Have there been any because the IMA level may have risen and returned to normal
changes in the last year? within that time frame.
Do you experience swelling in your feet or ankles?
Can you climb a flight of stairs without becoming
short of breath? CARDIAC RHYTHM/
Can you walk a block without feeling cramps in your legs? DYSRHYTHMIA

A
How do you cope with stress?
s a basis for understanding cardiac dysrhythmias, the
How do you relax? normal sinus rhythm must first be understood.
OBJECTIVE DATA
Take vital signs; temperature, pulse, respirations,
and pulse oximetry. ■ NORMAL SINUS RHYTHM

T
Check pupils.
Check capillary refill. he electrical conduction of the heart begins with the
SA (refer to Figure 5-7) node located in the superior
Check the skin, lips, fingers, and feet for cyanosis. section of the right atrium. From the SA node, the elec-
Listen to the apical pulse and palpate the radial trical impulse spreads in wave fashion through the atria
pulse at the same time. similar to the ripples from a pebble dropped in water. The
Listen to breath sounds on anterior and posterior firing of the SA node and the electrical impulse spreading
aspects of chest
across both atria yields a P wave on the ECG. The P wave
represents the electrical activity causing the contraction of
Listen to bowel sounds. both atria.
Palpate abdomen for edema or tautness. After the atria contract, the electrical impulse reaches
Examine legs, ankles, and feet for swelling. the AV node, where it pauses for approximately one-tenth of
a second, allowing blood to enter both ventricles. The elec-
Examine legs for hair distribution.
trical impulse then starts down the AV bundle that divides
Check for areas for decreased sensation. into right and left bundle branches in the interventricular
Check peripheral pulses noting the quality, rhythm, septum. The electrical impulse continues from the right and
and amplitude. the left bundle branches to the Purkinje fibers that transmit
the electrical impulse to the myocardial cells resulting in
Check extremities for areas of brownish discolor-
depolarization or contraction of the ventricles. On an ECG
ation, ulcerations, and bruising. the QRS complex represents the electrical impulse as it
Complete a Homans’ sign. travels through the AV node, AV bundle, bundle branches,
Purkinje fibers, and myocardial cells, ending with the

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126 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Table 5-1 Common Diagnostic Tests for Cardiovascular System Disorders

Laboratory Tests Serum lipids (lipid profile)

Arterial blood gasses (ABGs) Cholesterol
Basic metabolic panel (BMP) High-density lipoprotein (HDL)
Cardiac biomarkers Low-density lipoprotein (LDL)
Creatine kinase (CK) Very low-density lipoprotein (VLDL)
CK-MB (CK2) Triglycerides
High-sensitivity C-reactive protein (hs-CRP) Thyroid stimulating hormone (TSH)
B-type natriuretic peptide (BNP) Urinalysis (UA)
N-terminal pro BNP (NT-pro-BNP)
Radiologic Tests
Troponin
Chest x-ray
Myoglobin
Cardiac positron emission tomography scan
Ischemia-Modified Albumin (IMA)
Radionuclide angiography (multiplegated
Complete blood count (CBC)
radioisotope scan, multigated acquisition scanning,
Comprehensive metabolic panel (CMP)
MUGA)
Cystatin C
Technetium pyrophosphate scanning
Platelet count
Thalium scan
Hemoglobin (Hgb)
Hematocrit (Hct) Other Diagnostic Tests
Electrolytes Cardiac biopsy
Erythrocyte sedimentation rate (ESR) Cardiac catheterization
Glomerular filtration rate (GFR) Echocardiogram
Glucose Electrocardiogram (ECG)
Glycosylated hemoglobin (HbA1c) Holter monitor

COURTESY OF DELMAR CENGAGE LEARNING

Liver function Magnetic resonance imaging (MRI)
Prothrombin time (PT) Pericardiocentesis
Partial thromboplastin time (PTT) Pulse oximetry
International normalized ratio (INR) Stress test
Arterial plethysmography (pulse volume recorder)
Venous plethysmography (cuff pressure test)

Table 5-2 Cardiac Biomarkers Elevation Times

CARDIAC BIOMARKER ONSET OF ELEVATION DURATION OF ELEVATION AFTER
INJURY
Troponin I 4–6 hours 4–7 days

Troponin T 4–6 hours 10–14 days

Creatine kinase-MB (CK-MB) 4–6 hours 48–72 hours

Myoglobin Less than 3 hours (Myoglobin is not

specific to the heart. However, it is the first
COURTESY OF DELMAR CENGAGE LEARNING

biomarker to elevate.)

Ischemia modified albumin Few minutes to a few hours IMA is not as valuable with a client who has
(IMA) experienced chest pain for several hours
because the IMA level may have risen and
returned to normal within that time frame.

ventricles contracting. The Q wave is not always present on ventricular muscles. The T wave represents the repolarization
the ECG strip. of the ventricles.
The pause after the QRS complex is called the ST seg- After the repolarization of the ventricles, the entire
ment. This represents the period between the contraction cycle begins again at the SA node. In this way the P
and the beginning of the recovery or repolarization of the wave, QRS complex, and T waves are repeated with each

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 CHAPTER 5 Cardiovascular System 127

R
Atrial Ventricle Cycle
Sinoatrial
depolarization repolarization begins
(SA) node
(contraction systole) (relaxation diastole) again
P wave

PR T

Voltage
P U P
segment
Atrioventricular T
(AV) node P
Q U-wave
(AV) Bundle S occurs in
some patients
Bundle Ventricle
QRS
of HIS depolarization
complex
(contraction systole)

Right and left Time

bundle branches

P wave is a positive wave representing atrial depolarization.

Purkinje fibers
PR segment represents the electrical impulse as it moves through

COURTESY OF DELMAR CENGAGE LEARNING

the AV node, AV bundle, Bundle of HIS, bundle branches, and
Purkinje fibers prior to ventricular contraction.
Q wave is negative deflection or wave.
R wave is a positive deflection or wave.
S wave is a negative wave.
QRS complex represents ventricular depolarization.
T wave is a positive wave and represents ventricular repolarization.
U wave (occasionally seen in some patients) is a positive deflection
and associated with repolarization.

Figure 5-7 Relationship of the Conduction System to an ECG Strip

COURTESY OF DELMAR CENGAGE LEARNING

COURTESY OF DELMAR CENGAGE LEARNING

R R
P T P T
QS Q
S

Figure 5-8 An ECG Strip Showing a Normal Sinus Figure 5-9 Sinus Bradycardia
Rhythm with the P Wave, QRS Complex, and T Wave Identified

heartbeat. Figure 5-8 shows an ECG strip of normal sinus

rhythm. BRADYCARDIA
Sinus bradycardia is a HR of 60 beats per minute or less (Fig-
ure 5-9). Causes of sinus bradycardia are myocardial ischemia,
■ DYSRHYTHMIAS electrolyte imbalances, vagal stimulation, beta blockers, heart

A
block, drug toxicity, intracranial tumors, sleep, and vomiting.
dysrhythmia is an irregularity in the rate, rhythm, or The treatment for bradycardia is the administration of atro-
conduction of the electrical system of the heart. Dys- pine. Some clients with bradycardia may require a permanent
rhythmia can occur in the atria, ventricles, or any part of the pacemaker. Asymptomatic bradycardia related to physical fit-
conduction system. Specialized cells in the heart muscle have ness is usually not treated.
the ability to generate an electrical impulse. Under certain
conditions these cells start sending impulses to other cells
in the heart, causing irregular beats called ectopic beats. The
most common causes of dysrhythmias are coronary artery
disease (CAD), CHF, and myocardial infarction (MI). Other TACHYCARDIA
causes of dysrhythmias are electrolyte imbalances and drug Tachycardia is a sinus rhythm with a HR ranging from 100 to
toxicity. 150 beats per minute (Figure 5-10, following page). Causes
Symptoms of a client experiencing a dysrhythmia vary of tachycardia are exercise, emotional stress, fever, medica-
from asymptomatic to cardiac arrest. The client experiences tions, pain, anemia, thyrotoxicosis, pericarditis, HF, excessive
fainting, seizures, fatigue, decreased energy level, exertional caffeine intake, and tobacco use. When the heart is beating
dyspnea, chest pain, and palpitations. at this rate, there is limited time for the ventricles to fill with

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128 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

COURTESY OF DELMAR CENGAGE LEARNING

COURTESY OF DELMAR CENGAGE LEARNING
Figure 5-10 Sinus Tachycardia Figure 5-11 Atrial Flutter

blood, and less blood is pumped to the coronary arteries and and is usually initiated by a premature beat. PSVT can stop as
throughout the body. The client may experience anginal pain. abruptly as it begins. It can be caused by myocarditis, caffeine,
The treatment for sinus tachycardia depends on the cause. alcohol ingestion, smoking, and stress. PSVT may also be pres-
ent in clients with coronary artery disease, mitral valve prolapse,
and acute pericarditis. The physician performs vagal stimula-
ATRIAL DYSRHYTHMIAS tion procedures such as the Valsalva maneuver and carotid sinus
pressure or massage, which usually stops the dysrhythmia.
Atrial dysrhythmias occur from electrical conduction distur-
bances in the atria, resulting in premature beats or abnormal
atrial rhythms. Common causes for atrial dysrhythmias are Atrial Flutter
myocardial infarction, CHF, electrolyte imbalances, emo- Atrial flutter, a rapid contraction of the atria, yields a HR of
tional stress, and drugs. 250 to 350 beats per minute (Figure 5-11). The ECG displays
a sawtooth wave pattern. The AV node attempts to block
Premature Atrial some of the atrial impulses, but usually the ventricles are also
contracting at a rate of 300 beats per minute. This causes a
Contractions decreased blood supply to the body because the atria and ven-
A premature atrial contraction (PAC) is an ectopic impulse tricles are unable to fill with blood when they are contracting
not originating in the sinoatrial node, but in the atrial tissue. at such a fast rate. This requires immediate intervention.
This causes an atrial depolarization to occur earlier in the cycle
than expected, thus the term premature atrial contraction.
PACs do not cause physical symptoms depending on
Atrial Fibrillation
how often they occur. Generally they are benign and occur Atrial fibrillation is an erratic electrical activity of the atria,
several times a day in healthy individuals. If their occurrence resulting in a rate of 350 to 600 beats per minute (Figure 5-12).
causes an increase or decrease in the pulse rate, they should be Atrial depolarization is so uncoordinated during the dysrhyth-
evaluated. PACs can be a symptom of myocardial ischemia, mia that the atria quiver rather than contract. The AV node is
developing CHF, digitalis toxicity, hypokalemia, or an inflam- bombarded with impulses and randomly transmits the impulses
matory condition. Stress, caffeine, and smoking also cause to the ventricles, causing varied irregular contractions of the
PACs. PACs can be the first indication that more serious atrial ventricles with a ventricular rate of 100 to 180 beats per minute.
dysrhythmias could occur if not treated properly. The underlying cause is mitral valve disease or dysfunction,

Atrial Tachycardia
COURTESY OF DELMAR CENGAGE LEARNING
Atrial tachycardia is an ectopic impulse that causes the atria
to contract at the rate of 140 to 250 beats per minute. This is
sometimes referred to as a supraventricular dysrhythmia, mean-
ing the impulse causing the dysrhythmia is occurring above the
ventricles. This dysrhythmia occurs as a continuous rhythm or
as short, sudden eruptions that start and end spontaneously.
Atrial tachycardia occurs with hypokalemia, digitalis
toxicity, and ischemia. Potassium supplements are given for
hypokalemia. If an increased level of serum digitalis is the Figure 5-12 Atrial Fibrillation
cause, digitalis is withheld until the level returns to normal.
An artificial pacemaker may be surgically inserted to regulate
the atrial tachycardia.
LIFE SPAN CONSIDERATIONS
Paroxysmal Supraventricular Antidysrhythmic Medications
Tachycardia Antidysrhythmic medication doses are reduced
Paroxysmal supraventricular tachycardia (PSVT) was previ- in the elderly if they have hepatic or renal
ously called paroxysmal atrial tachycardia (PAT). PSVT is a impairment.
rapid atrial beat accompanied by an abnormal conduction in
the AV node. The dysrhythmia occurs suddenly (paroxysmally)

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 CHAPTER 5 Cardiovascular System 129

CAD, acute MI, hypertensive heart disease, HF, cardiomyopa-

thy, or hyperthyroidism. Because the atria are not contracting
Ventricular Tachycardia
properly, blood pools in the atria, predisposing the person to Ventricular tachycardia (VT) is the occurrence of three or
thrombi forming on the walls of the atria. The clots can dis- more consecutive PVCs. The ventricular rate may go as high
lodge and travel to the brain, lungs, and other parts of the body. as 140 to 240 beats per minute. Underlying conditions in
Most cardiac clients take a low dose (81 mg) of aspirin daily which VT occurs are cardiomyopathy, hypoxemia, digitalis
to prevent clot formation. Once the underlying condition is toxicity, and electrolyte imbalance.
treated, atrial fibrillation may stop. If the dysrhythmia cannot be During VT, the client has a low blood pressure, weak or
controlled with medication, cardioversion may be necessary. absent peripheral pulses, body weakness, and may become
unconscious. The ventricle is beating so rapidly that it is
unable to fill with blood or eject blood properly. This causes
VENTRICULAR DYSRHYTHMIAS blood to back up in the pulmonary circulation, leading to pul-
monary congestion.
Ventricular dysrhythmias originate in the ventricles. They It is important that VT be treated promptly because
are more life threatening than atrial dysrhythmias because a ventricular tachycardia rhythm may lead into ventricular
the ventricles supply blood to the lungs and body. These fibrillation, a life-threatening dysrhythmia. The client is given
dysrhythmias must be treated promptly. oxygen, and an intravenous line is inserted if one is not already
in place. The drug of choice is amiodarone (Cardarone) given
Premature Ventricular intravenously. Lidocaine hydrochloride (Xylocaine HCL),
sotalol (Betapace), and magnesium sulfate (Magnesium) may
Contractions also be given. If the VT is not controlled with medications,
Premature ventricular contractions (PVCs) arise from ectopic the client is cardioverted if peripheral pulses are present, or
beats in the ventricles and are the most common ectopic beats defibrillated if peripheral pulses are absent.
(Figure 5-13). PVCs can easily be identified on the ECG
because of the wide, bizarre QRS complexes. No P waves pre- Cardioversion
cede the QRS complex. Cardioversion is the delivery of a synchronized electrical shock
Coronary artery disease is the most common cause of to change a dysrhythmia to a rhythm that circulates more
PVCs. Other causes of PVCs are myocardial ischemia, CHF, blood to the body tissues and improve oxygenation of the tis-
electrolyte imbalances, digitalis toxicity, anxiety, exercise, sues. The electrical shock is delivered on the R wave because a
hypoxia, caffeine, and excessive alcohol consumption. shock during ventricular depolarization may cause ventricular
If PVCs occur without the presence of other cardiac con- fibrillation. Cardioversion is done as an elective or emergency
ditions, there is no treatment other than removing the precipi- treatment. Electrodes are placed to the right of the sternum
tating cause, such as stress or caffeine. Potassium supplements below the clavicle and at the apex of the heart. The electrodes
are given for hypokalemia induced PVCs. Administering are lubricated with a special gel or placed on gel pads or defi-
oxygen may increase the oxygen perfusion to the myocardial brillator pads. The electrical current delivered through the
tissue and decrease the frequency of premature beats. electrodes depolarizes the myocardium and allows the heart’s
pacemaker to reestablish a sinus rhythm.
The client is NPO for 8 hours before an elective car-
PROFESSIONAL TIP dioversion. Diuretics and digitalis preparations are withheld
24 to 72 hours before the cardioversion because they make
Six authors from Stanford reported a 7-year study myocardium cells less responsive to conversion to a normal
on 1,847 heart failure-free clients in the Archives rhythm or may cause a serious dysrhythmia after the cardio-
of Internal Medicine in 2008. Forty-six percent of version. Anticoagulants and oral antidysrhythmics are still
the clients developed PVCs during exercise and
given before cardioversion. Anticoagulants are given so a
thrombus is not released into the system. A sedative such as
34% developed PVCs while recovering from the
diazepam (Valium) or midazolam hydrochloride (Versed) is
exercise period. Nine percent of these clients died given intravenously before the procedure. Monitor the client’s
in 5 years. The study conclusion was that clients vital signs and ECG strip closely for the first hour afterward
experiencing PVCs in the recovery or rest period and then as ordered by the physician.
after exercise had an almost “doubled propensity-
adjusted mortality rate” (Lundberg, 2008, p. 93). Defibrillation
Defibrillation is the delivery of an unsynchronized, high-
energy electrical shock during an emergency situation, such as
a cardiac arrest or pulseless VT, to convert the life-threatening
COURTESY OF DELMAR CENGAGE LEARNING

dysrhythmia or arrhythmia to a sinus rhythm. Defibrillation

is done by a physician or a nurse who has had special educa-
tion to handle emergency situations. Paddles are lubricated
with a special gel, or gel pads or defibrillator pads are applied
to the skin where the paddles will be placed. The paddles are
placed to the right of the sternum below the clavicle and at
the apex of the heart. When the electrical shock is delivered
to the client, everyone stands clear of the bed to prevent
Figure 5-13 Premature Ventricular Contraction them from also receiving the electrical shock. More than one

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130 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

COURTESY OF DELMAR CENGAGE LEARNING

Dual-chamber
ICD device
Figure 5-15 Ventricular Fibrillation (VF)

Complications after the insertion of an ICD are atelecta-

sis, pneumonia, pneumothorax, thrombus, and a seroma at

COURTESY OF DELMAR CENGAGE LEARNING

the generator site (a swelling from serum collecting around
the device that initiates the shock). According to Shaffer
(2002), anger and depression are common, expected side
effects.

Ventricular Fibrillation
The most common cause for VF is CAD. VF is a disorga-
Figure 5-14 An Implantable Cardiovert-Defibrillator: nized, chaotic quivering of the ventricles. The ventricles are
A dual-chamber ICD device with a pulse generator is implanted unable to contract, and no blood is ejected into the circulatory
below the collarbone and endocardial leads positioned in the system. The ECG reading is a series of jagged, unidentifiable
heart through a vein. waves (Figure 5-15). The client will not have a pulse, blood
pressure, or respirations. This dysrhythmia is serious. Aggres-
sive measures must be taken to initiate CPR and defibrillate
electrical shock may be delivered in an attempt to convert the the client immediately.
rhythm.
If conservative measures do not control the VT and
the client has periodic episodes of VT, an implantable
Ventricular Asystole
cardioverter-defibrillator (ICD) is implanted in the Ventricular asystole is represented by a P wave or a straight
client (Figure 5-14). This device senses the dysrhythmia and line on the ECG (Figure 5-16). The ventricles are not con-
automatically sends an electrical shock directly to the heart to tracting, and the client is in cardiac arrest. The client loses
defibrillate it. consciousness and has no pulse or respirations. Aggressive
Most ICDs have 1–3 endocardial leads that are guided treatment should be initiated within 1 minute to prevent
through a vein into the right side of the heart where they chemical changes within the body that jeopardize recovery.
become embedded into the heart tissue. The pulse genera- CPR is started, and the client is defibrillated. Atropine sulfate
tor is placed under the skin below the collarbone. The ICD and epinephrine are given intravenously.
detects VT and ventricular fibrillation (VF) through the leads
attached to the heart muscle. Once VT or VF is detected, an
electrical shock is sent from the pulse generator. The ICD is ATRIOVENTRICULAR BLOCKS
capable of delivering three more shocks to the heart muscle
if the heart does not return to normal sinus rhythm (NSR). In atrioventricular blocks, the electrical conduction is inter-
Usually, clients are converted to NSR with the first shock. rupted to some degree between the atria and ventricles at
Some ICDs also deliver cardiac resynchronization therapy the AV node. The extent of interruption is classified as first
(CRT) for clients with advanced HF. These devices have degree, second degree, or third degree.
three leads; one lead is placed in the right atrium and one lead
is placed in each of the ventricles. When this device functions First-Degree AV Block
as an ICD, it senses abnormal heart beats and delivers a shock In first-degree block, the impulse is delayed in traveling
to the heart to initiate a normal rhythm. When functioning through the AV node. The impulse eventually reaches the
as a CRT, it coordinates the beating of the ventricles so they
effectively work together and pump blood throughout the
body (FDA, 2002). Some ICDs also function as a pacemaker
COURTESY OF DELMAR CENGAGE LEARNING

and an ICD; delivering shocks as needed to correct abnormal

rhythms but also initiating heartbeats when the heartbeat is
too slow. Another ICD, called antitachycardia pacing (ATP),
sends a fast impulse to correct the rhythm after an ICD shock
and detects and treats rapid atrial heartbeats (Stanford Hos-
pital and Clinics, 2009; FDA, 2002). ICDs store the client’s
dysrhythmic activity and allow the health care practitioner
to test the electrophysiologic activity noninvasively (AHA,
2007). Figure 5-16 Asystole

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 CHAPTER 5 Cardiovascular System 131

ventricles but is delayed. There are no physical symptoms or

treatment for first-degree block.
CLIENTTEACHING
Second-Degree AV Block Pacemaker
In second-degree block, some of the impulses pass through the • High-tension wires, high-voltage electrical
AV node to the ventricles and others are blocked. Symptoms generators, or MRIs may cause pacemaker
include irregular pulse, vertigo, and weakness. A temporary malfunction.
pacemaker may be inserted until the conduction pattern is
stabilized. If the dysrhythmia persists, a permanent pacemaker • Avoid contact sports.
may be implanted. When the impulse is blocked, the ECG • Pacemakers may activate airport security alarms.
reveals an extended PR interval that is not followed by a QRS
complex.
of a client with a pacemaker shows the impulse from the
Third-Degree AV Block pulse generator by a pacemaker spike, a vertical line before
each QRS on the ECG strip.
Third-degree heart block is when no impulses are able to Before discharge, teach clients to take accurate apical
pass from the atria through the AV node to the ventricles. and radial pulses. Inform clients to report dizziness, faint-
The atria and ventricles beat independently of each other. ing, or fever. Clients are taught to have regular pacemaker
The causes of third-degree block are myocardial ischemia, checks or transtelephonic monitoring in which an ECG
drug toxicity, and electrolyte imbalances. Atropine sulfate strip is sent by phone to a designated hospital or physician’s
may be given to improve conduction through the AV node. office.
A permanent pacemaker is usually required to control the
dysrhythmia.
A pacemaker is an electronic device that stimulates the Medical–Surgical
heart to beat when the heartbeat is slow or drops below a
set HR. It consists of one or two lead wires that are attached
Management
to the endocardium of the right atrium, right ventricle, or Pharmacological
both, and a pulse generator that is “the ‘brain’ of the pace- Dysrhythmias originating in the atria are treated with
maker” (Stanford Hospital and Clinics, 2009). The electrodes amiodarone (Cardarone), diltiazem hydrochloride (Cardizem,
sense the heart’s electrical activity and relay the information to Dilacor, Tiazac), and digitalis (Digoxin). Dysrhythmias
the pulse generator. The purpose of the pacemaker is to regu- originating in the ventricles are treated with amiodarone
late the HR and increase CO. When the heart beats slower (Cardarone), lidocaine hydrochloride (Xylocaine HCL), and
than the programmed rate, an electrical impulse is sent to magnesium sulfate.
the lead that causes the heart to beat faster. Pacemakers are
used for bradycardia, tachycardia, myocardial infarction, Diet
and heart block.
Some pacemakers have leads in the atrium, ventricle, or The client is usually placed on a low-fat, low-cholesterol diet.
both to sense electrical activity and set the beating pace of one Caffeine consumption is restricted.
or both chambers. Sometimes in CHF the ventricles do not
pump effectively together, decreasing the amount of blood Nursing Management
pumped throughout the body. A biventricular pacemaker Monitor vital signs including apical pulse. Provide rest
paces the ventricles together increasing the pumping effective- periods throughout the day. Explain all procedures and
ness of the ventricles. The pacing of a biventricular pacemaker treatments. Encourage client to verbalize concerns about
is called cardiac resynchronization therapy because it puts the condition and potential complications. Teach relaxation
ventricles back in synch. methods.
A pacemaker is used either temporarily or permanently.
A temporary pacemaker is used until a client’s condition
improves or until a permanent pacemaker is inserted. With
a temporary pacemaker, the pulse generator remains out- NURSING PROCESS
side of the body. The permanent pacemaker has a lead wire
threaded through a vein to the heart and the pulse generator Assessment
is implanted subcutaneously under the collarbone. An ECG Subjective Data
Inquire if the client has experienced palpitations, lightheaded-
ness, nausea, dyspnea, anxiety, fatigue, or chest discomfort.
SAFETY
Safety: Pacemaker and ICD Objective Data
If a client is experiencing dysrhythmias, check the HR, blood
Encourage the client to carry an ID card and
pressure, and respirations. While listening to the apical pulse
wear a medical identification tag indicating the and respirations, note abnormal heart sounds and monitor
presence of a pacemaker or ICD. breath sounds for crackles. Crackles indicate the lungs are filling
with fluid. Observe the skin for pallor and cyanosis, especially
during and after activity/exercise. Urine output may decrease.

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132 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with dysrhythmias include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Decreased Cardiac Out- The client will have in- Apply electrodes for telemetry monitoring.
put related to inadequate creased CO. Balance activity with rest periods, and monitor vital signs
electrical conduction during activity and at rest.
Listen to the apical pulse, especially noting rate and rhythm.
Elevate the extremities so they are not in a dependent position.

Anxiety related to fear of The client will relate fears of Care for the client in a calm, confident, and efficient manner.
potential diagnosis, treat- potential cardiac problems. Remain with the client and explain procedures and treatments.
ment regimen, and death Encourage client input regarding the care.
Encourage the client to verbalize concerns about the dysrhyth-
mia and potential future complications.
Teach the client relaxation activities.

Deficient Knowledge The client will describe Explain medication administration times, action, side effects,
related to electrical con- electrical disorder and and symptoms that need reporting. Provide written instructions
duction of the heart and treatment methods. to the client and family.
treatment methods Explain symptoms of dysrhythmias such as fatigue, edema,
palpitations, lightheadedness, nausea, dyspnea, and anxiety.
If a pacemaker is needed, explain to client and family the pur-
pose, insertion procedures, and home care.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

INFLAMMATORY DISORDERS ■ INFECTIVE ENDOCARDITIS

I nflammatory disorders include rheumatic heart disease,

infective endocarditis, myocarditis, pericarditis, and valvu-
lar heart disease.
I nfective endocarditis is an inflammation or infection of the
inside lining of the heart, particularly the heart valves. The
etiology of inflammatory endocarditis is a collagen-vascular
disease or rheumatic fever. Infective endocarditis is caused
by bacteria, fungi, or virus. As the microorganisms invade the
valves, they form fibrinous substances called vegetations. The
■ RHEUMATIC HEART DISEASE vegetations cause scar tissue on the valves resulting in hard,

R
brittle valves that do not close properly and allow blood to
heumatic heart disease is a complication of rheumatic flow back into the previous chamber. The valve is said to be
fever and is also linked to group A streptococcus after insufficient. Sometimes the vegetations cause the valve flaps
an upper respiratory infection. Rheumatic fever is a systemic to grow together, resulting in a narrowing of the opening. This
inflammatory disease that occurs 2 to 3 weeks after an inad- is called a valvular stenosis. The mitral valve is more frequently
equately treated pharyngitis caused by group A beta-hemolytic affected than any other. When the mitral valve is affected, it is
streptococcus. Symptoms of rheumatic fever are a mild fever, termed mitral insufficiency or mitral stenosis.
polyarthritis, carditis, chorea, and a rash. The endocardium, Historically, rheumatic fever was the common cause of
myocardium, and epicardium can become inflamed, with the endocarditis. Clients at risk for endocarditis are individu-
most damage occurring to the mitral valve. The mitral valve als that use IV drugs, are immunosuppressed, have dental
becomes incompetent because of thickening and stenosis of caries and abscesses, and a history of valvular heart disease.
the valve leaflets. Mitral prolapse (valve leaflets flip back into Goldrick (2003) reports that endocarditis is associated with
the left atrium during systole) may result. body piercing.
A person who had rheumatic fever is more likely to have There are two forms of endocarditis: acute and subacute.
a recurrence. It is treated with intravenous antibiotics, anti- Symptoms of acute endocarditis are tachycardia, pallor,
inflammatory agents, corticosteroids, and strict bed rest. The diaphoresis, and symptoms of a systemic infection, such
main goal is to treat the inflammation, prevent cardiac compli- as temperature of 103°F and shaking chills. Clients with
cations, and prevent the recurrence of the disease. These clients subacute endocarditis have low-grade fever, malaise, weight
are placed on prophylactic antibiotic therapy before dental pro- loss, and anemia. Clients with both types may have murmurs
cedures or invasive surgery. Antibiotic therapy reduced the mor- and symptoms of CHF, such as dyspnea, peripheral edema,
tality from 15,000 in 1950 to 3,676 in 1999 (AHA, 2001c). and pulmonary congestion.

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 CHAPTER 5 Cardiovascular System 133

Endocarditis is diagnosed by the client’s history and monitored for signs of CHF. A pericardial friction rub is
symptoms. Transesophageal echocardiography (TEE) often heard if the pericardium becomes involved. The friction
can confirm the diagnosis by ultrasonic imaging of the cardiac rub is a “squeaky” sound heard through the stethoscope when
structures through the esophagus. The erythrocyte sedimenta- the two inflamed pericardial surfaces rub together with the
tion rate (ESR) and WBC are elevated. A blood culture and contraction of the heart.
sensitivity is done to determine the causative organism and the Myocarditis diagnostic symptoms are nonspecific. They
most effective antibiotic. include elevated ESR and elevated LDH, CK, and SGOT
levels. The diagnosis of myocarditis can be confirmed with an
Medical–Surgical endomyocardial biopsy.

Management
Surgical
Medical–Surgical
Surgical repair or replacement of a valve is done in severe cases.
Management
Pharmacological
Pharmacological Digitalis preparations are given to try to prevent CHF.
Clients are treated with antimicrobial drugs (endocarditis) Broad-spectrum antibiotics are also given to treat the infection.
and intravenous antibiotics. The antibiotics are usually continued Anti-inflammatory agents may be given to reduce the
for 2 to 6 weeks. The most commonly used antibiotics are inflammation. Oxygen is administered as needed.
penicillin V potassium (V-Cillin K), vancomycin hydrochloride
(Vancocin), and gentamicin sulfate (Garamycin). Activity
The client is placed on bed rest to decrease the workload of
Diet the heart.
Provide the client with a well-balanced nutritious diet, with
between-meal snacks.
Nursing Management
Activity Monitor the client for symptoms of CHF or pericarditis. Place
The client is on bed rest to decrease the workload of the heart. the client in a semi-Fowler’s position to assist with breathing.
Provide a calm, quiet environment. Provide a quiet environment and frequent rest periods. Apply
a pulse oximeter to monitor oxygen saturation.
Health Promotion
Clients who previously had endocarditis or have a mitral valve
prolapse are more prone to develop endocarditis. They should ■ PERICARDITIS
take antibiotics prophylactically before having dental work
and genitourinary or gastrointestinal invasive procedures.
Amoxicillin trihydrate (Amoxil) 1 hour before the procedure
W hen the membranous sac surrounding the heart
becomes inflamed, the condition is called pericardi-
tis. Causative organisms are viral, bacterial, fungal, or parasitic.
and again after the procedure is the usual order. Inflammation can also occur from rheumatic or collagen-
vascular conditions such as systemic lupus erythematosus.
Nursing Management The most common cause of pericarditis is idiopathic, meaning
no known cause. Symptoms of pericarditis are severe precor-
Administer oxygen as needed, and measure blood pressure dial pain (pain on the anterior surface of the chest over the
and pulse before and after activity to monitor toleration. Note heart) and a pericardial friction rub. The pain may radiate to
apical pulse rate and rhythm and assess breath sounds for the neck, back, or abdomen and become worse when the client
adventitious sounds. Balance activity with rest periods. Moni- coughs or lies on the left side. If the client sits erect and leans
tor BUN and creatinine levels if a client is on vancomycin forward, the pain is relieved. Pericardial effusion (excess fluid
hydrochloride (Vancocin) or gentamicin sulfate (Garamycin) in pericardial space) may develop. Cardiac tamponade will
because both of these drugs are nephrotoxic. result if the fluid rapidly increases and hinders the functioning
of the ventricle. The S1 and S2 sounds are often muffled and
hard to hear because of fluid accumulation.
■ MYOCARDITIS With inflammation, scar tissue develops in the pericardial
sac. Heart movement is limited by the scar tissue and cardiac
M yocarditis is an inflammation of the myocardium of
the heart. Lymphocytes and leukocytes invade the
muscle fibers of the heart, causing the chambers to enlarge
failure results.

and the muscle to weaken. This can lead to CHF. Myocarditis

is caused by bacteria, viruses, fungi, or parasites. It can also Medical–Surgical
be an autoimmune reaction such as with rheumatic fever or Management
lupus erythematosus. Usually the cause is a virus. Myocarditis
is more prevalent in clients with AIDS. Medical
Acute myocarditis presents with flulike symptoms of The physician performs a pericardiocentesis to aspirate
fever, pharyngitis, myalgias, and gastrointestinal complica- the excess fluid from the pericardial sac. A needle is inserted
tions. The client will also have chest pain and should be through the chest wall into the pericardial space.

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134 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Surgical pumped. This is called regurgitation. The client with valvular

heart disease often has a history of rheumatic fever.
If fibrotic scar tissue in the pericardium hinders heart perfor-
mance, a pericardiectomy or pericardial window is done. Peri-
cardiectomy is removal of the pericardium. When a pericardial ■ STENOSIS AND INSUFFICIENCY

T
window is done, a section of the parietal pericardium is cut and
tacked back onto itself, allowing fluid to escape from the pericar- he definitions, symptoms, diagnostic findings, medi-
dial sac. cal–surgical management, and nursing interventions for
mitral and aortic valve conditions are covered in Table 5-3.
Pharmacological
Clients are given antipyretics, analgesics, and anti-inflammatory ■ MITRAL VALVE PROLAPSE

M
agents. The infection is combated with antibiotics. A digitalis
preparation and diuretic are given to improve the pumping itral insufficiency can lead to mitral valve prolapse in
action of the heart and decrease fluid retention. which the valve leaflets, chordae tendineae, and papil-
lary muscle become damaged. The valve leaflets flip back into
Nursing Management the left atrium when the left ventricle contracts. This condi-
tion affects more women than men. Often the client remains
Assess the client’s apical pulse and blood pressure and monitor asymptomatic. The symptoms that a client may experience
the ECG for dysrhythmias. Assess for signs of cardiac tamponade depend on how seriously the mitral valve is affected. Some-
such as decreased pulse and blood pressure, muffled heart sounds, times clients experience palpitations and fatigue caused by
increased respirations, restlessness, and oliguria. Administer decreased CO. They also may experience angina, dizziness,
oxygen as needed, and assist the client to a position of comfort. and syncope. Some clients have panic attacks. Often a click or
Administer analgesics, antibiotics, and anti-inflammatory agents murmur is heard.
as ordered and monitor the client’s responses. Encourage the
client to verbalize concerns and fears. Medical–Surgical
Management
■ VALVULAR HEART DISEASES Medical
V alvular heart disease occurs when the valves do not open
and close properly. When the valve does not close com-
pletely, blood leaks back into the chamber from which it was
Clients with valvular heart disease are to take antibiotics pro-
phylactically before any dental procedures and genitourinary
or gastrointestinal invasive procedures.

Table 5-3 Mitral and Aortic Valve Stenosis and Insufficiency

VALVE DEFINITION SYMPTOMS DIAGNOSTIC MEDICAL- NURSING
CONDITION FINDINGS SURGICAL INTERVENTIONS
MANAGEMENT

Mitral The diseased Gradual onset Chest x-ray: Medical Encourage rest
stenosis valve becomes of symptoms: hypertrophy and management: periods, administer
narrowed and the exertional dyspnea, enlargement of left diuretics, digitalis, oxygen, elevate
leaflets thickened, fatigue, orthopnea, atrium and right anticoagulants, head of bed,
preventing paroxysmal ventricle. antidysrhythmics, reposition frequently
blood from freely nocturnal dyspnea, ECG: atrial fibril- prophylactic to decrease pressure
flowing from the murmur. lation. antibiotics points, elevate
left atrium into the Later symptoms: Echocardiogram: for invasive legs, low-sodium
left ventricle. peripheral edema, fusion of valve procedures, low- diet, monitor for
atrial fibrillation, leaflets, enlarged sodium diet, semi- signs of right and
jugular venous left atrium, Fowler’s position, left-sided HF, teach
distention, decreased blood activity restrictions stress reduction
hepatomegaly, flow through valve. as needed. techniques, daily
abdominal Surgical weight.
distention, management:
hypotension, commissurotomy,
thrombus from percutaneous
blood pooling in balloon mitral
the left atrium. valvuloplasty, mitral
valve replacement.

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 CHAPTER 5 Cardiovascular System 135

Table 5-3 Mitral and Aortic Valve Stenosis and Insufficiency (Continued)
VALVE DEFINITION SYMPTOMS DIAGNOSTIC MEDICAL- NURSING
CONDITION FINDINGS SURGICAL INTERVENTIONS
MANAGEMENT

Mitral The valve leaflets Gradual onset Chest x-ray: Medical Same as mitral
insufficiency become hard of symptoms: hypertrophy and management: stenosis,
and do not close exertional dyspnea, enlargement of same as mitral teach exercise
completely. Blood palpitations, left atrium and left stenosis. modification.
backs up in both fatigue, atrial ventricle. Surgical
the left atria and fibrillation, loud ECG: atrial management:
ventricle, causing murmur and gallop. fibrillation. valvuloplasty,
both chambers to mitral valve
hypertrophy. replacement.

Aortic The valve cusps Syncope, Chest x-ray: Medical Same as mitral
stenosis become hard exertional dyspnea, enlargement of management: stenosis.
and calcify due arrhythmias, left ventricle, same as mitral
to rheumatic angina, murmur, calcification of stenosis.
fever, syphilis, and gallop; sudden aortic valve. Surgical
a congenital death may occur. ECG: hypertrophy management:
anomaly, or the Later symptoms of left ventricle percutaneous
aging process. as the disease inverted T wave balloon aortic
progresses: echocardiogram valvuloplasty, aortic
paroxysmal atrial fusion of valve replacement.
tachycardia, valve leaflets,
orthopnea. regurgitation.

Aortic The valve cusps Palpitations, chest Chest x-ray: Medical Same as mitral
insufficiency become so pain, exertional hypertrophy and management: stenosis,
hardened they dyspnea, nocturnal enlargement of left same as mitral teach exercise
do not close angina, dizziness, ventricle. stenosis. modification.
completely. The fatigue, decreased Surgical
blood no longer activity, intolerance, management:

COURTESY OF DELMAR CENGAGE LEARNING

flows through the paroxysmal aortic valve
aorta but backs nocturnal dyspnea, replacement.
up into the left visible pulsation
ventricle. of the neck veins,
murmur, lung
congestion.

Surgical ring. The mitral valve is replaced when other repair measures
are not feasible.
When the activities of a client with valvular heart disease The aortic valve is not repaired, only replaced, if the
become curtailed because of decreased CO and the symptoms symptoms cannot be controlled by medical means. The
can no longer be controlled by medical means, surgery is per- preferred treatment for a client with an aortic stenosis is per-
formed. The type of surgery performed will depend on the cutaneous aortic valvuloplasty. This treatment is often used
client’s overall condition and on the involved valve. in elderly or high risk surgical clients. A catheter is advanced
For the mitral valve, surgery alleviates the symptoms, to the affected valve and a balloon is inflated in the stenosed
but it does not cure the condition. Surgeries frequently have valve. The narrowed valvular space is expanded by the bal-
to be repeated. A commissurotomy is done for mitral steno- loon, leaving a wider opening. Later, large balloons may be
sis, which surgically separates the valve leaflets. For mitral used to expand the opening as needed.
regurgitation or insufficiency, a valvuloplasty is becoming the Mitral and tricuspid valves are now repaired or replaced
treatment of choice. A percutaneous mitral valvuloplasty is with robotically-assisted closed-chest heart surgery. Cardiac
a repair of perforated cusps or torn chordae tendineae. The surgeons perform these minimally invasive valve surgeries
risk of a thrombus is less with valvuloplasty than with grafts with a robot. Some valves are still repaired and replaced with
or prosthetic valves. An annuloplasty, a repair of an annulus the open chest method, but there are several advantages to
or valvular ring, can also be done (see Figure 5-17A). The robotically assisted surgery. They require smaller incisions
annulus is tightened with a purse-string suture or an annular with minimal scarring. The client experiences less trauma,

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136 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

A both types of valves. The biological valves come from calves,

pigs, or humans. The disadvantage of the biological valves is
tissue degeneration and calcification of the valve. Carpentier-
Edwards produced the first biomechanical valve that consists
of a mechanical device and natural tissue.

Nursing Management
Assess for dyspnea, fatigue, palpitations, lightheadedness,
cough, and numbness and tingling in the extremities. Pro-
vide rest periods during the day. Encourage smokers to
stop. Refer client and family to dietitian for information on
low-sodium diets. Encourage client’s input regarding care
decisions.
Image not available due to copyright restrictions

NURSING PROCESS
Assessment
Figure 5-17 A, Annuloplasty B, Carpentier-Edwards Subjective Data
Perimount Mitral Pericardial Bioprosthesis (Image A courtesy of Review past medical history for conditions such as rheumatic
Delmar Cengage Learning; image B courtesy of Edwards LifeScience.) fever or streptococcal infections. Document if the client has
experienced any dyspnea, palpitations, fatigue, cough, light-
headedness, or numbness and tingling in the extremities.
pain, and bleeding. Clients have a decreased need for pain
medication and a decreased risk of infection. The hospital stay
is shorter than open heart surgery and the recovery is quicker, Objective Data
with a prompt return to daily activities. Take the vital signs and listen to the apical pulse for rate,
There are two types of replacement valves: mechanical and rhythm, murmurs, and S3 sound. Auscultate breath sounds for
biological. The mechanical valve is the caged-ball valve (Figure adventitious sounds. Note edema, jugular distention, cyano-
5-17B). There is a greater risk of a thromboembolism with a sis, and equality of peripheral pulses. Test for Homans’ sign
caged-ball valve. Clients remain on anticoagulant therapy with because dysrhythmias may produce clots.

Nursing diagnoses for a client with cardiac valvular disorders include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Decreased Cardiac The client will have increased CO. Administer oxygen as needed.
Output related to Help the client balance activities with rest periods. The
structural changes in pulse should return to the baseline within 10 minutes
valves of activity; if not, activity has been excessive.
Discourage smoking and refer clients to support
groups to assist them to stop smoking.

Excess Fluid Volume The client will have a decrease in Administer diuretics as needed.
related to decreased CO edema. Support extremities so they are not in a dependent
position.
Encourage the client to maintain a low-sodium diet.

Anxiety related to threat to The client will list ways to cope with Calmly explain the procedures before doing them.
or change in health status stressors. Encourage the client’s input to decisions regarding
care.
Assist the client and the client’s family in identifying
ways to cope with stressors.
Teach relaxation techniques.

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 CHAPTER 5 Cardiovascular System 137

Nursing diagnoses for a client with cardiac valvular disorders include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will relate the disease Explain the valvular disease process, medication actions,
related to disease process process and needed self-care dosage times, and medication side effects to report.
and treatment management. Refer the client and family members to the dietitian for
low-sodium diet instructions.
Encourage the client to begin an appropriate exercise
program.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

These vessels enlarge in an attempt to supply blood to the

OCCLUSIVE DISORDERS affected area. Collateral circulation increases the blood supply

O
to tissues with an inadequate blood supply.
cclusive disorders include arteriosclerosis, angina pecto- Many people experiencing ischemic attacks do not
ris, and myocardial infarction. experience angina. This is called silent myocardial infarct
or ischemia. Symptoms are chest pressure or heaviness,
restlessness, shortness of breath with increased respiratory
■ ARTERIOSCLEROSIS rate, a sensation of epigastric fullness with noisy belching,
numbness or tingling in both arms or shoulders, physical or
A rteriosclerosis is a narrowing and hardening of arter-
ies. A buildup of lipids, collagen, and smooth muscle
cells narrows the lumen of the vessel. Decreased blood flow
mental fatigue, and dizziness. The person may also experience
a change in sleep patterns and mental alertness. The person
states that he or she “feels funny.” Clients that are more likely
through the vessel causes decreased perfusion to cells beyond to experience a silent myocardial infarction are women, older
the narrowed or hardened area. adults, and individuals with diabetes or a history of HF
There are three types of arteriosclerosis: atherosclerosis, (Overbaugh, 2009).
calcific sclerosis, and arteriolar sclerosis. Atherosclerosis Two other types of angina are unstable angina and Prin-
is fatty deposits on the inner lining of vessel walls. The fat zmetal’s angina. Unstable angina occurs at rest or with mini-
deposit is called plaque. In calcific sclerosis, calcium deposits mal exertion and is not relieved with nitroglycerin. The client
are on the middle layer of the wall of the arteries. Hyperten- is more susceptible to myocardial infarction and sudden death.
sion causes a thickening of the arterioles and is called arteriolar Prinzmetal’s angina is caused by a coronary artery spasm and
sclerosis. With these conditions, vessels lose their elasticity, occurs at rest.
resulting in various conditions, such as arteriosclerotic heart There is a high incidence of angina pectoris in clients with
disease, angina, myocardial infarction, stroke, and peripheral hypertension and diabetes mellitus. The diagnosis of angina is
vascular disease. made after reviewing the client’s history, lifestyle, laboratory
tests, and stress test. A lipid profile (cholesterol, HDL, LDL,
and triglycerides), hs-CRP, and lipoprotein A [Lp(a)] are
■ ANGINA PECTORIS evaluated. Angina pectoris is diagnosed by a stress test, thal-

W hen coronary arteries lose elasticity or become nar-

row as a result of plaque collection, the heart muscle
lium scan, or a coronary arteriogram.

receives less blood and oxygen. Physical exertion, emotional

stress, smoking, exposure to extreme cold, heavy meals, or an Medical–Surgical
arterial spasm may cause a temporary inadequate blood and Management
oxygen supply to the heart. Myocardial ischemia and angina
pectoris result. Myocardial ischemia is a temporary inadequate Medical
blood and oxygen supply to the myocardial tissues. When this Treatment for angina includes measures to increase the blood
temporary condition occurs, the person experiences chest supply to the affected area. Clients are administered 162 to 325
pain or angina pectoris. mg of chewed or crushed aspirin by mouth because it prevents
At first, the person may experience a squeezing pain platelet aggregation and vasoconstriction. Oxygen is given at
under the sternum, which radiates to the left shoulder. For 2 to 4 L/min per nasal cannula to maintain the SaO2 >90%.
some, the pain may radiate to the right shoulder, jaw, or ear. Nitroglycerin tablets 0.3 to 0.4 mg are given sublingually
The discomfort may vary from mild discomfort to immobiliz- every 5 minutes up to 3 doses because it is a vasodilator and
ing pain. Anginal attacks usually increase in frequency and increases the oxygen supply to the myocardium. If the pain is
severity over time. The severity of the condition depends on not relieved with the nitroglycerin, morphine sulfate 2 to 4 mg
the development of collateral circulation. IV push is administered because it is a vasodilator and analge-
Collateral circulation develops as larger vessels gradu- sic. The morphine dose can be repeated every 5 to 15 minutes
ally narrow or harden. Blood that normally passes through until the pain is under control. The nurse should closely
the larger vessels is shunted into surrounding smaller vessels. monitor the BP, respirations, and SaO2 because the side effects

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138 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Atherosclerotic material Balloon catheter with

MEMORYTRICK (plaque) expandable stent

MONA for Anginal Pain Artery wall

M = Morphine sulfate 2 to 4 mg IV push

Inflated
O = Oxygen 2 to 4 L/min per nasal cannula to balloon
maintain SaO2 above 90%
N = Nitroglycerin tablets 0.3 to 0.4 mg sublingually
every 5 minutes up to 3 doses
Expanded
A = Aspirin 162 to 325 mg by mouth (chewed or stent presses
crushed) plaque against
(Overbaugh, 2009) artery wall

of morphine are hypotension and respiratory depression.

A mnemonic to recall the treatment of angina is MONA (see Plaque
Memory Trick: MONA). Even though the letters are not in the
order of administration, it helps the nurse recall the treatment

COURTESY OF DELMAR CENGAGE LEARNING

for angina (Overbaugh, 2009).
Silent ischemia is treated in the same way symptomatic A
ischemia is treated. The client needs to be educated about
cardiac risk factors, the importance of following the pre- Stent is left B
scribed medical regimen, and maintaining regular physical in place and
checkups. balloon catheter
is deflated
and removed
Surgical
A percutaneous transluminal coronary angioplasty (PTCA) Figure 5-19 Placement of a Stent in a Coronary Artery;
may be done if only one coronary artery is involved and if A, Palmaz-Schatz Stent; B, Gianturco-Roubin Ex-Stent
the atherosclerotic material is small and has not hardened.
When a PTCA is done, atherosclerotic matter is pressed
against the walls of the coronary vessels to improve circula- An intracoronary stent may be implanted into a stenosed
tion to myocardial tissue supplied by that coronary artery vessel to prevent the vessel from collapsing and to keep the
(Figure 5-18). A guidewire is inserted to the stenosed atherosclerotic plaque pressed against the vessel wall. A
area, and a special balloon-tipped catheter is placed in stent is a tiny metal tube with holes in it (Figure 5-19). The
the narrowed sclerotic area. When the balloon is inflated, procedure is sometimes done when a vessel collapses after a
the atherosclerotic material is pressed against the wall of the PTCA or in place of a PTCA. The stent is tightly wrapped
vessel. The vessel, now open, allows more blood to flow to around a balloon catheter. When the balloon catheter has
the myocardial tissue. During this procedure, a piece of the been threaded through a vessel to the stenosed area, the bal-
atherosclerotic material may break off and occlude the ves- loon is inflated and the stent expands and presses the plaque
sel. If this occurs, the client would have to undergo imme- against the vessel wall. The stent remains in the vessel and the
diate coronary artery bypass graft (CABG) surgery. Other catheter is withdrawn.
complications of the procedure are occlusion of the vessel If a CABG is performed, the internal mammary artery,
because of a vascular spasm. the saphenous vein, or an accordion type of synthetic graft
material is used. The vein or synthetic material is grafted to
the aorta and passed beyond the obstruction in the coronary
Catheter threaded vessel (Figure 5-20). The graft provides an increased blood
into aorta
supply to the affected myocardium. The client then has less
angina and an increased tolerance for activities.
A minimally invasive direct coronary artery bypass graft
(MID CABG) surgery is now an option for clients whose
surgeons use a left internal mammary artery to bypass an
COURTESY OF DELMAR CENGAGE LEARNING

occlusion in the left anterior descending artery (see Figure

5-20B). With a MID CABG the client is not connected to a
heart bypass machine and only small incisions (2−3 inches)
are needed for the procedure. There is decreased risk of
infection and the client experiences less bleeding and pain.
The average recovery time is 2 to 4 weeks compared with 6 to
Balloon in position in
right coronary artery
8 weeks with the traditional heart surgery.
Another recent advance in CABG surgery is Cardica’s
Figure 5-18 Demonstration of the Function of a Balloon- C-Port Flex-A System that completes the vessel anastomosis
Tipped Catheter During a PTCA Procedure by arranging tiny, stainless steel staples attaching the bypass

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 5 Cardiovascular System 139

invasive surgery while the heart is still beating. There is no

need for a heart bypass machine or a sternotomy. This surgery
has all the advantages of a minimally invasive surgery (Broad-
Left internal cast Newsroom, 2009).
thoracic artery
Pharmacological
Vasodilators, such as nitroglycerin tablets, cause the blood
vessels to dilate, providing an increased blood supply to
Saphenous tissues. The client may not need as much analgesic medica-
vein graft
tion if beta blockers are given. Beta-adrenergic blockers and
calcium channel blockers slow the HR and decrease the
oxygen demand of the heart. Calcium channel blockers also
dilate vessels and decrease spasms of the coronary vessels.
All of these measures provide an increased blood supply to
the myocardium.

Diet
The client is placed on a low-fat, low-cholesterol, sodium-
Right internal restricted diet. Sodium restriction may vary from no salt to
thoracic artery
4 grams daily depending on the ability of the client’s kidneys
A to excrete excess sodium. An increase of fruits and vegetables
is recommended in the diet.

Activity
Activity should be slower and for shorter periods of time with
more rest periods.

Health Promotion
To prevent coronary artery disease from resulting in angina,
it is recommended that a person limit fat intake to 30 grams
or less per day and exercise 5 times per week for at least
30 minutes. Simple activities such as parking a car farther
from an entrance to increase walking distance and taking stairs
instead of an elevator improve circulation and help decrease
Image not available due to copyright restrictions
cholesterol levels. Activities such as gardening or housework
are also good.

Nursing Management
Assess pain and medicate client as ordered. Monitor vital
signs. Emphasize taking rest periods. Encourage client to
always carry nitroglycerin and to get regular exercise as
recommended by the physician. Answer questions about
the low-fat, low-cholesterol, sodium-restricted diet that is
prescribed.

NURSING PROCESS
Assessment
Figure 5-20 A, Coronary Artery Bypass Graft (CABG) with Subjective Data
the Saphenous Vein and Intern Mammary Vein; B, Robotic-assisted Ask the client to describe the pain regarding type, radiation,
Surgery Completing a CABG (Image A courtesy of Delmar Cengage
onset, duration, and precipitating factors.
Learning; image B courtesy of Intuitive Surgical, Inc. ©2005.)

vessel to the coronary artery. (To view the Cardica C-Port Objective Data
Flex-A System used in a robotic CABG or an animation of the Observe and document the client’s actions during the anginal
C-Port Flex-A System, go to http://www.cardica.com.) The attack. Take vital signs and attach the client to an ECG moni-
anastomosis is completed with robotic arms in a minimally tor and observe for any dysrhythmias.

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140 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with angina include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will experience Administer nitroglycerin tablets sublingually. The pain should be
decreased oxygen supply decreased episodes of relieved within 1 to 2 minutes. If the pain has not stopped after
to the myocardium angina. 3 doses 5 minutes apart, notify the emergency personnel.
Administer other medication such as beta blockers or calcium
channel blockers as ordered and monitor client’s response.

Anxiety related to The client will relate con- Assist the client in learning to decrease personal expectations
perceived threat of death cerns and practice stress and to live within personal activity limitations.
or change in lifestyle reduction techniques. Emphasize the importance of getting adequate rest and stop-
ping before becoming too exhausted.

Deficient Knowledge The client will explain the Explain the cause of angina. Teach the client to avoid stress-
related to disease disease process, medica- ful situations that may produce angina. Other ways to prevent
process, medications, tion actions, dosage times angina are to sleep in a warm room, eat smaller proportions at
and treatment regimen and side effects, and self- mealtimes, and not exercise outside in cold weather.
care practices. Inform the client to always carry nitroglycerin in a tightly closed
container.
Nitroglycerin may cause orthostatic hypotension, so inform the
client to sit after taking it and to change position slowly after tak-
ing the medication.
Encourage the client to start and maintain a regular exercise
program as recommended by the physician.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

client’s prognosis is better if a small coronary artery or arteriole

■ MYOCARDIAL INFARCTION is obstructed and there is good collateral circulation to the

I
heart. If a large vessel is obstructed and the client does not have
n 2002, an estimated 1.1 million persons in the United sufficient collateral circulation, the client may die immediately.
States had an acute myocardial infarction (MI), and about The typical symptoms of men experiencing an MI are
45% died. Half of those who died did so before arriving at a feelings of chest heaviness or tightness that progresses to
hospital (Nagle & Nee, 2002). The most common cause for a severe gripping pain in the lower sternal area. Pain also
myocardial infarction is atherosclerosis. occurs in the arm, neck, back, or epigastric area and may or
A myocardial infarction is caused by an obstruction in may not radiate to these areas. The pain is not relieved by
a coronary artery, resulting in necrosis (death) to the tissues rest or nitroglycerin, and the client becomes short of breath
supplied by the artery. The obstruction is usually caused by (dyspneic), diaphoretic, and anxious. The client frequently
atherosclerotic plaque, a thrombus, or an embolism. The area becomes nauseated and vomits. The pulse may be irregular,
most commonly affected is the left ventricle. rapid, and weak, and the blood pressure is low. The skin is
Obstruction of a large coronary artery damages the myo- pale and then turns cyanotic. Even though a person may not
cardial tissue and affects the pumping efficiency of the heart. A experience the typical MI symptoms, the condition can still
be serious or fatal. Complications such as HF and stroke may
also occur.
PROFESSIONALTIP Women experiencing an MI present with atypical symp-
toms that often delay an accurate diagnosis. Women are more
Risk Factors for Myocardial Infarction likely to have upper abdominal pain, heartburn, nausea, dys-
pnea, fatigue, lethargy, dull pain, anxiety, as well as chest pain
• Overweight (Cheek & Cesan, 2003; Joy, 2006). Women have pain in the
• Cigarette smoking back or left side of the chest rather than substernally and report
• Hypertension the symptoms as a numb, tingling, burning, or stabbing sensa-
• Diabetes tion (Overbaugh, 2009).
• Family history of heart disease A myocardial infarction is diagnosed by client symptoms,
• High cholesterol level ECG tracings, cardiac biomarker values, and a radioactive
• High LDL isotope scan; however, in women the ECG stress test has less
(Lab Tests Online, 2009) diagnostic value than in men. An exercise echocardiography is
more reliable for women (Cheek & Cesan, 2003). When an

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 CHAPTER 5 Cardiovascular System 141

MI is evolving in men, the ECG has an elevated ST segment, inserted. Clients with multiple vessels occluded, or for whom
which eventually changes into an inverted T wave. thrombolytic therapy and PTCA have not been effective, have
A CK-MB fraction that measures an isoenzyme specific to the CABG procedure performed.
the cardiac muscle increases within 3 to 6 hours of the onset
of a myocardial infarct, peaks in 18 to 24 hours, and returns to
normal in 72 hours. CK studies are performed as soon as the Pharmacological
client is admitted and then every 8 hours until four samples Oxygen is given by a Venturi mask or nasal cannula. Morphine
have been obtained. A CK-MB fraction >5% indicates myo- sulfate is given intravenously for pain. Medications include
cardial damage. nitrates (IV or sublingually) to relieve pain and dilate coronary
Two other important lab values for diagnosing an MI are arteries, sedatives to calm and relax the client, and a stool soft-
cardiac troponin I and myoglobin. Cardiac troponin I is a pro- ener to prevent rectal straining.
tein found in cardiac cells. When cardiac cells are damaged, Thrombolytic therapy is sometimes used within 3 to
the protein is released, resulting in an elevated level (normal 6 hours of the myocardial infarction to dissolve a clot blocking
level is <0.6 ng/mL) for 7 days. Within an hour of an MI, the an artery and reperfuse the area. Medications such as strep-
myoglobin blood level increases, peaks in 4 to 12 hours, and tokinase (Streptase), anistreplase (Eminase), and alteplase
returns to normal in 18 hours. If an MI is suspected, the lab recombinant (Activase) are used. A possible complication
value must be obtained quickly. from thrombolytic therapy is bleeding. Be alert for symptoms
During the first 3 days after the infarction, the client may of hemorrhaging in the gastrointestinal tract (hematemesis
have a low-grade fever and an increased white cell count. The and tarry stools), retroperitoneum (low back pain and numb-
infarcted heart tissue is soft and necrotic and incapable of ness in lower extremities), or cerebrum (headache, vomiting,
responding to electrical stimuli. Life-threatening dysrhythmias and confusion). Heparin therapy inhibits further clotting.
are most likely to occur at this time. Four to seven days after the Aspirin and/or clopidogrel (Plavix) is given to prevent vaso-
infarction, the infarcted tissue is the softest and weakest. An constriction and platelet aggregation.
aneurysm, or ballooning effect, can occur in the infarcted area
with the potential of rupturing. There is a possibility of the Diet
ventricle rupturing from the time of the infarct to 2 weeks after Until the client is stabilized, a diet is withheld in case a PTCA
the infarct. Collateral circulation begins forming around the or CABG procedure is required. Fluids may be offered during
edges of the infarct, but it will be 2 to 3 weeks before the collat- the acute stage. A liquid diet is progressed to a regular low-fat,
eral circulation functions effectively. Two to three months will low-cholesterol, low-sodium diet. The client tolerates small
pass before the heart muscle regains maximum strength. frequent feedings better than three large meals. Avoid caffeine
and extremely hot and cold foods.
Medical–Surgical
Management Activity
It is vital that the client receive physical, mental, and emotional
Medical rest. Less stimuli places less demand on the heart. Explain
Medical–surgical management focuses on reducing oxygen procedures so the client understands the care provided.
demands, increasing oxygen supply to the myocardium, reliev- The client is usually limited to bed rest during the first
ing pain, improving tissue perfusion, and preventing compli- 24 hours and progressed to sitting in a chair by the second
cations and further tissue damage. Immediately after an MI, a day. If pain returns or other complications occur, the client is
client is admitted into a coronary care unit. The client’s heart back to bed rest. Early ambulation is encouraged to prevent
is constantly monitored for dysrhythmias, and vital signs are thrombosis. During and after each activity, assess the client’s
monitored for any changes. tolerance by monitoring the HR for an increase of 20 beats
Three dysrhythmias that may occur after an MI are ven- per minute, checking for a decrease in systolic blood pressure,
tricular fibrillation, bradycardias, and tachycardias. Ventricular and observing for dyspnea and dysrhythmias. Document ver-
fibrillation is treated by defibrillation. Atropine and, if needed, bal and nonverbal statements of fatigue and chest pain.
a temporary pacer is inserted for bradycardias. Two tachycar- Before discharge, low-intensity tests are performed to
dias that may occur are atrial fibrillation and ventricular tachy- determine the types of activities in which the client may
cardia. Atrial fibrillation is treated with digoxin (Lanoxin) engage at home. When the client is able to climb two flights of
diltiazem hydrochloride (Cardizem), or amiodarone hydro- stairs, sexual activity is resumed.
chloride (Cordarone). Ventricular tachycardia is treated with
Cordarone, lidocaine hydrochloride (Xylocaine), or cardio- Health Promotion
version. If dysrhythmias continue, magnesium may be given.
Medical complications that can occur following an MI are A diet of less than 30 grams of fat per day reduces the progres-
acute left ventricular failure, cardiogenic shock, pericarditis, embo- sion of atherosclerosis, but there is no documented evidence
lism and/or thrombosis, and cardiac rupture. The health care team that diet will prevent the disease in clients with hereditary
must closely monitor the client for signs of these complications. hyperlipidemia. Regular exercise, 30 minutes at least 5 days
Women have a worse prognosis and die more often than men after per week, and smoking cessation help prevent an MI.
a heart attack or bypass surgery (Cheek & Cesan, 2003). Participation in a cardiac rehabilitation program provides
the client with monitored exercise sessions as well as educa-
tion and counseling about reducing the risk of future heart
Surgical problems and coping with a new lifestyle. Because women
Primary treatment may be PTCA instead of thrombolytic have a worse prognosis than men, it is critical for women to
therapy. Along with balloon compression, a stent(s) may be participate in a cardiac rehabilitation program.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
142 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing Management medications. Assess pain regarding onset, duration, intensity,

location, radiation, and precipitating factors; ask the client to
Assess for pain. Observe for verbal and nonverbal signs of describe the symptoms. Not all persons having angina or an MI
pain. Have client describe symptoms. Monitor vital signs, will experience or state having pain. Some may describe feelings
breath sounds, pedal pulses, and ECG strips. Maintain cli- of chest heaviness, indigestion, or “something not right.” Explore
ent on bed rest with call light and other items within reach. these statements with the client so the client can explain them in
Accurately record I&O. Provide a quiet, calm environment. more detail. Dizziness, weakness, and shortness of breath may
Balance activity with rest periods. be expressed. Ask how the client tried to relieve pain.
Objective Data
NURSING PROCESS Assess vital signs, skin changes, breath sounds, and ECG
rhythm strips. Monitor vital signs for an irregular or increased
Assessment pulse, hypotension, or slight temperature elevation. The client
may have pallor, cyanosis, diaphoresis, vomiting, cool clammy
Subjective Data skin, or confusion. Assess breath sounds for lung congestion,
Note the medications the client has taken, including over- and monitor the ECG for dysrhythmias. Note any client
the-counter medications, anticoagulants, and thrombolytic clenching of hands or clutching at the chest.

Nursing diagnoses for a client with myocardial infarction include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Decreased Cardiac The client will have increased Maintain bed rest with head of bed elevated 30° until the
Output related to CO. condition is stabilized.
damaged heart tissue Auscultate breath sounds and palpate pedal pulses every 4 hours.
Administer oxygen per mask or nasal cannula at 2 to 4 L/min.
Start an IV so medications such as morphine and
antidysrhythmics can be administered.
If beta blockers are administered, monitor closely for a drop in
HR and blood pressure.
Constantly monitor the client for dysrhythmias. Place a rhythm
strip on the chart at least once per shift.
Monitor I&O.
Administer medications as prescribed by the physician.

Acute Pain related to The client will verbalize Maintain client on bed rest and observe for verbal and nonverbal
decreased oxygenation of decrease in frequency and signs of pain such as grimacing, diaphoresis, or increased HR.
myocardial tissue intensity of chest pain. Ask the client to rate the pain on a scale of 0 to 10, 0 being
no pain and 10 extreme pain.
Administer analgesic, usually morphine and oxygen, as ordered.

Risk for Activity Intoler- The client will increase Place objects within reach of the client.
ance related to decreased activities with decreased Balance activity with rest periods.
circulation to body tissues symptoms of angina, dyspnea,
cyanosis, and dysrhythmia. Assist the client and partner to discuss their fears and feel-
ings candidly about resuming sexual activity.

Death Anxiety related to The client will verbalize Encourage the family and client to verbalize their feelings.
change in health status situations that are causing Provide a quiet, calm environment to relax the client and family.
and threat of death stress.
Administer sedatives to help the client relax and provide
periods of uninterrupted rest.
Since the myocardial client may be in denial, be aware of
denial symptoms such as attempting to conduct business
over the phone while hospitalized or statements that the pain
is really nothing.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 5 Cardiovascular System 143

■ HEART FAILURE Medical–Surgical Management

H
Medical
F is often the final stage of many other heart conditions.
A weakened muscle wall from a myocardial infarction Goals for treating HF are to improve circulation to the coro-
or a heart that has been stressed over a period of time to meet nary arteries and decrease the workload of the left ventricle.
metabolic needs of the body can cause HF. HF develops when To meet these goals, cardiac efficiency is increased with medi-
the heart is no longer capable of meeting the oxygen needs cation; oxygen requirements of the body are decreased by bed
of the body. The muscles of the left ventricle hypertrophy rest with the head elevated 45 degrees; edema and pulmonary
(increases in muscle mass), and often the ventricular chamber congestion are treated with medications, diet, and restricted
enlarges in an attempt to meet the oxygen needs of the body. fluid intake; and fluid retention is monitored by weighing the
Both the right and left ventricles act as pumps for the heart. client daily. A chest x-ray directly visualizes the ventricles and
Each of these pumps can fail separately, resulting in two types of evidence of lung congestion. An ECG is done and arterial
HF: right-sided HF and left-sided HF. HF usually begins on the blood gases are evaluated. The client’s oxygen saturation level
left side. Some of the causes of right-sided failure are untreated is monitored by pulse oximetry. Depending on the seriousness
left ventricular failure, right ventricular myocardial infarction, of the client’s condition, a pulmonary artery catheter (Swan-
chronic obstructive coronary disease, cor pulmonale, and pul- Ganz catheter) may be inserted to determine left ventricular
monic valve stenosis. Left-sided failure is caused by left ventricu- function.
lar myocardial infarction, aortic valve stenosis, prolapsed valve In right-sided failure, the symptoms of edema, hepatomeg-
complications, and hypertension. Notice that right- and left-sided aly, and neck vein distention are significant diagnostic evidence.
failure are caused by a defect of the ventricle or an increased
resistance in the path of the blood pumped by the ventricles. This Surgical
causes an increased workload for the involved ventricle. Two mechanical devices are available: an intra-aortic balloon
When left-sided HF occurs, the left ventricle is not able pump and a ventricular assist device (VAD). An intra-aortic
to completely empty of blood or effectively pump blood out balloon is threaded through the femoral artery to the descend-
through the aorta to the body systems. Usually the right ventri- ing aorta (Figure 5-21). The pump is synchronized with the
cle continues to pump adequate quantities of blood. This causes contractions of the left ventricle so the balloon inflates during
blood to back up in the left ventricle, left atrium, and pulmonary diastole and deflates during systole. Inflation of the balloon
veins. The lungs become congested with fluid as fluid leaks increases the blood flow to the coronary arteries, thus increas-
through the capillaries and fills air spaces in the lungs. The client ing oxygenation of the myocardium. Deflation of the balloon
becomes cyanotic, dyspneic, restless, and coughs up blood- allows the left ventricle to pump blood to the body tissues
tinged sputum. The breath sounds have moist crackles. Often with less peripheral resistance.
the client has tachycardia with low blood pressure because the The ventricular assist device (VAD) does not replace the
heart is not able to pump sufficient blood to meet the body’s heart, but it assists a weakened heart to pump sufficient blood
demands. The client may have decreased urinary output because throughout the body. It is referred to as “a bridge to transplant”
enough blood is not pumped through the kidneys. As the blood because a client uses the VAD while waiting for a heart transplant.
oxygen level decreases, the client becomes confused. Some clients who are not transplant candidates may use the VAD
As the right side of the heart fails, blood becomes congested until death. A left VAD takes blood from the left ventricle and
in the inferior vena cava, causing edema first in the extremities delivers it to the aorta (see Figure 5-22); a right VAD takes blood
and then in the trunk of the body. As the condition progresses, from the right ventricle and delivers it to the pulmonary artery.
the client experiences edema of the ankles, lower legs, thighs, Potential complications are bleeding, blood clots, respiratory
and finally in the abdomen. The excess abdominal fluid causes failure, renal failure, infection, stroke, and device failure.
the client to be anorectic. Hepatomegaly (enlargement of the
liver) and splenomegaly (enlargement of the spleen) develop. Pharmacological
The jugular veins in the neck become distended when the cli- Medications to reduce the heart’s workload in moderate HF
ent is sitting or standing, and pitting edema occurs in the lower are angiotensin converting enzymes (ACE) inhibitors, angio-
extremities. Refer to Figure 5-6. Oliguria occurs as decreased tensin receptor blockers, vasodilators, nitrates, beta blockers,
amounts of blood are pumped through the kidneys. diuretics, digitalis, and aspirin (Table 5-4). The client with HF
In the early stages of HF, the client experiences fatigue, will receive diuretics such as furosemide (Lasix) to decrease
dyspnea with slight exertion, pedal edema, and a slight cough fluid retention. ACE inhibitors, such as captopril (Capoten)
with a small amount of expectoration. The client may also or enalopril (Vasotec), are given to reduce blood pressure and
have paroxysmal nocturnal dyspnea. peripheral arterial resistance and improve CO. Beta blockers
carvedilol (Coreg) and metoprolol succinate (Toprol XL),
CRITICAL THINKING the only beta-blockers approved for HF in the United States,
are then added (Ammon, 2001). A digitalis preparation may
Lifestyle Changes for MI be required to increase the strength and contractility of the
heart muscle. Vasodilators such as nitroglycerin (Cardabid)
are given to dilate the veins so the blood will stay in the periph-
What would you teach a client to assist him in
eral vessels and decrease blood return to the right side of the
decreasing risk factors for an MI? heart, thereby decreasing the workload on the heart. Clients
What lifestyle changes could you take to decrease in severe HF who are already taking an ACE inhibitor may be
the risk factors for an MI? given spironolactone (Aldactone) (Ahmed, 2008). Morphine
sulfate is given in the acute phase to control pain and decrease
anxiety.

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144 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Image not available due to copyright restrictions

PROFESSIONALTIP
Cardiac Early cardiac Late cardiac
systole diastole diastole Digoxin in Older Adults
HF is the leading cause of hospitalization in adults
65 years of age and older. New data indicates that
a low dose (0.125 mg/day or lower) of digoxin
decreases hospitalization due to HF and may also
reduce mortality. Lower doses also decrease the risk
of digoxin toxicity and the need for frequent serum
digoxin levels. Digoxin in low doses is recommended
for older adults with chronic HF (Ahmed, 2008).
COURTESY OF DELMAR CENGAGE LEARNING

Balloon
Activity
Balloon Balloon fully
collapsed inflating inflated Activity orders will depend on the client’s activity tolerance.
The client’s activity may vary from strict bed rest to ambula-
tion depending on the severity of the condition. When in bed,
B
the head of the bed is elevated 45 degrees. Visitation privileges
are monitored to provide rest periods.
Figure 5-21 An intra-aortic balloon pump increases
circulation to the coronary arteries and decreases the workload Health Promotion
of the left ventricle.
The most common cause of HF is left ventricular failure after a
myocardial infarction. To prevent HF following coronary artery
disease, a diet low in fat, high in fiber, and balanced in caloric
intake to maintain optimum weight is recommended. Stress
Diet reduction and a regular exercise program will also decrease the
A daily weight and strict intake and output are necessary to risk of developing HF. Clients with congenital heart defects
assess fluid retention. Sometimes fluid intake is limited. The may not be able to prevent HF, but following the prescribed
client is generally on a low-sodium diet. medical regimen may prevent the early development of HF.
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 CHAPTER 5 Cardiovascular System 145

Table 5-4 Recommended and Contraindicated Medications in Heart Failure

RECOMMENDED MEDICATIONS FOR HEART CONTRAINDICATED MEDICATIONS FOR HEART
FAILURE THERAPY FAILURE PATIENTS
• Loop diuretics for volume overload • Alcohol
• ACE inhibitors (titrate upward to optimal dose) • Cocaine
• Beta blockers (titrate upward to optimal dose with sup- • Antiarrhythmic agents except amiodarone
port and monitoring) • Calcium channel blockers except amlodipine
• Digitalis • NSAIDs (associated with development of CHF and interact
• Spironolactone for advanced heart failure (with optimal with ACE inhibitors)
doses of ACE inhibitors and beta blockers. Monitor for • Thiazolidinediones (may cause fluid retention)
complications such as hyperkalemia)
• Metformin
• ARBs if ACE inhibitors are not tolerated
From State of the Science for Care of Older Adults with Heart Disease, by C. Deaton, J. Bennett, & B. Riegel, (2004). In Nursing Clinics of North America,
39(3), 495–528; Polypharmacy and Comorbidity in Heart Failure, by F. Masoudi & H. Krumholz, (2003), in British Journal of Medicine, 327(7414), 513–514.

Nursing Management Objective Data

Monitor client’s level of consciousness, skin color and turgor, Assess the client’s level of consciousness to determine cir-
and jugular veins for distension. Assess breath, heart, and bowel culation of blood to the brain. Check skin color for pallor or
sounds. Check capillary refill and peripheral and abdominal cyanosis. Assess skin turgor to help determine the level of
edema. Weigh client daily at same time, on same scale, in same hydration. Jugular distention indicates right ventricle func-
type of clothes. Monitor electrolytes and vital signs. Keep bed tioning. Assess breath sounds for adventitious sounds and
in semi-Fowler’s position. Maintain accurate intake and output. heart sounds for gallop or murmurs. Bowel sounds may be
Provide frequent rest periods and minimal interruptions at hypoactive depending on the amount of fluid retention in
night. Teach about disease process, medications, and diet. the abdomen. Check peripheral pulses and capillary refill to
assess the level of circulation to the extremities. Assess edema
in the extremities and abdomen according to the edema rating
NURSING PROCESS scale. Monitor the client’s weight daily for possible increase
from fluid retention. The physician should be notified if there
Assessment is a gain of more than 2 pounds in one day. Monitor I&O and
assess for oliguria.
Subjective Data
Ask the client about dyspnea, orthopnea, fatigue, anxiety,
weight gain, edema, pain, or difficulty in performing activities
of daily living.

Nursing diagnoses for a client with HF include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Decreased Cardiac The client’s vital signs will Take an apical pulse on all cardiac clients, especially checking
Output related to remain stable. the rate and rhythm.
mechanical failure of heart The client will have Monitor the client’s HR and rhythm by telemetry.
muscle decreased adventitious Auscultate breath sounds every 4 hours.
breath sounds.
Administer diuretics, digitalis, and vasodilators as prescribed.
Closely monitor the electrolytes, especially the potassium
level, as diuretics can deplete the potassium level. Administer
potassium supplements as ordered.
Take the apical pulse before giving a digitalis preparation. If
the HR is below 60, withhold the medication and notify the
physician. In some institutions the HR can drop to 50 before
the physician is notified if the client is taking a calcium channel
blocker or beta-blocker along with digitalis.

(Continues)

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146 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with HF include the following: (Continued)

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client will have Provide oxygen by mask or nasal cannula at 2 to 6 L/min. Apply
related to decreased CO increased gas exchange. a pulse oximeter and monitor the oxygenation status. If the
and pulmonary edema pulse oximeter is ≤90%, notify the physician.
Elevate the head of the bed to a semi-Fowler’s or Fowler’s
position to relieve pressure on the diaphragm.

Excess Fluid Volume The client will have less Encourage elevation of the client’s legs, not letting them hang in
related to decreased edema of the extremities. a dependent position.
cardiac output and Maintain an accurate intake and output.
decreased renal output
Weigh daily at the same time each day, on the same scales, and
with the client wearing the same type of clothing.
If the client is on a fluid-restricted diet, offer hard candies to
quench the thirst.

Risk for Activity The client will have an Schedule nursing care so the client is given frequent rest periods
Intolerance related to increased tolerance for with minimal interruptions at night.
edema, dyspnea, and activity. Teach the client to take frequent rest periods and to stop activities
fatigue before becoming tired.
Monitor the client’s vital signs for an increase or decrease in HR or
blood pressure, especially after periods of activity.
Have an occupational therapist assist the client in energy saving
methods.
Instruct the client to call the physician if there is more dyspneic, fa-
tigue, less activity tolerance, or weight gain or loss when at home.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

rejected. Some immunosuppressant medications are azathio-

COR PULMONALE prine (Imuran), cyclosporine (Sandimmune), antithymocytic

I
globulin, ATG (Atgam), antilymphocytic globulin (ALG),
n this condition, the heart is affected because of a lung con- rapamycin, and FK 506 (Prograf).
dition that interferes with the exchange of carbon dioxide
and oxygen in the alveoli. The carbon dioxide level increases
in the blood. For some unknown reason, the pulmonary PERIPHERAL VASCULAR
arteries vasoconstrict, causing pulmonary hypertension. The
right ventricle is forced to pump against increased pulmonary DISORDERS

D
pressure. The right ventricle enlarges and finally weakens in
isorders in this category include aneurysm, hyperten-
the attempt to pump blood into the lungs. The symptoms the
sion, venous thrombosis/thrombophlebitis, varicose
client experiences and medical and nursing care are the same
veins, Buerger’s disease, and Raynaud’s disease.
as for right-sided HF.

CARDIAC TRANSPLANTATION ■ ANEURYSM

C ardiac transplantations are done for cardiomyopathy,

end-stage coronary artery disease, and valvular disease.
Recipients are evaluated for emotional stability, minimal
A n aneurysm is a localized dilation occurring in a weak-
ened section of an artery’s medial layer. The main cause
for aneurysms is atherosclerosis (Mayo Clinic, 2002). Some
disease involvement, and a good support system. The heart aneurysms occur because of congenital conditions such as
donor and the recipient’s tissues are matched. Marfan’s syndrome or because of trauma to the vessel wall.
The transplant is performed by removing the recipient’s Two other possible causes of an aneurysm are an increased
heart except for posterior sections of the atria. The posterior turbulence in a section of the vessel and a slower production of
sections of the atria are removed from the donor’s heart, and smooth muscle cells. Clients have a higher tendency to develop
then the heart is sutured to the recipient’s posterior atria. an aneurysm if they smoke cigarettes and have hypertension.
The recipient must remain on an immunosuppressant Aneurysms can occur in any artery but occur most often
medication for the remainder of life so the donor heart is not in the abdominal aorta. Abdominal aneurysms occur more

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 5 Cardiovascular System 147

frequently in men over the age of 55 (Mayo Clinic, 2002).

Other involved vessels are the ascending, transverse, and
descending aorta, thoracic aorta, popliteal arteries, and femo-
ral arteries.
Deposits of atherosclerotic plaque on the tunica intima
cause a hardening of the vessel, and the media layer of the ves-
sel loses elasticity. Atherosclerosis and a lack of elastin in the
vessel wall predisposes the vessel to a weakened area, which

COURTESY OF DELMAR CENGAGE LEARNING

develops into an aneurysm.
Symptoms of an aneurysm depend on its location.
Aneurysms are often asymptomatic until they start leaking
or pressing on other structures. A thoracic aneurysm may
press on surrounding structures, causing dull upper back
pain or deep, scattered chest pain. Pressure on the trachea
and bronchus may cause dyspnea, coughing, wheezing,and
hoarseness. Pressure on the esophagus causes dysphagia. A B
The most common location of an abdominal aortic
aneurysm is between the renal and iliac arteries. There Figure 5-23 A, Aortoiliac Aneurysm; B, Bifurcated
may be no symptoms, but as it enlarges and presses on Synthetic Graft
other vessels, organs, and nerves, the client may experience
abdominal, back, or flank pain. The client may feel a pulse in coming from the heart. Clients with hypertension are given
the abdomen when in a supine position. A tender pulsating antihypertensive medications and diuretics. Analgesics are
mass may be palpated slightly left of the umbilicus. Popliteal given to control pain.
and femoral aneurysms may cause decreased pedal pulses.
Rupture of an aneurysm is an emergency situation. Signs of Activity
rupture may include hypotension, tachycardia, pallor, cool Any activity that increases blood pressure, especially exercise
and clammy skin, and intense abdominal, back, or groin and lifting, can increase pressure in the arteries and should be
pain. An aneurysm is usually diagnosed when a client has an avoided.
x-ray or ultrasound done for other conditions/symptoms.
Health Promotion
Medical–Surgical Clients are encouraged not to smoke. Education for the hyper-
Management tensive client includes the importance of closely monitoring
the blood pressure and taking antihypertensive medication as
Medical prescribed.
If the client has hypertension, control of the hypertension is
the focus of care. Aneurysms are monitored for enlargement.
Thrombi formation and ischemia may also result. Nursing Management
Preoperatively, monitor vital signs and peripheral pulses.
Surgical Assess capillary refill, feet for mottling, and for edema. Post-
operatively, add checking operative site frequently. Check
Before elective surgery, the status of the client’s carotid arteries
function and drainage of NG tube. Measure abdomen for
and peripheral vessels are checked with a Doppler ultrasound.
increasing size indicating internal hemorrhage. Measure out-
Cardiac status is usually evaluated by a stress test or cardiac
put hourly for at least 25 to 30 mL of urine.
catheterization before surgery is scheduled. The surgeon often
orders an angiogram, ultrasound, or CT scan of the affected
vessel before surgery to assess the blood supply to the area NURSING PROCESS
surrounding the aneurysm. Before surgery, 4 to 8 units of
blood are placed on hold because hemorrhage is a possibil-
ity. The surgeon clamps the aorta, removes the section of the
Assessment
vessel involving the aneurysm, and replaces it with a section Subjective Data
of the client’s saphenous vein or a synthetic graft (Figure Preoperatively, the client may be concerned about an abdomi-
5-23). Complications that can occur from clamping the aorta nal pulsation when reclining. The client may have chest, back,
are myocardial infarctions, strokes, and renal damage. Vessels abdominal, or flank pain depending on the aneurysm location.
below the repaired aneurysm may become occluded because Postoperatively, listen for statements of pain and assess the level of
of decreased blood flow during surgery or from plaque that pain according to a scale of 1 to 10 or the facility-approved scale.
has broken off from the wall of the vessel. A nasogastric tube
may be inserted to decrease pressure on the aneurysm repair Objective Data
site and incision. After surgery, the client may be in the ICU Palpate the abdomen for a pulsating mass, and check vital signs.
with mechanical ventilator assistance in breathing. Immediate intervention is needed if symptoms of bleeding or a
rupturing aneurysm occur. Check the peripheral pulses before
Pharmacological surgery. Pulses can then be compared preoperatively and post-
Clients with aortic aneurysms may be given propranolol operatively. Postoperatively, assess the extremities for color,
hydrochloride (Inderal) to decrease the pressure of the blood warmth, peripheral pulses, and sensation.

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148 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with an aneurysm include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Tissue The client will have well- Monitor for symptoms of an occluded vessel (pain, paleness,
Perfusion (Peripheral) oxygenated tissues as cyanosis, and coldness).
related to decreased manifested by strong pulses Monitor the temperature, color, and fullness of the peripheral pulses
arterial blood flow and the skin remaining in both extremities and compare them to the preoperative pulses.
baseline color and warm.
Assess capillary refill and client’s feet for mottling and darkened
areas on the toes and soles of the feet.
Notify physician immediately if any of these symptoms occur.

Risk for Deficient Fluid The client will have Monitor vital signs closely for signs of hemorrhage.
Volume related to adequate fluid volume. Check the operative site frequently to make sure the dressing is
hemorrhage dry. Turn the client to make sure blood is not pooling under the
client’s body. Monitor for other signs of hemorrhaging.
Measure the abdomen for increasing abdominal girth indicating
internal bleeding. If the client has low back pain, there may be
hemorrhaging in the retroperitoneal space. Other symptoms of
hemorrhage are lightheadedness, dizziness, and tachycardia.
Check for adequate functioning and drainage of the NG tube to
decrease pressure on the aneurysm repair site and incision.

Ineffective Tissue The client will have a urine Measure hourly output to make sure the client has at least 25 to
Perfusion (Renal) related output above 25 mL/hour. 30 mL of urine per hour. Assess for edema which could indicate
to interruption of blood fluid overload or a vessel occlusion.
flow during surgery Provide fluids as ordered.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Malignant hypertension is a rapidly progressing, severe

■ HYPERTENSION elevation of BP (diastolic 120 mm Hg). It damages small arte-

H
rioles in the major organs. Arteriole inflammation in the eyes
ypertension (HTN), also known as high blood pres- is the primary distinguishing finding. It is most common in
sure, is defined as an elevated arterial blood pressure. black males younger than 40 years of age.
A systolic blood pressure at or above 140 or a diastolic blood Renal diseases that interfere with blood flow to the
pressure at or above 90 indicates hypertension. Fifty million kidneys cause them to release an enzyme called renin. The
adults in the United States have hypertension (NIH, 2002). released renin interacts with plasma proteins, forming a vaso-
Before age 55, more men than women have hyperten- pressor called angiotensin. Vasoconstriction caused by angio-
sion, but after age 55, more women have hypertension (CDC, tensin increases blood pressure when more force is required
2002). Unalterable risk factors include African-American to push the blood through the vessel. Vasodilation decreases
race, male gender, aging, postmenopausal women, and fam- vascular or peripheral resistance (pressure within a vessel
ily history of hypertension. Modifiable risk factors include that resists the flow of blood such as plaque buildup or vaso-
smoking, lack of exercise, obesity, stress, low socioeconomic constriction). Figure 5-24 depicts how renal disease causes
status, diet high in sodium and fat, alcohol intake, and oral hypertension.
contraceptives. Arteriosclerosis causes the vessel walls to have less elas-
When the cause of hypertension is unknown, it is called ticity, decreasing their ability to expand and recoil. Because
primary hypertension or “essential hypertension.” Eighty the vessel is not able to expand, more pressure is needed to
to ninety-five percent of clients with hypertension have pri- force the blood through the vessel. The plaque buildup causes
mary hypertension (Klabunde, 2007). In 5% to 10% of resistance to blood flow through the vessel, and more pressure
the cases, the cause of hypertension is another condition is needed to get the blood through the vessel. Hypernatremia
within the body such as renal artery stenosis, chronic renal (increased blood sodium) causes vasocongestion, and the
disease, primary hyperaldosteronism, sleep apnea, hyper- or heart must pump with more force, increasing the pressure in
hypothyroidism, pheochromocytoma, preeclampsia, or aortic the arteries, thus causing HTN.
coarctation (Klabunde, 2007); this is known as secondary Stress stimulates the sympathetic nervous system, which
hypertension. Arteriosclerosis, atherosclerosis, hypernatremia supplies nerves to the smooth muscles of the arteries, arteri-
(increased sodium in the blood) or prolonged stress may also oles, veins, and venules. Stimulation of these smooth muscles
cause hypertension.

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 CHAPTER 5 Cardiovascular System 149

Renal disease Table 5-5 Classification Of Blood Pressure

Decreased blood flow to kidneys CATEGORY SYSTOLIC DIASTOLIC
(MM HG) (MM HG)
Release of renin
Normal <120 and <80
Renin interacts with plasma protein Prehypertension 120–139 or 80–89

Angiotensin formed Hypertension

COURTESY OF DELMAR CENGAGE LEARNING

Stage 1 140–159 or 90–99
Vasoconstriction
Stage 2 ≥160 or ≥ 100
Increased peripheral resistance
From The Seventh Report of the Joint National Committee on Preven-
tion, Detection, Evaluation, and Treatment of High Blood Pressure, 2003,
Increased blood pressure
Bethesda, MD: National Institutes of Health.

Figure 5-24 Pathophysiology of Renal Diseases and Pharmacological

Hypertension
Diuretics are usually the first pharmacological step in treating
HTN. Diuretics increase the renal excretion of sodium and
causes the vessels to constrict, leading to elevated blood water from the body, decreasing the total fluid volume. When
pressure. less fluid is in the body, less pressure or force is needed to
Some complications of HTN are cerebral vascular accident pump the blood through the body.
(stroke), myocardial infarction, HF, and renal failure. Table 5-5 Beta-adrenergic blocking agents are given to block the epi-
lists the recognized classification of blood pressure. nephrine and norepinephrine receptor sites. With these receptor
sites blocked, the vessels do not constrict and the blood has
less resistance flowing through the vessel. Diuretics and anti-
Medical–Surgical hypertensive medications may cause impotence.
Management Diet
Medical A low-fat, low-cholesterol, and low-sodium diet is encouraged.
The main goal for a client with HTN is keeping the blood Restricting sodium intake to 2.3 grams of sodium or 6 grams of
pressure within normal limits. The regimen is referred to as a sodium chloride per day assists in decreasing blood pressure.
stepped-care approach. The first step is to encourage the client Avoiding processed foods, carbonated drinks, and most cere-
to try some diet and lifestyle changes, including losing weight als helps decrease sodium intake. Encourage the client to have
if >15% over optimum weight; limiting sodium, saturated fat, an adequate intake of potassium, magnesium, and calcium.
cholesterol, and alcohol intake; exercising on a regular basis; These minerals are obtained by eating fresh oranges, bananas,
stopping the use of nicotine; and maintaining an adequate intake broccoli, and collards. Fresh foods are better sources for min-
of calcium, magnesium, and potassium. This step is tried for 3 erals than frozen foods. Yogurt is a good calcium supplement.
to 6 months, and if the BP then is < 140/90 mm Hg, these steps The National Committee on Prevention, Detection, Evalua-
are continued. If the BP still remains high, the second step is the tion, and Treatment of High Blood Pressure recommends that
addition of a diuretic or a beta-blocker to the client’s care regi- clients with hypertension not consume more than 2 ounces of
men. The client is again evaluated for a period of time, usually 2 alcohol at a time and no more than twice a week.
months. If the BP still is not <140/90 mm Hg, the third step of
increasing the drug dosage, trying another drug, or adding a sec- Activity
ond antihypertensive drug from another class of drugs is imple- A regular aerobic exercise regimen assists in lowering blood pres-
mented. If the BP is maintained at <140/90 mm Hg, the regimen sure. The client is to gradually increase the exercise period to
is continued. If the BP is still high, the last step is implemented by
adding a second or third antihypertensive drug.

COLLABORATIVECARE
Hypertension
CULTURAL CONSIDERATIONS
Assisting a client to eliminate hypertension is a
Hypertension multidisciplinary task. Members of the care team
most often include physician, nurses, dietitian,
African-American clients develop hypertension fitness center therapist, smoking cessation
earlier in life, and it is more severe at any decade counselor, and stress management advisor.
of life, than other ethnic groups.

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150 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

CRITICAL THINKING
NURSING PROCESS
Lifestyle Changes for Hypertension Assessment
How can you best teach the hypertensive client Subjective Data
ways to modify the present lifestyle? Ask about general lifestyle habits such as smoking, alcohol
consumption, exercise routine, dietary intake, and family
history of hypertension. Note any dizziness, blurred vision,
and headache in the occipital region upon rising in the
morning.
30 to 45 minutes 3 to 5 times per week with a pulse rate at 75%
of the target HR (target HR = 220 − age × 0.75). Walking, swim-
ming, and jogging are excellent aerobic exercises. Objective Data
The basic assessment is taking the blood pressure. An accurate
Health Promotion reading requires the correct width of blood pressure cuff,
Measures to prevent hypertension are exercising regularly; determined by the circumference of the client’s extremity.
reducing sodium in the diet; maintaining an optimum weight; The cuff bladder should encircle 80% of the arm to obtain
reducing and managing stress; maintaining intake of potas- an accurate blood pressure ( JNC 7 Express, 2003). The
sium, calcium, and magnesium; decreasing alcohol consump- blood pressure is taken in both arms in supine and sitting
tion; and ceasing smoking. positions. Before taking the blood pressure, the client should
rest quietly in a chair, rather than on an exam table, for
Nursing Management 5 minutes with both feet on the floor and the arm supported
at heart level. If the client has an elevated BP, a repeat blood
Monitor BP. Make referrals to assist in lifestyle changes. pressure is taken 15 minutes later and compared to previous
Explain pathophysiology, risk factors, suggested lifestyle readings. Measure client height and weight, heart sounds, and
changes, and complications. peripheral pulses.

Nursing diagnoses for a client with hypertension include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Health The client will relate needed Make referrals to the appropriate personnel to teach
Maintenance related to changes in lifestyle habits to the client lifestyle changes. These may include a
lack of knowledge about decrease blood pressure. dietitian, smoking cessation clinic, fitness center, or
lifestyle habits contributing to stress management seminars.
hypertension Explain the pathophysiology, risk factors, lifestyle
changes, medication actions and side effects, and
complications of hypertension.

Noncompliance related to The client will keep appointments Regularly inquire about the client’s satisfaction in
individual’s value system (lack for regular check-ups and take regard to the prescribed regimen of diet, exercise, and
of physical symptoms and medications as prescribed. prescribed medication(s).
expense of medication) If the client cannot afford needed medications, refer the
client to financial assistance programs.
Encourage the client to become an active participant in
the treatment because this will give the client a sense of
control over the condition.
Encourage the client to record BP readings, weekly
weight, exercise activities, and dietary intake as a
way of giving a sense of control and encouraging
compliance.

Imbalanced Nutrition: More The client will maintain weight at Give basic dietary instructions as stated under
than Body Requirements no more than 15% over optimum medical management or make a referral to a dietitian.
related to excess caloric intake weight and have no more than Weigh the client at scheduled appointments.
and excess sodium intake 2.3 grams of sodium per day.

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 CHAPTER 5 Cardiovascular System 151

Nursing diagnoses for a client with hypertension include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Sexual Dysfunction related The client will state satisfaction Because diuretics and antihypertensive medications
to altered body structure or with sexual function while taking may cause impotence, discuss this effect in an open
function and side effects of antihypertensive medications. and candid manner, so the client and spouse will be
antihypertensive medications feel comfortable discussing sexual difficulties.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Hypertension

T.L., a 28-year-old African-American client, is in his last year of law school and is clerking for a prestigious law
firm. He and his fiancé plan to marry as soon as he graduates. During the last week he has had four dizzy spells
and a headache at the base of his skull upon awakening for the last 2 days. His father has a history of hyper-
tension, so T.L. is aware that his symptoms may indicate high blood pressure. T.L. stops by the clinic on his way
home from work and asks the nurse to check his blood pressure. The nursing assessment has the following data.
Subjective data: States he has had four dizzy spells and has awakened with a headache in the occipital
lobe the last two mornings. T.L. has 1 glass of wine at lunch and 2–3 beers in the evening to relax from
the tension of school and work. Most of his meals are at fast-food establishments and have a high fat
content. T.L. does not smoke. He used to jog 4 mornings a week but quit when he started clerking. He has
had nocturia for the last 3 weeks. He is not taking any medication. T.L. states he is concerned about having
hypertension because he does not want to take medication.
Objective data: T 98.6°F, AP 78 beats/min, R 16 breaths/min, BP 142/92 mm Hg, Wt 190 lbs (optimum
weight 160). No edema noted in hands, feet, or legs.
NURSING DIAGNOSIS 1 Ineffective Health Maintenance related to ineffective individual coping as
evidenced by high-fat diet, lack of exercise, stressful job, and alcohol intake
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Health-Promoting Behavior Health Education
Knowledge: Health Promotion Self-Responsibility Facilitation
Risk Identification

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

T.L. will change lifestyle habits by Refer T.L. to a dietitian to learn ways Knowledge encourages
engaging in aerobic exercises at to cut fat and sodium in his diet. compliance.
least 3 times a week for 30 to 45
minutes, stating three ways to Discuss ways T.L. can exercise and Encourages exercise if he sees
reduce stress, and limiting alcohol still meet responsibilities of work, ways that he can still meet
consumption to 2 ounces twice a school, and personal and social life. responsibilities of life.
week.
Explain alcohol content in various Encourages compliance.
beverages.

EVALUATION
T.L. begins exercising with his fiancé 3 times a week. T.L. uses breathing techniques and a hot shower to
reduce daily stress. T.L. limits alcohol consumption to 1 beer a day.
NURSING DIAGNOSIS 2 Imbalanced Nutrition: More than Body Requirements, related to excessive
caloric intake as evidenced by 30 pounds overweight and high-fat diet
(Continues)

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152 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

SAMPLE NURSING CARE PLAN (Continued)

Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)

Nutritional Status Nutrition Management
Teaching: Nutrition Nutrition Monitoring

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

T.L. will lose 30 pounds and Refer T.L. to a weight support It is easier to lose weight with
maintain a low-fat, low-sodium group. support of others.
diet. Encourage T.L. to record a weekly Promotes self-care.
weight and daily intake of fat.

EVALUATION
T.L. is maintaining a diet low in sodium and no more than 30 grams of fat per day. T.L. keeps a weekly
record of his weight.

NURSING DIAGNOSIS 3 Anxiety related to threat to or change in health status and stress as evi-
denced by alcohol consumption to relax and statement of not wanting to take medications
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Anxiety Reduction Anxiety Reduction
Coping Anticipatory Guidance

PLANNING/OUTCOMES INTERVENTIONS RATIONALE

T.L. states preventive measures to Have T.L. identify stress factors in life. Action to cope with stressors
reduce blood pressure. can be taken only if stressors are
identified.

Discuss stress reduction techniques Knowledge promotes compliance.

with T.L.

Discuss risk factors of hypertension Promotes identification of risk

and ways to reduce it. factors in personal life.

Explain to T.L. and his fiancé Knowledge promotes compliance.

that hypertension is a chronic
condition, possibly without
symptoms, but with some
potentially serious complications.

EVALUATION
T.L. states four ways to reduce blood pressure.

blood pooling in the vessel, trauma to the vessel’s endothelial

■ VENOUS THROMBOSIS/ lining, or a coagulation problem with little or no inflammation
in the vessel. Thrombophlebitis is the formation of a clot
THROMBOPHLEBITIS caused by an inflammation in the wall of the vessel.

T he terms phlebitis, thrombosis, phlebothrombosis, and throm-

bophlebitis are often used interchangeably even though
each word has a separate meaning and etiology. Phlebitis is an
In 1846, Virchow listed three factors leading to the
formation of a clot: pooling of blood, vessel trauma, and a
coagulation problem. These are known as Virchow’s triad.
inflammation in the wall of a vein without clot formation. The Risk factors for thrombi formation are prolonged bed rest, leg
formation of a clot in a vessel is a thrombosis, and a formed trauma, oral contraceptives, obesity, varicose veins, hip frac-
clot that remains at the site where it formed is a thrombus. If tures, and total hip and knee replacement.
the thrombus moves, it becomes an embolus, a mass such as There are two types of thrombi: a superficial thrombus
a blood clot or an air bubble that circulates in the bloodstream. and a deep vein thrombus (DVT). A superficial vein thrombus
Phlebothrombosis is the formation of a clot because of forms in a superficial vein such as the saphenous vein in the leg.
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 CHAPTER 5 Cardiovascular System 153

A DVT forms in the deep veins of the arms, pelvic area, or legs, if the tissue in the area becomes ischemic or gangrenous or if
but the legs are the most common site. Leg veins in which clots the client has a history of thromboemboli.
form are the femoral, popliteal, iliac, and deep veins of the calf. Another surgical procedure is a vena cava interruption
Phlebitis can either form spontaneously or as a result of surgery (venacaval plication) in which a Greenfield vena cava
IV catheters or cannulas, IV medications such as potassium or filter or umbrella filter is placed in the inferior vena cava to
antibiotics, or direct trauma to a vein. A clot may then form as prevent thromboemboli from traveling from the lower extrem-
red blood cells pass over the damaged area, rupture, and start ities to the lungs, heart, or brain. Figure 5-25 shows these
the clotting process. filters and their placement in the vena cava. The procedure is
Phlebitis manifests as a reddened streak over a vein. If a clot done on clients with a history of pulmonary emboli.
is in a superficial vein, the site becomes reddened, warm, tender,
and swollen. A hardening is palpated in a section of the vein. Pharmacological
There are no symptoms with a deep vein thrombus, or there
If a client is at risk for a thrombus or phlebitis, anticoagulant
may be warmth and tenderness at the site, unilateral edema of
therapy is initiated. A prophylactic heparin dose is given.
the affected extremity, positive Homans’ sign, dilation of super-
Enoxaparin injection (Lovenox), a low-molecular-weight hep-
ficial veins, and cyanosis of the foot. The client may say the leg
arin, is used prophylactically after hip replacement surgery. It
feels “tight” or “heavy.” If the clot is in the calf of the leg, the calf
should be used cautiously with clients on oral anticoagulants.
may feel tender. If the swelling restricts the arterial blood flow,
If a clot forms, the client is immediately started on heparin
the leg may be cool and pale. If there are obvious clinical signs of
as an IV bolus and then followed with a continuous IV drip of
a thrombosis, Homans’ sign should not be assessed because the
heparin. Before heparin is started, a partial thromboplastin time
clot may be dislodged and become an embolus.
(PTT) or activated partial thromboplastin time (APTT) and a
A complication of a DVT is a pulmonary embolus that
platelet count are drawn by the laboratory to establish a baseline
may result in death. Symptoms of a pulmonary embolus
level. The heparin dose is regulated by the PTT or the APTT.
are sudden and severe chest pain, dyspnea, and tachypnea.
For effective heparin therapy, the client’s PTT or APTT level
Emboli may travel and block other vessels in the heart, brain,
should be 2.5 times the baseline. A baseline level is a value at
or peripheral vessels. a particular time that serves as a reference point for future value
Medical–Surgical levels.
Clients are usually discharged on Coumadin. Because
Management of rapid hospital discharges, clients are often started on Cou-
madin the next day after heparin has been initiated. Once the
Medical Coumadin dose is regulated, heparin is stopped.
A superficial phlebitis or thrombus may need no treatment, or
warm soaks may be applied to the affected area. Acetamino-
phen or an NSAID is given for pain. Elevating the extremity cm Renal
decreases swelling and improves venous return. Some doctors Veins
1
recommend the application of elastic support hose. If a DVT
is diagnosed, the client is placed on bed rest. Once the client
improves and becomes ambulatory, below-the-knee compres- Filter
sion stockings are recommended. 2

Surgical A 3
If a clot has formed in a large vein and all conservative meth-
ods have failed, the clot may be removed surgically. This Vena
procedure is called a thrombectomy and is performed only Cava
4

CLIENTTEACHING 5

Thrombophlebitis
• Drink 2 to 3 quarts of water per day.
• Do not sit with legs crossed.
• Elevate both legs when sitting.
COURTESY OF DELMAR CENGAGE LEARNING

• Avoid sitting or standing for extended periods.

• Wear support hose.
B
• When standing, shift weight frequently and
occasionally stand on tiptoes to stimulate the
calf muscle to pump blood.
• Notify the physician immediately if leg pain,
tenderness or swelling, difficulty breathing, or
chest pain is experienced. Figure 5-25 Filter in the Vena Cava Prevents an Embolus
from Traveling to the Heart, Lungs, or Brain; A, Greenfield Filter
in Place; B, Umbrella Filter

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154 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

After the initial Coumadin dose, the daily Coumadin

dose is regulated by the prothrombin time (PT) or the
Nursing Management
International Normalized Ratio (INR). The client generally Monitor vital signs for changes and IV sites for redness and
remains on Coumadin for 3 to 6 months. warmth. Do not do a Homans’ sign if there is a diagnosis of
Thrombolytic drugs, urokinase (Abbokinase), strepto- a thrombus. Measure the circumference of the affected leg.
kinase (Streptase), and tissue plasminogen activator, t-PA Assess peripheral pulses and capillary refill. If on anticoagulant
(Alteplase), are used locally and systemically if there is a mas- drugs, assess for signs of bleeding. When on bed rest, elevate
sive DVT. Streptokinase should only be used on the same client the entire affected leg. Remove elastic support or pneumatic
once every 6 months. If the client has had a recent streptococcal compression stockings daily for hygiene.
infection, streptokinase may not be effective (Spratto & Woods,
2010). The main complication in a client receiving throm-
bolytic drugs is bleeding. Heparin and Coumadin are given NURSING PROCESS
after the thrombolytic drugs to prevent thrombi formation.
Assessment
Diet Subjective Data
Adequate hydration is important for clients at risk for Ask the client if there was any recent injury to the extremity,
thrombi. This is accomplished orally or intravenously. if the affected area is tender to the touch, or if there have been
clots previously. Note any chest pain, dyspnea, tachycardia, or
hemoptysis.
Activity
During the acute stage, the client is placed on bed rest to pre- Objective Data
vent the clot from dislodging and embolizing. Later, the leg is Check IV sites at least once per shift to see if a phlebitis or
elevated periodically to improve venous return and decrease reddened area is developing at the insertion site. If a positive
swelling. The client’s leg should never be massaged because a Homans’ sign is detected during an assessment, notify the phy-
clot could be dislodged and become an embolus. sician and do not perform another Homans’ sign until a clot has
been ruled out. Assess the skin for redness, tenderness, hard-
ness, or warmth, and measure both legs to determine baseline
Health Promotion measurements. Measure the circumference of the affected leg
Prevention is the best way to treat a DVT. Early ambula- every shift to determine an increase or decrease in swelling.
tion, adequate hydration, alternating pneumatic compression Assess peripheral pulses every 4 hours and more frequently if
devices, prophylactic anticoagulants, elevation of legs, leg the client experiences increased pain in the leg, cyanosis of the
exercises, and deep breathing exercises all contribute to the foot or extremity, or increased swelling. These are signs of an
prevention of thrombi. occlusion.

Nursing diagnoses for a client with a venous thrombosis include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Tissue Perfusion The client will have adequate Elevate the client’s entire affected leg when on bed rest to
(Peripheral) related to tissue perfusion. improve venous return. When elevated, the leg should be
decreased venous blood flow slightly flexed at the knee with a pillow under the thigh and calf.
and/or clot formation Apply elastic support or intermittent pneumatic compression
stockings on the client. Use intermittent pneumatic
compression stockings only if a clot is not present.
If the client has received thrombolytic or anticoagulant drugs,
assess for signs of bleeding, which include hematuria, bruis-
ing, bleeding from the gums, and blood in the stool.
Monitor pedal pulses and capillary refill and measure thigh
or calf circumference daily.

Acute Pain related to inflam- The client will state absence If the client has phlebitis, apply warm moist soaks to the
matory process of pain. affected area as ordered.
Administer acetaminophen or a nonsteroidal anti-
inflammatory as ordered for discomfort.

Anxiety related to possibility of The client will express anxiety Encourage client to discuss the possibility of embolus
the clot becoming an embolus about possible embolus. formation.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 5 Cardiovascular System 155

measure is used when there is a threat of thrombus or leg ulcers.

■ VARICOSE VEINS Vein ligation is tying off an involved section of a vein with

V
suture. Endovenous laser ablation is another method of treating
aricose veins, also called varicosities, are visibly promi- varicose veins.
nent, dilated, and twisted veins, usually in the lower
extremities, but the veins in the esophagus (esophageal Pharmacological
varices) and anus (hemorrhoids) can also be affected. Usually,
the saphenous vein is affected in the leg. Women are more Analgesics are given for leg discomfort. Anticoagulants may be
prone to varicose veins than men. Risk factors for developing given to prevent clot formation.
varicose veins are a familial tendency, congenital abnormali-
ties, pregnancy, obesity, constrictive clothing, and occupa- Activity
tions that require prolonged standing. Pregnancy and obesity The client is encouraged to exercise regularly. Walking is a
cause more pressure in the veins of the legs. very good exercise to improve circulation because the blood
The causes of varicose veins are incompetent valves and circulates faster in response to an increased heartbeat. Muscles
veins that have lost their elasticity. The wall of the vessel is in the legs apply pressure to the veins, forcing the blood
weakened from a lack of elastin or collagen and is unable to toward the heart. Ankle exercises such as rotating the ankle in
support the normal pressure of the blood in the vessel. The circular motions also improves circulation.
vein dilates as the blood in it flows backward. As the walls of
the vein dilate, the valves become incapable of holding the Health Promotion
blood and allow blood to leak backward through the space
between the valves. Refer to Figure 5-5C. The client has pain Encourage clients with a familial tendency for varicose veins
in the feet and ankles, swelling, and ulcers on the skin. Trende- to elevate their legs 6 to 10 inches on a small stool when sitting
lenburg’s test is used for diagnosis. in a chair. Frequent position changes and not standing in one
spot for extended times also improve circulation.

Medical–Surgical Nursing Management

Management Assist the client in elevating the legs above the heart when in
Medical bed or elevating the feet 6 to 10 inches on a pillow or stool
when sitting in a chair.
Varicose veins are usually treated conservatively with elastic After sclerotherapy, the affected area may be tender
support hose, elevation of the legs when sitting, not crossing and discolored. Most discoloration will disappear in a few
legs, and ankle and leg exercises. weeks, but a darkened pigmentation may last for 6 to 8
Sclerotherapy involves injecting a chemical into the vein, months. Repeated sclerotherapy may be needed. Encourage
causing the vein to become sclerosed (hardened) so blood no the client to maintain a walking exercise program to improve
longer flows through it. A compression bandage or elastic stock- circulation to the legs.
ing is applied to the extremity for 4 to 5 days. The client wears After a vein stripping, the client is on bed rest for the first
support hose for 5 more weeks. Complications of the procedure 24 hours. Elastic hose are worn continuously for 5 days to
are necrosis (tissue death) at the injection site, vasospasm, aller- compress the blood into the deeper veins and for 5 weeks after
gic responses, and hemolysis (destruction of red blood cells). the surgery. Administer pain medication 30 minutes before the
client ambulates until walking is tolerated without discomfort.
Surgical Encourage walking and leg exercises.
In more severe cases, varicose veins can be ligated (tied off)
or stripped. Vein stripping involves introducing a wire into a
vein. The wire has collapsible claws on the end. As the wire is ■ BUERGER’S DISEASE
withdrawn, the claws expand and strip the walls of the vein. This (THROMBOANGIITIS
OBLITERANS)
CLIENTTEACHING
Varicose Veins B uerger’s disease is an inflammatory disease of small and
medium arteries and veins that leads to vascular obstruc-
tion. Inflammation occurs in the adventitia and media layers
Apply support hose after the legs have been of the vessels and may affect only a portion of the vessel or
elevated for an extended time, 10 to 15 minutes, the entire vessel. Hands and feet are mainly involved, but
so the venous blood drains from the legs. Applica- the wrists and lower extremities may also be affected. The
tion before getting out of bed in the morning is distal tips of the hands and feet are pale, but as the disease
ideal. Do not fold or roll hose down from the top progresses, the hands and feet become reddened when held
because this would act like a tourniquet, causing in a dependent position. At first, pain in the palm of the hand
pooling of blood. Smooth the hose on the legs
and arch of the foot is the main symptom. Pain becomes more
severe with disease progression, and as ischemia affects the
because wrinkles or creases may cause extra pres-
nerves, the client may experience numbness, burning, pain
sure, leading to stasis or pooling of blood or pres- when at rest, and decreased sensation in the hands and lower
sure ulcers. Remove hose daily so the leg can be extremities. The dorsalis pedis, posterior tibia, and ulnar and
washed and dried before reapplication. radial pulses are weak or absent. Skin color changes, cold sen-
sitivity, ulcers, and gangrene occur in the later stages.

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156 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Buerger’s disease occurs primarily in men between the During a spasm that lasts approximately 15 minutes, the fin-
ages of 20 and 40 of Israeli, Indian, and Asian descent. There is gers become pale and then cyanotic. As the circulation returns
a correlation between smoking and Buerger’s disease. Tests for to the fingers, the fingertips become reddened and the person
diagnosis include arteriography and Doppler ultrasound. experiences a tingling or throbbing pain in the fingers. Some
people experience only pallor and cyanosis. The episode may
Medical–Surgical last 1 to 2 hours. Symptoms usually occur when the person is
Management exposed to cold or experiences emotional stress. Gangrene is
not common but can occur in the fingertips. Ulcerations can
Medical also occur and are difficult to heal because of decreased circu-
lation in the fingers.
The client is encouraged to stop smoking and is referred to a When associated with a connective tissue or collagen vas-
smoking clinic or seminar. Buerger-Allen exercises are recom- cular disease, medications, or occupational trauma, the condi-
mended and explained. Buerger-Allen exercises consist of tion is called Raynaud’s phenomenon or secondary Raynaud’s.
elevating the legs until they blanch and supporting them at Raynaud symptoms may occur 10 years before the related dis-
that angle for 2 to 3 minutes. The legs are then lowered to a ease is diagnosed. A 2-year history of signs and symptoms with
dependent position until they become red and supported at no evidence of underlying disease, especially an autoimmune
that level for 5 to 10 minutes. The legs are then placed flat on disease, is necessary for a diagnosis of Raynaud’s disease.
the bed with the client in a supine position for 10 minutes. Raynaud’s is more prevalent in cold climates. Women are
The exercises are repeated as tolerated by the client. nine times more likely to be affected than men (Raynauds
Association, 2008). Primary Raynaud’s begins between the
Surgical ages of 15 and 25 (NIAMS, 2006). Secondary Raynaud’s
A sympathectomy (excision of a nerve, plexus, or ganglion of begins later in life, between the ages of 35 to 40 (NIAMS,
the sympathetic portion of the autonomic nervous system) 2006). Persons who use vibrating hand tools such as air ham-
is done to relieve pain and prevent vasospasm in the affected mers or grinding wheels or who perform repetitive move-
area. Digits and toes are amputated if gangrene occurs. ments such as typing or playing the piano are at risk.
Diagnostic examinations include a complete blood count,
Pharmacological digital blood pressure measurement, digital plethysmography
Analgesics are given to control pain. Vasodilators are given to waveforms, and a cold-challenge test. A digital blood pres-
increase circulation to the affected area. sure of 30 mm Hg below the brachial pressure indicates a
digital artery obstruction. A sedimentation rate, antinuclear
Nursing Management antibody, and rheumatoid factor determine the presence of
autoimmune diseases. During a cold-challenge test, thermis-
Nursing diagnoses and interventions are the same as for other tors are placed on the fingers and a baseline temperature is
obstructive vascular conditions and are described under Ray- taken. The hands are submerged into ice water for 20 seconds
naud’s disease. and then removed. The temperature of the hands is then taken
every 5 minutes until it returns to the baseline level. Hand
x-rays determine the presence of subcutaneous calcium depos-
■ RAYNAUD’S DISEASE/ its and narrowing of bone in the digits. The diagnostic tests
PHENOMENON distinguish between Raynaud’s phenomenon and Raynaud’s
disease. If a client has unilateral or single-digit Raynaud’s, an

R aynaud’s disease or primary Raynaud’s is an intermit-

tent spasm of the digital arteries and arterioles resulting
obstruction or emboli is suspected.

in decreased circulation to the fingers and toes. Sometimes

the tip of the nose and ears are also affected. The cause of Medical–Surgical
the condition is unknown but seems to be related to vasos- Management
pastic disorders, a disturbance with the innervation of the
sympathetic nervous system, and angiography complications. Medical
Raynaud’s phenomenon is treated conservatively. The client
is assessed regularly for symptoms of autoimmune diseases.
MEMORYTRICK If the symptoms of Raynaud’s are caused by a vasospastic
disease, relief is best achieved with medications. Alternative
Peripheral Vascular Disorders therapies such as relaxation techniques and biofeedback may
Assessment be beneficial.
The nurse remembers 5 Ps when assessing clients
with peripheral vascular disorders:
Surgical
A sympathectomy is sometimes done to alleviate the client’s
P = Pain
symptoms; however, it usually provides temporary relief and
P = Pulse is not a routine treatment.
P = Pallor
P = Paresthesia Pharmacological
P = Paralysis Calcium channel blockers, such as nifedipine (Adalat, Procardia),
amlodipine (Norvasc), and diltiazem hydrochloride (Cardizem),

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 CHAPTER 5 Cardiovascular System 157

improve symptoms in severe Raynaud’s phenomenon by

vasodilating small vessels in the hands and feet and decreasing
Nursing Management
the frequency and intensity of attacks (Mayo Clinic, 2008). Assess digits for pallor, blanching, cyanosis, rubor, coldness,
Clients may be given nifedipine (Adalat, Procardia) at night for and texture. Encourage client to keep indoor temperature at
severe cases of Raynaud’s phenomenon. Clients may also take the a comfortable level. Teach relaxation exercises to enhance cir-
medication 1 to 2 hours before engaging in an outdoor activity culation. Encourage the use of mitts when pushing shopping
during cold weather. They may not need to take the medication carts and the wearing of wear mittens and socks to bed. Apply
during warmer months. Alpha blockers, such as prazosin lotion regularly to prevent dry, chapped skin.
hydrochloride (Minipress) and doxazosin mesylate (Cardura),
interfere with the effects of norepinephrine, a hormone causing
vasoconstriction. Some clients benefit from topical nitroglycerin.
Other drugs in Raynaud’s research trials are losartan potassium NURSING PROCESS
(Cozaar), sildenafil citrate (Viagra), fluoxetine hydrochloride
(Prozac), and prostaglandins (Mayo Clinic, 2008). Assessment
Beta blockers, birth control pills, cold medications, and Subjective Data
diet pills cause some clients to have Raynaud’s phenomenon. Ask the client how frequently the vasospastic episodes
Chemotherapy drugs such as bleomycin sulfate (Blenoxane) and occur, what symptoms are experienced, what triggers the
cisplatin, CDDP (Platinol), also cause secondary Raynaud’s. episodes, which digits are affected during an episode, and
how long the incident lasts. Inquire about daily activities
Health Promotion the client finds difficult, such as tying shoes, washing dishes,
Encourage the client to avoid decongestants, caffeine, expo- or handling frozen foods. Obtain a history of occupational
sure to cold, repetitive hand movements, and stressful situ- activities.
ations. Also encourage the client to quit smoking and avoid
secondary smoke because nicotine is a potent vasoconstrictor.
Stress management techniques (e.g., biofeedback and tai chi) Objective Data
may assist in alleviating some distress from the condition. Assess the digits for pallor, blanching, cyanosis, rubor, cold-
Wearing mittens in cold weather or when handling cold foods ness, and texture. If the disease is longstanding, the digits may
keeps fingers warmer than wearing gloves. Keeping the entire be tapered and the skin shiny in appearance. There may be
body warm is helpful. ulcerated or gangrenous areas on the fingertips.

Nursing diagnoses for a client with Raynaud’s disease include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Tissue The client will have fewer Encourage the client to use caution when engaging in activities
Perfusion (Peripheral) vasospastic episodes and that may cause a cut or scratch because healing may be
related to vasospasm of increased circulation in impaired because of decreased circulation.
peripheral arteries digits. If a client has ulcers, wash the areas with soap and water
and administer prescribed medications such as ciprofloxacin
(Cipro) and intravenous iloprost.

Acute Pain related to The client will experience Teach client to keep the indoor temperature at a comfortable
decreased circulation in decreased pain as level to avoid ischemic attacks.
digits vasospasms are controlled. Encourage client to avoid dramatic changes in environmental
temperatures (e.g., entering a cold air-conditioned room during
hot summer months). Encourage the client to wear woolen or
wind-proof gloves or mittens and layered clothes when exposed
to colder temperatures. Mittens may be better than gloves so the
fingers can obtain warmth from each other. Chemical warming
devices may be used inside gloves and shoes.
Encourage the client to stop smoking and make a referral to a
smoking cessation clinic.
Teach the client relaxation exercises that may decrease the
number of ischemic attacks.

Situational Low Self- The client will learn ways Encourage client to use mitts or potholders when removing
esteem related to inability to handle activities of daily items from the freezer or handling cold food to decrease the
of hands to perform living. risk of a Raynaud’s episode. Clients can wear mittens or
activities of daily living

(Continues)

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158 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with Raynaud’s disease include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
socks to bed. Use of insulated mugs, foam rubber holders, or
stemware glasses may reduce ischemic attacks.
Instruct client to wash vegetables under tepid water instead of
cold, to bathe in lukewarm water, and to apply lotion regularly
to prevent dry and chapped skin.
Encourage client to use gloves when pushing shopping carts or
operating some vibrating machines because this may decrease
the cold sensation and soften the vibration.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CASE STUDY
L.J., a 55-year-old truck driver, is admitted to the emergency room with a feeling of heavy squeezing pressure in
his sternal area. The pain is radiating to his left shoulder. He is diaphoretic, short of breath, and nauseated. He
states the sternal pain came on suddenly while watching a football game. He had been mowing his yard and
decided to rest. The emergency physician gives L.J. a nitroglycerin tablet and connects him to an ECG monitor.
Cardiac biomarkers (CK-MB, troponin, and myoglobin) with an IMA and a chest x-ray are requested STAT.
Morphine sulfate 2 mg is given intravenously. Oxygen is given by mask at 4 liters/minute. L.J.’s apical pulse is
102 beats/min and his blood pressure is 130/88 mm Hg. A cardiac catheterization with fluoroscopy is ordered to
determine the patency of the coronary blood vessels and functioning of the heart muscle.
Three hours after admission, crackles are heard in the lungs.
The following questions will guide your development of a nursing care plan for the case study.
1. List symptoms/clinical manifestations, other than L.J.’s, that a client may experience when having a myocardial
infarction.
2. List two reasons morphine sulfate was given to L.J.
3. List two other diagnostic tests that may have been ordered for L.J.
4. List subjective and objective data a nurse would want to obtain about L.J.
5. Write three individualized nursing diagnoses and goals for L.J.
6. L.J. is moved from the critical care unit. List pertinent nursing actions a nurse would do in caring
for L.J. related to:
oxygenation activity
cardiac output medications
comfort/rest teaching
7. List teaching that L.J. will need before his discharge.
8. List at least three successful client outcomes for L.J.
9. How might the MI symptoms for a woman differ from L.J.’s symptoms?

SUMMARY
• The function of the heart is to pump blood through the • Typical symptoms experienced by a person with cardiac
vascular system. Blood is the medium by which oxygen problems include chest pain, dyspnea, edema, fainting,
and nutrients are provided to the body cells and carbon palpitations, diaphoresis, and fatigue.
dioxide and waste products are removed from the body • A lipid profile and cardiac biomarkers provide diagnostic
cells. information about the risk of heart disease and the
• The coronary arteries supply blood to the heart. If the occurrence of a myocardial infarction.
blood flow through these vessels becomes diminished or • A dysrhythmia is an irregularity in the rate, rhythm, or
occluded, ischemia to the heart tissue occurs, resulting in conduction of the electrical system of the heart.
angina or a myocardial infarction.

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 CHAPTER 5 Cardiovascular System 159

• Inflammatory or infectious conditions of the heart • Three factors leading to the formation of a clot—pooling
include endocarditis, myocarditis, and pericarditis. of blood, vessel trauma, and a coagulation problem—are
Endocarditis may cause valvular heart disease with the called Virchow’s triad.
possibility of the valve needing to be surgically repaired • A client with a DVT may be asymptomatic or may have
(valvuloplasty) or replaced with a mechanical (caged-ball warmth and tenderness at the site, edema of the extremity,
valve or tilting-disk valve) or biological valve from a calf, a positive Homans’ sign, cyanosis of the foot, and a
pig, or human. sensation of heaviness or tightness in the extremity.
• Atherosclerosis causes a narrowing and occluding of • It is important for the nurse to measure the leg
vessels and is a primary cause of angina and myocardial circumference every shift and check peripheral pulses for
infarction. the client with a thrombus.
• Surgical treatment for angina includes a PTCA, • The cause of varicose veins is incompetent valves and
intracoronary stent, transcatheter ablation, or a coronary veins that have lost their elasticity.
artery bypass graft. • Primary Raynaud’s disease is an intermittent spasm of
• Heart failure is often the final stage of many other heart the digital arteries and arterioles, resulting in decreased
conditions in which the heart is no longer able to fulfill the circulation to the digits.
demands of the body. • Symptoms of an aneurysm depend on the location of the
• To assess the peripheral vascular system, the nurse assesses aneurysm in the body. Aneurysms are often asymptomatic
pain, pulse, pallor, paresthesia, and paralysis. until they start leaking or pressing on other structures.

REVIEW QUESTIONS
1. To assess a client with right-sided heart failure, the 2. administer oxygen.
nurse would: 3. listen to the heart sounds.
1. listen for a pericardial friction rub. 4. order cardio biomarkers.
2. listen for a muffled S1 and S2 heart sound. 7. A client is diagnosed with coronary artery disease
3. check for distended neck veins with the bed at a and his physicians recommended a coronary bypass
45-degree angle. giving the client the option of a robotic CABG. The
4. assess for radiation of the squeezing sensation client and his wife ask the advantages of a robotic
under the sternum. CABG as compared to a traditional CABG. The
2. It is important to teach a client with angina to: nurse states the advantages of robotic CABG as:
1. take antibiotics before having dental work. (Select all that apply.)
2. carry nitroglycerin tablets at all times. 1. The client has less bleeding.
3. perform the Valsalva maneuver daily. 2. The client’s recovery is 6 to 8 weeks.
4. massage the carotid sinuses in the neck. 3. The client will require less medication.
3. A nursing intervention to improve cardiac 4. The surgeon will do a complete sternotomy.
output is: 5. The client has a risk of increased infection.
1. encouraging the client to verbalize fears. 6. The client’s hospital stay is shorter.
2. teaching the side effects of new medications. 8. What ECG wave represents ventricular
3. a referral to a dietitian for low-sodium diet repolarization?
instructions. 1. P wave.
4. administer oxygen per physician orders. 2. QRS complex.
4. Instructions to a client on anticoagulant therapy 3. ST segment.
include: 4. T wave.
1. taking Coumadin twice a day. 9. A client is admitted to the floor from an intensive
2. watching for symptoms of bleeding. care unit and has a pacemaker pulse generator
3. taking over-the-counter medications as needed. lying beside his body. The client asks whether he
4. no dietary or activity limitations. will have to live the rest of his life with the pulse
5. The first step of the stepped-care approach in generator hanging from his body. The nurse’s best
treating hypertension is: response is:
1. lifestyle changes. 1. No, this is a temporary pacemaker. Your heart
2. diuretics. has maintained a regular rhythm for 2 days. As
3. beta blockers. your heartbeat continues to stabilize, it will be
4. adding a second or third antihypertensive. removed.
6. A client is admitted to the emergency room with 2. No, this is a temporary pacemaker. If you would
chest pain. The first nursing intervention is: need a permanent pacemaker, the energy source
would be placed in a belt you will wear around
1. attach the client to an ECG monitor.
your waist.

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160 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

3. Yes. The pacemaker wires will be connected to an 1. ambulate the client as soon as ordered.
energy source and placed in a belt you will wear 2. encourage the client to exercise his legs, such
around your waist. as making circular movements with his feet to
4. No, this pacemaker will be changed to an ICD increase circulation.
that will regulate your heart with intermittent 3. encourage the client to rest in bed when he is
electrical shocks. It will also regulate the rhythm dismissed.
of your heart. 4. request an order for a pneumatic compression
10. A client was admitted to the unit from the device if the client does not have one.
postoperative recovery room. He has a history of 5. check Homans’ sign every shift.
venous thrombus. Nursing measures to prevent 6. limit his fluid intake to 200 mL per shift.
the formation of a clot are to: (Select all that
apply.)

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Nursing2002, 32(4), 17. cdrh/mda/docs/p010031.html

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162 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

U.S. Food and Drug Administration (FDA). (2004). Ventricular assist Woods, A. (2001). Improving the odds against hypertension.
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RESOURCES
American Heart Association, The Mended Hearts, Inc., http://www.mendedhearts.org
http://www.americanheart.org U.S. Food and Drug Administration, http://www.fda.gov
National Heart, Lung, and Blood Institute, FDA heart health online illustration: Prosthetic heart valve,
http://www.nhlbi.nih.gov http://www.fda.gov/hearthealth/flash/fda_26.html
President’s Council on Physical Fitness and Sports, FDA heart health online illustration: Ventricular assist device,
http://www.fitness.gov http://www.fda.gov/hearthealth/flash/fda_25.html
Raynaud’s Association, Inc., http://www.raynauds.org

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 6
Hematologic and Lymphatic
Systems

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the hematologic and
lymphatic systems:
Adult Health Nursing
• Oncology • Endocrine System
• Respiratory System • Immune System
• Cardiovascular System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Relate anatomy and physiology of the blood and lymph systems to disease
processes.
• Relate diagnostic test results to the blood and lymph disorders.
• Describe nursing interventions in caring for clients with blood and lymph
disorders.
• Assist in developing a nursing care plan for clients with blood and lymph disorders.

KEY TERMS
agranulocytosis hemarthrosis leukopenia
apheresis hematocrit lymphoma
autologous hematopoiesis phlebotomy
bands hemolysis purpura
blastic phase hyperuricemia reticulocyte
erythrocytapheresis idiopathic sickle
fibrinolysis leukocytosis thrombocytopenia

163
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164 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

INTRODUCTION
The hematologic system of the body consists of blood and
blood-forming organs. Blood consists of formed elements
(red blood cells, white blood cells, and platelets) and plasma. A B
As blood is pumped through the body, it carries essential
Red blood cells Platelets
substances to the tissues and removes waste products from
the tissues. Disorders of the hematologic system usually result Granular leukocytes (granulocytes)
from abnormal production or functioning of the cells. Some
of these disorders are the result of genetics, environment, or
pathogenic organisms.
The lymph system consists of lymph vessels, nodes, and
organs. Lymph vessels collect and return lymph fluid to the
blood vessels through the right and left lymphatic ducts at the
right and left subclavian veins. The functions of the lymph Eosinophils Basophils Neutrophils
system are assisting with immunity, controlling edema, and
absorbing digested fats.
Medical management, nursing diagnoses, goals, and Nongranular leukocytes (agranulocytes)
interventions are given for each blood and lymph disorder.
A thorough understanding of the blood and lymph disorders
equips the nurse to provide quality client care.

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ANATOMY AND PHYSIOLOGY C

REVIEW Lymphocytes Monocytes

The anatomy and physiology of the blood and lymphatic
systems are discussed in the following section. Granular and nongranular white blood cells

Figure 6-1 The Cells in Blood; A, Red Blood Cells

Blood (erythrocytes); B, Platelets (thrombocytes); C, White Blood
Cells (leukocytes)
The heart pumps 5 to 6 liters of blood per minute through the
circulatory system of an adult. Blood is an aqueous mixture
consisting of plasma and cells (Figure 6-1). alveoli, blood receives oxygen (O2), and carbon dioxide (CO2)
is eliminated. The O2-enriched RBCs (oxyhemoglobin) carry
Plasma O2 to systemic capillaries, where O2 is exchanged for carbon
dioxide (CO2). The CO2-laden blood then returns the CO2 to
Plasma is a straw-colored liquid consisting of approximately the alveoli in the lungs, where it is again exchanged for oxygen.
90% water and 10% proteins. The water component assists The CO2 is exhaled from the body with each breath. Hemoglobin
in transporting body nutrients, hormones, antibodies, elec- is a protein in the RBC that carries O2 and is responsible for the
trolytes, and waste; regulating blood volume; and control- exchange of O2 and CO2.
ling body temperature. The proteins are albumin, globulins, The average life span for an RBC is 120 days. Blood cells
and fibrinogen. Albumin controls the volume of the blood originate from a single stem cell that proliferates and differenti-
and blood pressure by osmotic pressure that pulls tissue ates into lymphoid stem cells or blood stem cells (Figure 6-2).
fluid into the capillary system. There are three types of The lymphoid stem cells further divide and differentiate into T
globulins: alpha, beta, and gamma. Alpha and beta globu- cells and B cells. The blood stem cells divide and differentiate
lins are secreted by the liver and are carrier molecules for
substances. Gamma globulins are antibodies important in
the immune response of the body. Fibrinogen changes into
fibrin, a solid that controls bleeding in the blood-clotting T cells
Lymphoid stem cell
mechanism of the body. The formed elements in plasma B cells
are red blood cells (RBCs), white blood cells (WBCs), and
platelets.
COURTESY OF DELMAR CENGAGE LEARNING

Stem cell
RBCs
Red Blood Cells
Red blood cells, also called erythrocytes, are the most numer-
Blood stem cell WBCs
ous blood cells in the body, generally 4.5 to 6.1 million/mm3
in an adult. RBCs are biconcave disks that do not have a
nucleus. They are about the size of the smallest capillary but Platelets
are flexible and capable of changing shape so they can squeeze
through the capillaries.
RBCs, in conjunction with the respiratory and circulatory Figure 6-2 Origin of T Cells, B Cells, RBCs, WBCs, and
systems, oxygenate body tissues. In the capillary bed of the Platelets

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 6 Hematologic and Lymphatic Systems 165

into RBCs, WBCs, and platelets. The process of blood cell pro- Sticky platelets
duction and development is called hematopoiesis. RBCs are
produced daily by the bone marrow according to the demand of
the body. When the partial pressure of O2 decreases, a renal hor- Injury
mone, erythropoietin, stimulates the bone marrow to produce
Damaged
more immature RBCs (reticulocytes), which are released
tissue cells
into the bloodstream. These reticulocytes develop into mature
red blood cells. The number of circulating reticulocytes is used
as a diagnostic tool for RBC disorders.
As RBCs age, their outer membrane deteriorates and they Prostaglandins
are destroyed by large macrophages in the liver and are filtered
out of the body by the spleen. The iron from heme in the old cause constriction Clotting
RBCs is used in the production of new RBCs. of blood vessels factors
Hematocrit is the percentage of blood cells in a volume released
of blood. A normal hematocrit for a woman is 38% to 47% decreases blood flow
and, for a man, 40% to 54% (Daniels, 2009).

White Blood Cells Thrombo-

Prothrombin
White blood cells (WBCs), also called leukocytes, fight infec- plastin
tion and assist with immunity. The life span of a WBC varies,
depending on the type of WBC. Neutrophils, basophils, and
eosinophils live from a few hours to days, whereas lymphocytes
and monocytes live from days to years. The normal WBC count Thrombin Calcium
formed
is 4,100 to 10,800/mm3 of blood (Daniels, 2009). An increased
number of WBCs (leukocytosis) may signify the presence
of an infection, inflammation, tissue necrosis, or leukemia. A
decreased number of WBCs (leukopenia) may indicate bone
marrow failure, a massive infection, dietary deficiencies, drug
toxicity, or an autoimmune disease. Fibrinogen
WBCs are classified as granulocytes or polymorpho-
nuclear leukocytes (PMNs, or polys) and agranulocytes.
The granulocytes have granules (grainy substances) in their
cytoplasm, and the agranulocytes do not. Granulocytes are Fibrin
divided into three types: the neutrophils, eosinophils, and forms
RBCs and
basophils. Agranulocytes are classified into two groups: platelets
monocytes and lymphocytes. Neutrophils are the most enmeshed in

COURTESY OF DELMAR CENGAGE LEARNING

numerous, comprising approximately 60% of the total num- fibrin to
form clot
ber of WBCs. The main function of neutrophils is to digest
and kill microorganisms. If a client has an acute infection,
the bone marrow is stimulated to produce more neutrophils,
resulting in an increased circulation of immature neutrophils
called bands. An increased production of neutrophils indi-
cates the presence of an acute infection. An increased number
of basophils and especially of eosinophils indicates an allergic
response. Figure 6-3 The Process of Clot Formation
Monocytes become macrophages, cells that destroy
dead and injured cells and bacteria. There are two types of
lymphocytes, T cells and B cells, which are involved in the fibrin strands seal the opening or area, and a clot is formed
body’s immune response. (Figure 6-3).

Platelets Blood Types

Platelets (thrombocytes) are not typical cells but non- Genetically determined antigens called agglutinogens are
nucleated, granular ovoid, or spindle-shaped cell fragments. located on the surface of RBC membranes. The A and B
The normal life span of a platelet is approximately 10 days. antigens constitute the ABO blood group. If the A antigen is
Platelets are active in the clotting mechanism of the body. on the RBC membrane, the client has type A blood. If the B
When platelets flow over a rough or damaged area in a vessel, antigen is on the RBC membrane, the client has type B blood.
they adhere to the area and release thromboplastin and clot- If both an A and a B antigen are present, the client has type
ting factors that start the blood-clotting process. They also AB blood, and if no antigen is present, the client has type O
secrete prostaglandins and serotonin, which cause the vessel blood.
to constrict, thereby decreasing the blood flow through the Type A blood has anti-B antibodies in the serum, and
area. Prothrombin, thromboplastin, and calcium ions form type B blood has anti-A antibodies. If a person with type A
thrombin, which joins with fibrinogen to form fibrin. The blood receives type B blood during a transfusion, the anti-B

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166 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

antibodies attack the infused RBCs and hemolyze (destroy) and C viruses. When administering a blood transfusion, handle
them. The hemolyzing of RBCs releases hemoglobin that blood gently so the cells are not damaged. Administer blood
potentially causes kidney damage. within 30 minutes of obtaining it from the laboratory refrig-
A person with AB blood has neither anti-A nor anti-B erator. Take baseline vital signs—temperature, pulse, and blood
antibodies in the serum. People with AB blood are theoretically pressure—before administering the blood product. Once the
universal recipients because they can receive blood from all transfusion is started, temperature and pulse are measured
blood types. Type O blood has no antigens that the antibodies after 15 minutes, 30 minutes, and then hourly; blood pressure
can attack. Persons with type O blood can theoretically give is measured hourly during the transfusion. Blood is generally
blood to persons having any type of blood. Persons with type O administered through a peripheral vein using an 18- or 19-gauge
blood are called universal donors. The terms universal recipient cannula. A large cannula is used so the blood cells do not break
and universal donor are only theoretical because during blood when passing through the cannula.
transfusions, blood incompatibilities can occur because of other Before the transfusion, two nurses check the compatibility
types of antigens. of the blood product with the client’s blood. The first 50 mL is
There are 14 different blood groups and more than 100 given within 5 to 10 minutes. The client is observed closely for a
different antigens. The different blood groups vary in number hemolytic blood reaction during this time. If a client experiences
with different ethnic groups. any symptoms of a reaction, the infusion is stopped immediately
and the physician notified. Follow institutional protocol.
Rh Factor A blood transfusion should be completed within 4 hours of
Another factor to consider during blood transfusions is the Rh the start of administration. No medications are given at the blood
factor. Persons who have Rh antigens (the D antigen) are Rh administration site during infusion. Blood is administered with
positive. Those who do not have Rh antigens on their RBC 0.9% sodium chloride solution since other solutions cause the
membranes are Rh negative. Approximately 85% of Caucasian blood to clot.
people have Rh-positive blood and 15% have Rh-negative Autologous Transfusion If time and the client’s condi-
blood. The African-American population has 93% and 7%, tion permit, autologous (“from self ”) blood as opposed to
respectively (Daniels, 2009). homologous (“from a donor”) blood is collected and saved
If a person with Rh-negative blood is exposed to Rh- for the client. This may be used for elective surgeries. An
positive blood during a blood transfusion or during childbirth, alternate procedure is to recover the blood lost during
anti-Rh antibodies form in the blood serum. When a person surgery and transfuse it back into the client. The use of
with Rh-negative blood is exposed a second time to Rh-positive autologous blood eliminates the possibility of a transfusion
blood, the anti-Rh antibodies will react with the Rh-positive reaction and prevents the transmission of disease.
blood and cause hemolysis of the infused blood and a severe
blood reaction.
Lymphatic System
Blood Transfusions The lymphatic, or lymph, system is a separate vessel system.
Blood transfusions are given to replace needed blood com- The two main functions of the lymph system are to transport
ponents because of hemorrhage, anemia, clotting disorders, excess fluid from the interstitial spaces to the circulatory system
or blood deficiencies. Transfusable blood products are whole and to protect the body against infectious organisms.
blood, packed red cells, platelets, fresh frozen plasma, and
cryoprecipitate. Whole blood is given to increase blood volume Lymph Fluid and Vessels
and the various blood components. Packed red cells are given Lymph fluid is pale yellow. Fluid and substances move from
for anemia. Platelets assist in controlling bleeding. Fresh frozen the plasma through the capillary walls and become intersti-
plasma is administered for clotting disorders. Cryoprecipitate tial fluid (Figure 6-4). As fluid accumulates in the interstitial
corrects fibrinogen deficiencies. space, pressure within the interstitial space increases. The
Before blood products are given, the lab does a type and interstitial fluid then diffuses through the lymphatic vessel
crossmatch to check compatibility between the donor’s blood wall into the lymph vessel.
type and Rh factor and the client’s blood type and Rh factor. Semilunar valves in the lymphatic vessels assist the lymph
The lab also checks all blood products for HIV and hepatitis B system in returning the interstitial fluid, which is now called
lymph, to the venous system. When the valves do not work
properly or the vessels become obstructed, edema occurs.
The pumping action or contractions of the skeletal muscles
and the rhythmic action of the respiratory muscles assist in
the movement of the lymph toward the subclavian veins. The
CULTURAL CONSIDERATIONS right lymphatic duct drains lymph from the right side of the
head, neck, thorax, and arm into the right subclavian vein.
Jehovah’s Witnesses and Blood The lymph from the rest of the body drains into the left sub-
clavian vein through the thoracic duct.
• Many Jehovah’s Witnesses agree to autologous
blood transfusions. Lymph Nodes
• Some Jehovah’s Witnesses allow the use of cer- Lymph nodes are scattered throughout the body along the lymph
tain blood volume expanders and carry a card vessels (Figure 6-5) and contain dense patches of lymphocytes
identifying the desired expanders. and macrophages. Lymphocytes act against such foreign particles
as viruses and bacteria. Macrophages ingest and destroy foreign

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 CHAPTER 6 Hematologic and Lymphatic Systems 167

Interstitial substances, damaged cells, and cellular debris. The superficial

Blood fluid lymph nodes in the neck, axilla, and groin can be palpated,
capillary
especially when infected and swollen. The tonsils in the pharynx
and Peyer’s patch in the mucosal lining of the ileum are located
deeper within the body and cannot be palpated.
As lymph is collected from body tissues, cancer cells
enter the lymphatic system and escape into the circulation or
to other body tissues, such as the lungs. Wherever the cancer
cells collect, more cancer cells are produced. This is the way
cancer spreads to other body parts. Lymph nodes are biopsied
to check for the spread of cancer.

Lymph Organs
The spleen and thymus are lymph organs. The spleen removes
old RBCs, platelets, and microorganisms from the blood.
Approximately 350 mL of blood are stored in the spleen and
approximately 200 mL can be pumped out within a minute into

COURTESY OF DELMAR CENGAGE LEARNING

the body as needed (Thibodeau & Patton, 2009). During an
infection, the spleen enlarges to produce and release monocytes
and lymphocytes. Lymphocytes in the lymph tissue differenti-
ate into T lymphocytes (T cells) and B lymphocytes (B cells).
In infancy and childhood, the thymus gland is large but
Lymphatic decreases in size with age. In advanced age, it is replaced with
capillary fat and connective tissue. The thymus performs an important
role in the special processing and proper functioning of the
Figure 6-4 Flow of Fluid from the Blood into the thymus-derived T lymphocytes (T cells). The T cells are
Lymphatic System actively involved in immunity.

ASSESSMENT
Information is based on client report, physical examination,
and diagnostic tests.

Palatine tonsil
Left internal
jugular vein
Subjective Data
Thoracic duct
Biological and demographic data, including age, sex, ethnic back-
Submandibular node ground, and race, are important for many hematologic problems.
empties into left
Cervical node subclavian vein Inquire about the client’s occupation and hobbies because of
Right lymphatic Left subclavian possible exposure to radiation or chemicals. Past military expe-
duct vein rience is also important because some military personnel have
Axillary node been exposed to toxic chemicals. Obtain a medication history,
Right subclavian
vein Spleen including prescription and over-the-counter medications. Note
Aggregated
recent or recurring infections, night sweats, palpitations, bleeding
Thymus gland problems, previous blood transfusions, and any complications.
follicles
Lymphatic (Peyer’s patch) Assess neurological functioning by asking if the client has
vessel experienced any cognitive or mental difficulties or numbness
Illiac node
and tingling of the extremities. A headache may indicate a low
Thoracic duct erythrocyte count or intracranial bleeding. Note hearing or
vision difficulties.
Ask about past surgeries and any complications from surger-
Intestinal node Inguinal node ies; if the client has had a duodenal, gastric, or ileal resection, the
absorption of iron and vitamin B12 may be affected. Alcohol use
affects vitamin intake and is caustic to the gastrointestinal (GI)
tract. Ask about the presence of blood in the stool or urine and
COURTESY OF DELMAR CENGAGE LEARNING

any anorexia, nausea, vomiting, oral discomfort, or problems

with taste perception. A diet history is helpful when reviewing the
Lymphatic vessel erythrocyte level. Inquire if the client has difficulty accomplishing
ADLs because of decreased energy.

Objective Data
Begin by obtaining the client’s height, weight, and vital signs.
An elevated temperature is an indication of an infection. Note
Figure 6-5 The Lymphatic System recent weight gains or losses.

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168 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Laboratory tests are very important when assessing the RBC disorders discussed in this section are anemias and
hematologic and lymphatic systems. The nurse compares past polycythemia vera. The nursing process for anemias is pre-
and present laboratory results. sented after the discussion of sickle cell anemia because the
Palpate the lymph nodes in the neck, axillae, and groin; nursing diagnoses, goals, and interventions are similar for all
normal findings include small (0.5–1.0 cm) nodes that are freely anemias.
movable, firm, and nontender. Tender nodes indicate inflamma- Anemia is a common hematopoietic disorder in which
tion. Hard, fixed nodes may be malignant. See Table 6-2 for the the client has a decreased number of RBCs and a low hemo-
general “Rules of Thumb” regarding abnormal lymph findings. globin level. The causes for anemia are a decreased production
Next, inspect the skin and extremities for petechiae, of RBCs, an increased destruction of RBCs, or a loss of blood.
bruises, lesions, and brittle nails. Check urine and stool Anemias discussed in this section are iron deficiency anemia,
for blood. Note dyspnea, an enlarged abdomen, or swollen hypoplastic (aplastic) anemia, pernicious anemia, acquired
joints. Refer to Box 6-1, Questions to Ask and Observations hemolytic anemia, and sickle cell anemia.
to Make When Collecting Data, for guidance in completing
the client’s hematology and lymphatic assessment.
■ IRON DEFICIENCY ANEMIA
COMMON DIAGNOSTIC TESTS
Commonly used diagnostic tests for clients with symptoms of
I ron deficiency anemia is the most common type of ane-
mia and occurs when the body does not have enough
iron to synthesize functional Hgb. The decrease in iron
blood and lymph system disorders are listed in Table 6-3. may be caused by dietary deficiency, but the most com-
mon cause is blood loss such as in women with heavy
RBC DISORDERS menstrual periods or slow, chronic blood loss from a peptic

R
ulcer, kidney or bladder tumor, colon polyp, or colorectal
educed production of RBCs results in anemia, of WBCs cancer (Mayo Clinic, 2009). Decreased iron absorption,
results in infections, and of platelets results in bleeding. menstruating women, or an increased need for iron such as

BOX 6-1 QUESTIONS TO ASK AND OBSERVATIONS TO MAKE WHEN COLLECTING DATA

Subjective Data Examine the axillae bilaterally for redness and

Do you smoke? visible swelling.
Have you gained or lost weight in the last six Inspect and palpate lymph nodes.
months? Inspect for size and symmetry of extremities. If one
Do you feel fatigued? extremity is asymmetrical and increased in size, it
Have you noticed a decrease in your energy levels? may be indicative of lymph drainage obstruction on
Do you get frequent colds or infections? that side.
Do you ever have dizzy spells? Note and document any wounds or ulcerations,
Do your teeth or gums bleed? bruising or changes in vascular patterns.
Have you experienced any changes in skin color or While your patient is lying supine, palpate the
sensation? (See Table 6-1.) liver and spleen for tenderness, nodules, or
Have you noticed any change in the sensation in enlargement.
your fingers and toes? Inspect hip, knee, ankle, and toe joints for edema,
Do you experience numbness in your hands or feet? bruising, and deformity.
Do you notice excessive bruising? Observe the backs of the legs for changes in
Do you have any swollen “glands”? If so, is the vascular pattern.
swelling always there or does it come and go? When Inspect joints for edema or deformity and symmetry
is the swelling the worst? Is there any associated in size and shape bilaterally.
heat? Using the pads of the second, third, and fourth
Do you have any sores that do not heal? Where are fingers, lightly palpate for superficial lymph nodes.
they? Use a gentle circular motion in each lymph node
Do you bruise easily? area moving the overlying skin with your fingers.
Do you experience joint pain? Note any enlargement or palpable nodes. Observe
To your knowledge, have you been exposed to HIV? your client’s face during palpation for any signs of
discomfort with the exam. All lymph nodes should
Objective Data normally be nonpalpable and nontender. Lymph
Observe for apparent lymph nodes in the neck. nodes do not have a pulse, so if one is palpated, it is
Inspect skin for lesions definitely not lymph.
Palpate the supraclavicular lymph bilaterally in the For lymph nodes that are palpable, be careful
indentation just superior to the outer one third of to note size, shape, mobility, temperature, and
the clavicle. consistency.
Inspect shoulder, elbow, wrist, and finger joints for Palpate the tissues around any enlarged nodes for
edema, bruising, and deformity. changes adjacent to them.

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 CHAPTER 6 Hematologic and Lymphatic Systems 169

Table 6-1 Common Skin Findings in the Presence of Blood Disorders

Pallor Pale color of the skin. Lack of circulating oxygen to tissues. May indicate abnormal
destruction of or lack of production of RBCs.

Purpura Purplish discoloration greater than 0.5 cm in diameter resulting from bleeding under the
skin. May be caused by intravascular defects, platelet disorders, or infection (Seidel, Ball,
Dains, & Benedict, 2006).

Petechiae Reddish discoloration less than 0.5 cm in diameter. Also caused by platelet disorders,

COURTESY OF DELMAR CENGAGE LEARNING

infection, and vasculitis.

Ecchymosis Red-purple bruising caused by tissue injury and bleeding underneath the skin.

Spider angioma Small red center with red “spider leg” projections. May be caused by liver disease and
vitamin B deficiency (Seidel, Ball, Dains, & Benedict, 2006).

during growth periods or pregnancy are also causes. Iron Table 6-2 General “Rules of Thumb”
deficiency anemia is more frequently found in premature or Regarding Abnormal Lymph Findings
low-birthweight infants, adolescent girls, alcoholic clients,
and the elderly. The symptoms are fatigue, palpitations, Inflamed Lymph Nodes Malignant Lymph Nodes
tachycardia, exertional dyspnea, weakness, and pallor. Cli-
ents with chronic anemia have pica, stomatitis, glossitis, Enlarged Small

COURTESY OF DELMAR CENGAGE LEARNING

and brittle hair. Diagnostic tests reveal decreased RBCs, a
low Hgb level, a low Hct, a low serum iron, and a high total Soft Hard
iron-binding capacity (TIBC).
Mobile Attached to over- or

Medical–Surgical
underlying surfaces

Management Tender Nontender

Pharmacological
An oral iron preparation, usually ferrous sulfate (Feosol) is
ordered. These preparations are not given with food or milk
because they interfere with iron absorption. The administration
of iron with orange juice or vitamin C–rich drinks increases iron Activity
absorption. Iron dextran (InFeD), an intramuscular iron prepa- Space daily activities to provide rest periods between times of
ration, is given only in the upper, outer quadrant of the buttocks, exercise.
deep IM with Z-track method.

Diet
A diet high in iron is encouraged. Foods rich in iron are red ■ APLASTIC ANEMIA

T
meats, fish, raisins, apricots, dried fruits, dark green vegetables,
dried beans, eggs, and iron-enriched whole-grain breads. An he bone marrow decreases or stops functioning in
increase of vitamin C in the diet assists in the absorption of a client with aplastic anemia. The client with aplas-
iron. If the client has a loss of appetite, small frequent snacks tic anemia has pancytopenia, a decrease in the number
are tolerated better than three large meals. of RBCs, WBCs, and platelets. In most cases the cause
is unknown, but genetic factors are suspected. Secondary
aplastic anemia is caused by exposure to viruses, chemicals
(benzene or airplane glue), radiation, or medications. Some
CRITICAL THINKING medications that cause aplastic anemia are chloramphenicol
(Chloromycetin), mephenytoin (Mesantoin), trimethadione
Iron Deficiency Anemia (Tridione), mechlorethamine or nitrogen mustard (Mustar-
gen), methotrexate (Folex PFS), 6-mercaptopurine or 6-MP
How are the symptoms of iron deficiency anemia (Purinethol), and phenylbutazone (Butazolidin). Symptoms
related to a decreased red blood cell count and include fatigue, weakness, palpitvations, headaches, fever,
decreased hemoglobin? mouth ulcers, petechiae, gingival bleeding, and epistaxis.
These clients are extremely ill. Diagnosis is confirmed by a
bone marrow aspiration.

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170 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Foundation, 2006). Transfusions of packed red cells and

Table 6-3 Common Diagnostic Tests for platelets are given as needed.
Blood and Lymphatic System Disorders
Partial thromboplastin time (PTT)
Surgical
A bone marrow transplant is performed if the client’s bone
Activated partial thromboplastin time (APTT) marrow fails to respond to treatment. Cyclosporine (San-
Bleeding time dimmune), an immunosuppressant, is given for a bone
marrow transplant to decrease the graft rejection. The best
Blood culture and sensitivity response occurs in a young client who has not previously
Coombs’ test (direct antiglobulin test) had a transfusion because transfusions increase bone mar-
row graft rejection. Bone marrow transplants from a human
D-dimer test (fragment D-dimer, fibrin degradation
leukocyte antigen- (HLA-) matched sibling donor are the
fragment) treatment of choice for clients younger than 30 years of age.
Erythrocyte sedimentation rate (sed rate, ESR) The treatment of choice for an older adult or a client who
does not have an HLA-matched sibling donor is immuno-
Folic acid (folate level)
suppression with ATG and cyclosporine. (Bone marrow
Hematocrit (Hct) transplants are discussed in the section on acute myelocytic
Hemoglobin (Hgb)
leukemia.)
Hemoglobin electrophoresis Pharmacological
International normalized ratio (INR) Infections are treated with antibiotics. Steroids and androgens
Platelet count are sometimes used to stimulate the bone marrow.
Protein electrophoresis (immunofixation electrophoresis)
Prothrombin time (PT, protime) ■ PERNICIOUS ANEMIA
Red blood cells (RBCs)
Serum ferritin
T he parietal cells of the gastric mucosa secrete a protein
intrinsic factor that is essential for the proper absorp-
tion of vitamin B12. Pernicious anemia is an autoimmune
Sickledex (Sickle cell test) disease in which the parietal cells are destroyed and the gas-
Total iron binding capacity (TIBC) tric mucosa atrophies. Without the secretion of the intrinsic
factor, vitamin B12 cannot be absorbed in the distal portion
White blood cells (WBCs) of the ileum.
Differential count The onset of the disease occurs around the age of 60.
Pernicious anemia occurs most frequently in women of
Granulocytes Northern European descent and some African Americans.
Basophils Pernicious anemia occurs in clients who have had a gastrec-
tomy with the section of the stomach removed that secretes
Eosinophils the intrinsic factor. High levels of serum homocysteine and
Neutrophils methylmalonic acid (MMA) are confirming diagnostic tests
(NIH, 2009).
Bands
Pernicious anemia has an insidious onset because the
Agranulocytes body can store 3 to 5 years’ worth of vitamin B12 in the
COURTESY OF DELMAR CENGAGE LEARNING

Lymphocytes
liver. Neurologic changes, paresthesia, and numbness occur
before lab tests identify vitamin B12 deficiency (Holcomb,
Monocytes 2001). Symptoms include extreme weakness, a sore tongue,
Bone marrow aspiration edema of the legs, ataxia, dizziness, dyspnea, headache, fever,
blurred vision, tinnitus, jaundice with pallor, poor memory,
Radiologic lymphangiogram irritability, and loss of bladder and bowel control. The client
has decreased sensitivity to heat and pain because of neuro-
logical involvement. Clients with pernicious anemia are highly
susceptible to gastric carcinoma and are monitored closely for
Medical–Surgical symptoms.
Management Medical–Surgical
Medical Management
The cause of aplastic anemia is removed if possible. Immu-
nosuppressive therapy with antithymocyte globulin or Pharmacological
ATG (Atgam) and cyclosporine is given to suppress the Topical anesthetics are given to relieve oral discomfort during
reaction causing the aplastic anemia and to allow the cli- the acute phase of the disease. Vitamin B12 , cyanocobalamin
ent’s bone marrow to recover. A client who has a good crystalline (Rubesol-1000) is given IM until the Hct returns
response will improve in 3 to 6 months. The response rate to normal. Then it is given monthly for the rest of the client’s
is 70% to 80% (Aplastic Anemia & MDS International life. The frequency of administration depends on the client’s

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 CHAPTER 6 Hematologic and Lymphatic Systems 171

PROFESSIONALTIP ■ SICKLE CELL ANEMIA

(INHERITED HEMOLYTIC
Vitamin B12 Deficiency ANEMIA)
Strict vegetarians are at risk for vitamin B12
deficiency. A dietary supplement of vitamin B12 is
the treatment.
S ickle cell anemia is also known as inherited hemolytic
anemia or sickle cell disease. This genetic disorder has
abnormal hemoglobin S rather than hemoglobin A in the
RBCs. Sickle cell anemia is caused by a recessive gene or
genes that are passed through the generations (Figure 6-6).
The client with one s gene has sickle cell trait (Hb sA) and is
asymptomatic but is a carrier of the disease. The client with
symptoms and response to the medication. Oral administra- sickle cell anemia has two s genes (Hb ss) and manifests
tion of vitamin B12 is not effective because vitamin B12 cannot symptoms.
be absorbed without the intrinsic factor. Folic acid or folate The condition occurs most frequently in African-American
(Folvite) is prescribed. Encourage the client to increase clients, with an estimated 1,000 infants born with sickle cell
folic acid in the diet by eating green leafy vegetables, disease each year in the United States (SCDAA, 2005). It also
meat, fish, legumes, and whole grains. Iron is usually not occurs in persons from Asia Minor, India, and the Mediterra-
prescribed because once the condition is corrected with nean and Caribbean areas.
regular administration of cyanocobalamin, erythrocytes are Sickle cell tests are done on infants to diagnose sickle cell
produced and the Hgb and Hct return to normal. trait or disease. A screening test to detect the presence of Hb S
is Sickledex or sickle cell test. If Hb S is present, a hemoglobin
electrophoresis is done to distinguish between sickle cell trait
and sickle cell disease. If the hemoglobin electrophoresis test
■ ACQUIRED HEMOLYTIC is negative, the client has the sickle cell trait and not sickle cell
ANEMIA disease.

I
Situations that precipitate sickle cell crisis are dehy-
n hemolytic anemias, hemolysis, or destruction of RBCs, dration, deoxygenation, acidosis, and temperature changes
occurs, and iron and hemoglobin are released. Several causes (Platt, Beasley, Miller, & Eckman, 2002). In these situations
for acquired hemolytic anemia are an autoimmune reaction, crystallization of hemoglobin is promoted, which forces the
radiation, blood transfusion, chemicals, arsenic, lead, or medi- RBCs to sickle, i.e., become crescent-shaped and elongated
cations. Sulfisoxazole (Gantrisin), penicillin, and methyldopa
(Aldomet) are medications that cause hemolysis. A substance
produced by the bacterium Clostridium perfringens also causes
hemolysis. Clients may not notice symptoms or experience a
severe reaction. Symptoms are mild fatigue and pallor. More As
severe symptoms include jaundice, palpitations, hypotension, AA
dyspnea, and back and joint pain. Diagnostic tests reveal a low
Hgb and Hct and an increased level of lactate dehydrogenase no sickle cell sickle cell
(LDH). LDH is an enzyme in the heart, liver, kidneys, skeletal disease or trait trait
muscle, brain, RBCs, and lungs. As these tissues are damaged,
LDH is released into the bloodstream, causing an elevated
LDH.
As As
AA AA
Medical–Surgical
Management
trait trait

Medical
As As
Treatment is aimed at removing the cause, if possible. Clients
are given blood transfusions or erythrocytapheresis (a pro-
cedure that removes abnormal RBCs and replaces them with
healthy RBCs).
COURTESY OF DELMAR CENGAGE LEARNING

Surgical
The spleen destroys RBCs. In severe cases of hemolytic ane- As
mia, a splenectomy is performed in an attempt to stop the AA sA
ss
destruction of RBCs.
trait trait
sickle cell
Pharmacological anemia
Corticosteroids are administered to decrease the autoim-
mune response. Folic acid is given to increase the production Figure 6-6 Inheritance of the Sickle Cell Trait and Sickle
of RBCs. Cell Anemia

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172 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Normal red Sickle-shaped

blood cell red blood cell
CLIENTTEACHING
Sickle Cell Anemia
• Encourage client to avoid high altitudes and
nonpressurized airplanes.
• Encourage adequate fluid intake because dehy-
dration causes a sickle cell crisis.
• Treat all infections promptly.
• Encourage client to tight-fitting, restrictive
clothing, and strenuous exercise, smoking, and
cold temperatures.
• Encourage client to receive yearly flu vaccine
and pneumococcal vaccine.

Medical–Surgical
Figure 6-7 Blood Cells Magnified through a Scanning
Electron Microscope Show Normal and Sickle-Shaped Red Management
Blood Cells (Courtesy of Phillips Electronic Instruments Company.)
Medical
Infections are treated promptly with antibiotics. Large
and obstruct vessels, especially capillaries (Figure 6-7) (Platt amounts of oral and intravenous fluids (3–5 L/day) are
et al., 2002). The area normally supplied by these obstructed given to remove the by-products of broken RBCs. Oxygen is
blood vessels becomes infarcted and ischemic. The destruc- administered based on pulse oximetry and ABGs to combat
tion of sickled RBCs in 12 to 15 days causes chronic anemia; deoxygenation. Skin grafting is necessary for chronic leg
the heart enlarges in an attempt to circulate more blood ulcers.
for adequate oxygenation of body tissues. Other symptoms Genetic counseling is recommended for clients with
include fatigue, jaundice, chronic leg ulcers, tachypnea, dys- sickle cell trait and sickle cell anemia. There may be more
pnea, and arrhythmias. When the client experiences a sickle openness to counseling if the counselor is from the same com-
cell crisis, there is fever, severe pain, and loss of blood supply munity as the client.
to various organs because of obstructed vessels. Areas most
frequently affected are the joints, bone, brain, lungs, liver, kid-
neys, and penis. Joints become painful, swollen, and immobile. Pharmacological
Clients experience cerebrovascular accidents, renal failure, Hydroxyurea (Droxia) reduces the frequency of painful crisis
pulmonary infarction, shock, and priapism (a continuous, and the need for blood transfusions in adults (Spratto & Woods,
painful erection). 2004). Folic acid or folate (Folvite) is administered daily to assist
Assess extremity circulation frequently by doing capillary in the production of RBCs. Pentoxifylline (Trental) reduces
refill, peripheral pulses, and temperature. Application of warm blood viscosity and increases RBC flexibility. Blood transfusions
compresses to painful areas relieves pain. Encourage the client are given during a crisis.
to avoid restrictive clothing and anything that may restrict Patient-controlled analgesia (PCA) with morphine is
circulation. Teach clients to avoid high altitudes and have effective during a crisis. The client is progressed from narcot-
adequate fluid intake. ics to nonnarcotic analgesics as indicated.
CRITICAL THINKING
Anemias
Use the table and compare the etiologies, diagnostic tests, symptoms, treatments, and nursing interventions of
the listed anemias.

Iron deficiency Aplastic Pernicious Acquired hemolytic Sickle cell

anemia anemia anemia anemia anemia
Etiology
Diagnostic tests
Symptoms
Treatments
Nursing interventions

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 CHAPTER 6 Hematologic and Lymphatic Systems 173

Nursing Management may be caused by drugs and environmental conditions, so

information about medications taken and about environ-
Assess weight, vital signs, apical and peripheral pulses, mental situations at work and in recreational settings is
breath sounds, color, abdominal tenderness, and signs of important. The client is asked about fatigue, dyspnea with
bruising or jaundice. Review client’s history for possible exertion, palpitations, dizziness, pain, petechiae, tingling
familial illnesses. Encourage client to follow treatment and numbness in the extremities, blurred vision, and oral
regimen. Monitor laboratory test results. Administer blood discomfort.
products as ordered and monitor for a possible reaction.

NURSING PROCESS Objective Data

The client’s weight and vital signs; apical pulse and peripheral
Assessment pulses; breath sounds; sensation and movement in the extrem-
ities; abdominal tenderness; and edema, pallor, and signs of
Subjective Data bruising or jaundice are assessed. A thorough assessment of
Obtain a history of the client’s medical problems, including the cardiac system is completed because severe anemia causes
a history of familial hematopoietic illnesses. Some anemias cardiac enlargement and arrhythmias.

Nursing diagnoses for a client with decreased erythrocytes and hemoglobin

may include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge related to The client will relate the prescribed Teach the cause of the particular type
prescribed treatment regimen treatment regimen. of anemia and, if possible, ways to
avoid the occurrence of that anemia in
the future.
For iron deficiency anemia, teach the
importance of taking and increasing
iron in the diet.
Instruct clients with pernicious anemia
to obtain a vitamin B12 injection at
regularly scheduled times.
Teach clients with hemolytic anemias
the significance of following the
prescribed regimens.

Activity intolerance related to The client will increasingly tolerate Assist the client as needed with
imbalance between oxygen supply activity. activities of daily living.
and demand Teach the client to alternate periods of
rest with activity.

Ineffective Tissue Perfusion (Peripheral) The client will have increased tissue Administer oxygen as needed to relieve
related to a decreased hemoglobin perfusion. symptoms of dyspnea.
concentration in the blood Monitor Hgb, Hct, RBCs, pulse oximetry,
electrolytes, vital signs, and mental
alertness.
Monitor for symptoms of obstructed
vessels such as pain, leg ulcerations,
abdominal tenderness, dyspnea,
confusion, and blurred vision.
Administer blood products as ordered
and monitor the client closely after
blood transfusions for possible reactions
such as chills, fever, dyspnea, pruritus,
wheezing, and pain in the lumbar region.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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174 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

SAMPLE NURSING CARE PLAN

The Client with Sickle Cell Anemia
R.T., a 19-year-old African-American client, was diagnosed with sickle cell anemia 5 years ago. R.T. works for
a computer company and has been working 12-hour days to get a system installed. He felt fatigued lately
and decided to relax by playing golf on a warm Saturday morning. After the seventh hole, R.T. experienced
dyspnea and tingling and numbness in his legs. After the next hole, he experienced severe pain in his ankles
and knees. He was taken to the local medical center, where he was admitted. The physician ordered oxygen
by nasal cannula, IV fluids, and a PCA pump with morphine sulfate.
NURSING DIAGNOSIS 1 Acute Pain related to occlusion of small vessels by sickled cells as evidenced
by severe pain in the knees and ankles
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Comfort Level Pain Management
Pain Control Emotional Support
Heat/Cold Application
PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
R.T. will state pain has been Assess pain type, location, and Identifies where vessels may be
relieved. intensity. occluded.
Monitor analgesic administration Assesses relief from pain.
by PCA pump.
Support joints and lower Relieves joint pain.
extremities with pillows.
Keep bed linens off knees and Keeps linen from putting pressure
ankles with a bed cradle. on painful areas.

EVALUATION
The morphine in the PCA pump relieved R.T.’s pain, and oral analgesics were ordered.
NURSING DIAGNOSIS 2 Ineffective Tissue Perfusion (Cardiopulmonary and Peripheral) related to a
decreased number of RBCs and decreased oxygenation as evidenced by dyspnea and tingling and numb-
ness in his ankles and knees
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Tissue Perfusion: Peripheral Oxygen Therapy
Circulation Status Intravenous Therapy

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.T. will experience improved Elevate the head of the bed. Allows lungs to expand more fully.
circulation in his extremities. Administer oxygen as needed. Oxygen increases blood oxygen level.
Administer IV fluids as ordered. Decreases the possibility of RBCs’
sickling.
Encourage R.T. to drink 8 to 10 Prevents RBCs from sickling.
glasses of water daily.
Monitor for symptoms of obstructed Vessels supplying blood to other vi-
vessels such as pain, leg ulcerations, tal organs can become obstructed.
abdominal tenderness, dyspnea,
confusion, and blurred vision.
Administer blood products as ordered. Improves the blood oxygen con-
centration.
Closely monitor for possible blood Administration of blood products
transfusion reactions such as chills, may cause adverse reactions.
fever, dyspnea, pruritus, wheezing,
and pain in the lumbar region.

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 CHAPTER 6 Hematologic and Lymphatic Systems 175

SAMPLE NURSING CARE PLAN (Continued)

EVALUATION
Circulation in lower extremities has improved as manifested by prompt capillary refill and strong pedal
and popliteal pulses. Extremities are warm to touch.
NURSING DIAGNOSIS 3 Deficient Knowledge related to prescribed treatment regimen as evidenced
by a lack of rest and working long hours
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Energy Conservation Self-Modification Assistance
Knowledge: Treatment Regimen Teaching: Individual

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.T. will relate the prescribed treat- Teach R.T. the pathophysiology Improves compliance with the
ment regimen before discharge. related to sickle cell disease. medical regimen.
Encourage R.T. to take medica- Improves circulation and post-
tions as ordered. pones sickle cell crisis situations.
Explain the importance of avoid- These situations increase oxygen
ing stressful situations and the demands.
symptoms of infection.
Explain the importance of ad- Allows adequate oxygenation and
equate rest on a routine basis. reduces stress.

EVALUATION
R.T. states his RBCs have Hgb S rather than Hgb A, and a lack of oxygen causes his RBCs to sickle. Sickling
is caused by fatigue, lack of oral fluids, emotional and physical stress, infection, exposure to cold and an-
esthesia. He knows the purpose and side effects of each medication and the times he is to take them.
R.T. states he is to avoid high altitudes. R.T. states that he will try to routinely have enough rest.

NURSING DIAGNOSIS 4
Activity intolerance related to imbalance between oxygen supply and demand, as evidenced by
weakness, fatigue, dyspnea, tingling, and numbness

NOC: Activity Intolerance

NIC: Exercise Therapy, Prescribed Activity/Exercise

CLIENT GOAL
R.T. will tolerate minimal activity.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Assist R.T. as needed with activities of 1. Conserves energy resources.
daily living.
2. Teach R.T. the importance of alternating 2. Conserves energy.
periods of rest with activity.

EVALUATION
Is R.T. conserving his energy by alternating periods
of rest with activity?

Concept Care Map 6-1

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176 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

■ POLYCYTHEMIA CLIENTTEACHING
P olycythemia is a disease in which there is an increased
production of red blood cells. Usually the numbers of
WBCs and platelets are also increased. The increase in RBCs
Polycythemia
• Drink at least 3 L of water daily.
increases the blood volume and viscosity and decreases the • Elevate feet when resting.
ability of the blood to circulate freely. There are two types
• Avoid tight or restrictive clothing.
of polycythemia: polycythemia vera (PV) (primary poly-
cythemia) and secondary polycythemia. The average age for a • Wear support hose.
diagnosis of polycythemia vera is between the ages of 60 and • Take medications as ordered.
65. It is more prevalent in Jewish men of Eastern European • Report chest pain, joint pain, fever, or activity
ancestry (The Leukemia and Lymphoma Society, 2007). intolerance to physician.
Clients with PV have a mutation of the JAK2 ( Janus kinase
2) gene, but the exact role of the mutated gene in the cause • Keep appointments for laboratory testing and
is not known. A DNA abnormality occurs in an early mar- physician checks.
row cell that produces all of the blood cells in the individual.
Secondary polycythemia is a compensatory mechanism as the
body makes more red blood cells in response to low oxygen- clients with splenomegaly. However, interferon alfa is not
ation caused by long-term hypoxia, as in chronic obstructive used as often because of the expense and the side effects of
pulmonary disease, chronic heart failure, smoking, or living in the drugs (Stuart & Viera, 2004). Alkylating agents are not
a high altitude. used as frequently because of the incidence of leukemia in
Symptoms of the two types are the same. As the blood clients using these drugs (Stuart & Viera, 2004). Radioactive
viscosity and volume increase, the client experiences head- phosphorus (32p) decreases the production of blood cells in
aches, dizziness, tinnitus, blurred vision, fatigue, weak- the bone marrow and is used along with phlebotomy.
ness, pruritus, exertional dyspnea, angina, and increased
blood pressure and pulse. The client’s complexion becomes
ruddy (reddish), and the palms, earlobes, and cheeks are Diet
flushed. Some clients experience a burning sensation in The client is placed on a diet that has increased calories and
the feet. The client is susceptible to thrombi formation protein. A diet low in sodium decreases fluid volume. Iron-
because of the increased viscosity of the blood and increase containing foods are avoided.
in platelets. Even though there are more RBCs produced
in polycythemia, the RBCs have a shorter life span than Activity
normal. When RBCs die, uric acid is released, causing
hyperuricemia (increased uric acid blood level). The Activities of daily living are adjusted so the client can have
elevated uric acid levels cause or aggravate gout symptoms. regular periods of rest to relieve fatigue.
The Hgb and Hct increase in the same proportion as the
RBCs (Leukemia & Lymphoma Society, 2007). Nursing Management
Monitor vital signs, nutritional status, and oxygenation.
Medical–Surgical Keep accurate I&O. Initiate passive or active leg exercises or
Management encourage ambulation. Encourage compliance with regimen.

Medical
The treatment for polycythemia is phlebotomy, the removal NURSING PROCESS
Assessment
of blood from a vein. Generally 350 mL to 500 mL of blood is
withdrawn at regular intervals to decrease RBCs. A possible
side effect of phlebotomy is an increased platelet count (LLS, Subjective Data
2007). Polycythemia complications include cerebral vascular
accident, thrombosis, myocardial infarction, and hemorrhage. Ask about a history of difficulty breathing, chest pain, dizzi-
Clients with PV are more prone to develop leukemia because of ness, headache, pruritus, tinnitis, blurred vision, and sensitiv-
the disease process and medication side effects (LLS, 2007). ity to hot and cold. Assess client’s nutritional status for an
inadequate dietary intake because of GI symptoms of fullness
and dyspepsia.
Pharmacological
Low-dose aspirin is given to prevent clot formation, and Objective Data
hydroxyurea (Hydrea®), a myelosuppressive agent, reduces Observe the skin for bruises and changes in skin color. Assess
the hemoglobin, hematocrit, and platelet count. Anagrelide the cardiovascular system by checking for neck vein disten-
(Agrylin®) reduces bone marrow platelet formation (LLS, tion, edema, auscultating the apical pulse, palpating radial
2007). Allopurinol (Zyloprim) is given to decrease the pro- and pedal pulses, and checking for Homans’ sign. Assess the
duction of uric acid. Pruritus is relieved with the administra- respiratory system by observing for epistaxis and dyspnea and
tion of antihistamines. Interferon alfa (Intron® A, Roferan-A®) listening to the breath sounds. Check the central nervous sys-
reduces bone marrow production and splenomegaly and tem through pupil response, disorientation, and the presence
relieves pruritus. Interferon alfa is an option for younger of numbness or tingling.

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 CHAPTER 6 Hematologic and Lymphatic Systems 177

Nursing diagnoses for a client with polycythemia include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge related to The client will relate disease Explain the cause of the disease, possible symptoms,
disease process and treatment process and treatment. side effects of medications, and possible future
complications to report.
Teach client to report headache, chest pain, dyspnea,
or redness, swelling, or tenderness in the arms or legs
to the physician or nurse practitioner immediately.

Ineffective Tissue Perfusion The client will have 2+ Administer oxygen as needed for dyspnea.
(Peripheral) related to decreased peripheral pulses. Check vital signs frequently and assess Homans’ sign
blood circulation and signs of thrombi formation.
Explain phlebotomy process.

Risk for Injury related to The client will relate measures Encourage the client to change positions slowly to
dizziness to avoid injury. prevent dizziness.
Encourage activities of daily living when the client is
feeling well.
Teach client to avoid activities that cause bruising or
trauma.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

WBC ACUTE LEUKEMIA

WBC DISORDERS

W
Acute leukemias have a rapid onset and must be treated
BC disorders include leukemia and agranulocytosis. quickly for a good prognosis. ALL has a more rapid onset
than AML. ALL is the more common type of leukemia in
childhood with most cases occurring between the ages of 2
■ LEUKEMIA and 4 years of age (LLS, ACS, 2009c). The 5-year survival

L
rate for a child with ALL is more than 80%. (ACS, 2009c).
eukemia is a malignancy of blood-forming tissues in AML and CLL are more common in adults (LLS, 2009).
which the bone marrow produces increased numbers of AML in childhood occurs more frequently during the first 2
immature white blood cells that are incapable of protecting years of life and in teenage years. However, AML is more com-
the body from infections. The increased number of WBCs mon in older people with the average age for a diagnosis at 67
crowds out the other cells in the bone marrow, causing a years-of-age. The 5-year survival rate of a child with AML is
decreased production of RBCs and platelets. Anemia and more than 50%; more adults die from AML (ACS, 2009b).
bleeding result from the decreased number of RBCs and
platelets.
Leukemia is divided into 4 categories: acute myelogenous
leukemia (AML), acute lymphocytic leukemia (ALL), chronic Medical–Surgical
myelogenous leukemia (CML), and chronic lymphocytic Management
leukemia (CLL). An estimated 44,790 new cases of leukemia
were diagnosed in 2009 (ACS, 2009a). Medical
Because of the increased production of immature WBCs, Diagnosis of acute leukemia is confirmed with a CBC and a
clients with acute leukemia generally are fighting persistent bone marrow biopsy. A lumbar puncture determines the pres-
infections and have fever and chills. The decreased number ence of malignant cells in the central nervous system. An x-ray,
of RBCs causes symptoms of anemia such as fatigue, pallor, MRI, CT scan, or Gallium scan and bone scan of the chest and
malaise, tachycardia, and tachypnea. The decreased platelet skeleton determine the presence of infection and bone mar-
production causes bleeding tendencies, and the client experi- row tissue involvement.
ences petechiae, bruising, epistaxis, melena, gingival bleeding, Bone marrow transplantation is used with relapsed ALL
and increased menstrual bleeding. The client also experiences clients and AML clients. High doses of chemotherapy and
weight loss, night sweats, and swollen lymph nodes. As the radiation therapy are given to the client to destroy the bone
malignant cells invade the central nervous system, the client marrow. Leukemic white blood cells and healthy bone mar-
experiences headaches, seizures, vomiting, blurred vision, and row cells are both destroyed, placing the client at a high risk
difficulty maintaining balance (ACS, 2007a). Some clients for infection and death. Identical human leukocyte antigen
experience bone pain because the rapid production of WBCs (HLA) bone marrow from a sibling, the client, or an antigen-
crowds the cells in the bone marrow. matched donor is given intravenously in a manner similar to a

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178 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

blood transfusion. The transfused bone marrow finds its way

to the client’s bone marrow and starts producing WBCs, RBCs, Table 6-4 Chemotherapeutic Agents to
and platelets. The bone marrow is matched in a process very Treat Leukemia
similar to the process of crossmatching blood. If the client’s
own bone marrow is used, it is removed from the client, treated LEUKEMIA CHEMOTHERAPEUTIC AGENTS
with chemotherapy, and then reinfused into the client.
Maningo (2002) describes a fast-emerging alternative to Acute vincristine (Oncovin)
bone marrow transplantation, peripheral blood stem cell trans- lymphocyctic daunorubicin or daunomycin
plantation. The stem cell donor (client or HLA-matched donor) leukemia (ALL) (Cerubidine)
is given growth factors such as granulocyte colony-stimulating
factor (filgrastim [Neupogen]) and granulocyte macrophage– doxorubicin (Adriamycin)
colony-stimulating factor (sargramostim [Leukine]) to increase cytarabine (Cytosar)
the number of circulating blood stem cells. The peripheral stem
cells, collected with a large-bore central vascular access device, etoposide (VePesid)
are separated out of the whole blood. The RBCs, platelets, dexamethasone (Decadron)
WBCs, and plasma are returned to the donor. The stem cells are
then infused. Engraftment occurs in 2 to 4 weeks. prednisone (Deltasone)
6-mercapotopurine or 6-MP
Pharmacological (Purinethol)
Initial doses of chemotherapy are called induction doses. methotrexate (Methotrexate)
Small doses of chemotherapy given every 3 to 4 weeks to
maintain remission are called maintenance therapy. Acute daunorubicin HCl (Cerubidine)
Leukemic cells lie dormant in the brain and spinal area myelogenous
because the chemotherapeutic drugs are unable to pass cytarabine or ara-C (Cytosar-U)
leukemia (AML)
through the blood–brain barrier. Intrathecal (within the spinal 6-thioguanine or 6-TG (Thioguanine)
canal) administration of methotrexate has decreased recur-
rences of ALL. Methotrexate is given by a lumbar puncture vincristine (Oncovin)
into the cerebrospinal fluid or through a subcutaneous cere- etoposide (VePesid)
brospinal reservoir. Sometimes radiation therapy is also used
on the brain and spinal area. Chronic fludaravine (Fludara)
AML is treated with chemotherapeutic agents, blood myelogenous
products, and antibiotics. Chemotherapeutic agents used in pentostatine (Nipent)
leukemia (CLL)
treating acute leukemia are listed in Table 6-4. cladrivine (2-CdA, Leustatin)
chlorambucil (Leukeran)
Diet

COURTESY OF DELMAR CENGAGE LEARNING

Avoid extremely hot or cold foods and drinks as well as COP (Cytoxan, Oncovin, and
alcohol. A bland, high-protein, high-carbohydrate diet is prednisone)
usually ordered.
Chronic Tyrosine kinase inhibitors are more
Activity lymphocytic effective than chemotherapy.
Encourage clients to alternate periods of rest with activity and leukemia (CML) hydroxyurea (Hydrea)
keep frequently used items nearby to conserve energy.

CHRONIC LEUKEMIA 5 years after diagnosis (ACS, 2008b). The WBC count ranges
from 15,000 to 500,000. Most clients feel good and maintain
Chronic leukemia generally occurs in adults with a gradual a relatively normal life until later in the disease process, when
increase in the white cell count over months or years. The the chronic recessed phase changes into an intensified stage
prognosis depends on the severity of the disease at the time that resembles an acute phase of leukemia. This acute phase is
of diagnosis. called a blastic phase, in which there is an increased produc-
CLL clients have increased abnormal B lymphocytes, tion of WBCs. When this occurs, the general condition spirals
with a WBC count between 20,000 and 100,000. CLL devel- downhill and the client soon dies. The most common cause of
ops with advanced age and has a higher incident rate in men death in the leukemic client is viral and fungal pneumonia.
than in women (ACS, 2007e). There are two types of CLL.
One type of CLL grows slowly, rarely needs treatment with a
survival average of 15 years. The other type grows faster with a Medical–Surgical
survival average of 8 years. The CLL cells have a protein called Management
ZAP-70 and a substance called CD38. Clients with cells with
lower levels of ZAP-70 and CD38 have a better survival rate Medical
(ACS, 2007f). Diagnosis of chronic leukemia is confirmed with a CBC and a
CML is characterized by the Philadelphia chromosome, bone marrow biopsy.
indicating a possible genetic link. Treatment for CML has In the CML chronic phase, the HLA-identical allogenic
improved over the last few years and clients are surviving at least bone marrow is given, and the client’s own treated bone

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 CHAPTER 6 Hematologic and Lymphatic Systems 179

marrow is given in the blastic phase. Autologous or allogenic

peripheral blood stem cell transplantation is used.
Nursing Management
Assess for pain. Monitor for symptoms of infection and bleed-
ing. Check platelet count results. Follow proper hand hygiene
Pharmacological procedure and teach it to all visitors. Provide frequent oral
Refer to Table 6-4 for chemotherapeutic agents used in treating care with soft toothbrush or cotton swabs. Assist with or pro-
CLL and CML. Chemotherapy does not extend the length of vide daily personal hygiene with antimicrobial soap. Monitor
life but seems to give a better quality of life by prolonging the vital signs and report any temperature over 100°F. Encourage
chronic phase. Fludarabine (Fludara), a purine analog, is the client to use an electric razor. Administer antiemetics, stool
most effective single drug used to treat CLL. Purine analogs softener, and vitamins as ordered. Encourage client to talk
have significant side effects and cause increase susceptibility to about concerns and fears.
infections. Alkylating agents, such as chlorambucil (Leukeran),
and cyclophosphamide (Cytoxan) are used in treating CLL
clients who cannot tolerate aggressive treatment. Monoclonal
antibodies are medications that boost the client’s immune sys-
NURSING PROCESS
tem to respond and kill cancer cells. These medications attach
to specific targeted substances on the surface of the cancer cells.
Assessment
Alemtuxumab (Campath) attaches to the CD52 antigen on the B Subjective Data
and T lymphocytes. Campath is used when the client is no longer Ask the client or family about chromosomal abnormalities,
responding to chemotherapy. It is given subcutaneously or intra- exposure to chemicals, viral infections, and previous chemo-
venously. Since it increases the risk for infections, it is given with therapy or radiation therapy. Ask the client to describe the
antibiotics and antiviral medications (ACS, 2007b). Rituximab location, type, and duration of pain, especially in bones or
(Rituxan), a monoclonal antibody, targets the CD20 antigen on joints. Note symptoms of infection such as the presence of a
the surface of B lymphocytes. It is used along with chemotherapy cough or pain or burning on urination. Document a history of
for CLL and is given intravenously once a week (ACS, 2007b). bleeding such as epistaxis, gingival bleeding, melena, or hema-
Chemotherapy is no longer the main treatment for CML. turia. Fatigue, malaise, and irritability are often described.
Imatinib mesylate (Gleevec) is one of the main drugs to
treat CML. Chemotherapy is used in treating CML after the
tyrosine kinase inhibitors are no longer effective. Hydroxyu-
Objective Data
rea (Hydrea) is an oral pill taken to decrease very high WBC Note signs of infection, bleeding, and chemotherapy complica-
counts and to decrease spleen enlargement. tions. Common sites for infection include the mouth, pharynx,
lungs, skin, bladder, and perianal area. During chemotherapy,
Diet the reduced white cell count may stop the formation of pus, so
infection may manifest as redness, swelling, and pain.
The client is on a diet high in protein, carbohydrates, and
Assess for bleeding by monitoring the platelet count
vitamins. A bland, nonirritating diet prevents oral mucosal
because bleeding occurs easily if the platelet count falls below
irritation. Alcohol is avoided.
50,000. Clients bleed from any orifice, so inspect all body dis-
charge. Occult blood is present in the urine and stool.
Activity Chemotherapy complications are nausea, vomiting, and
It is important for the client to learn methods to conserve stomatitis. Alopecia occurs 1 to 2 weeks after treatments are
energy, such as placing frequently used items nearby. initiated.

Nursing diagnoses for a client with leukemia include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge related The client will relate Teach the client to observe for signs of infection and
to disease process and treatment methods and bleeding.
treatment possible complications of Review side effects of chemotherapy and radiation with
chemotherapy. the client, family members, and significant others.

Risk for Infection related The client will describe ways Follow good hand hygiene techniques.
to increased production of to prevent infection. Teach proper hand hygiene to the family and friends who
immature white blood cells come into contact with the leukemic client.
Use antimicrobial soaps for the client’s daily bath.
Provide frequent oral care with a soft toothbrush and
nonirritating mouthwash to prevent open sores and
stomatitis.
Wash the perianal area after each bowel movement to
decrease bacterial contamination and prevent rectal fissures.
(Continues)

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180 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with leukemia include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Avoid taking a rectal temperature and giving suppositories.
Monitor the temperature every 4 hours for signs of infection.
Report any temperature over 100°F to the physician.
Administer antibiotics and antifungals as ordered.
Closely monitor respiratory rate and breath sounds.

Risk for Injury related to The client will identify ways Frequently observe the client for signs of bleeding such
decreased production of to avoid injury and prevent as epistaxis, gingival bleeding, petechiae, ecchymoses,
platelets bleeding. hematemesis, enlarged abdomen, hematuria, melena,
and confusion, which occur from intracranial hemorrhage.
Administer stool softeners frequently to prevent anal
irritation from hard stools.
Use cotton swabs instead of a toothbrush for oral care.
Encourage the client to use an electric razor.
Avoid giving injections as much as possible.
If a catheter is needed, lubricate it well to avoid trauma to
the mucosal lining of the urethra.

Imbalanced Nutrition: Less The client will choose Administer antiemetics as ordered to relieve nausea and
than Body Requirements nonirritating, high-protein, vomiting.
related to effects of disease high-carbohydrate meals and Suggest that the client may tolerate small frequent
process and chemotherapy snacks. feedings better than three large meals.
on gastrointestinal tract
Provide the client with a high-protein, high-carbohydrate
diet to prevent infection and provide needed energy.
Administer vitamin supplements as ordered.
Teach the client to avoid raw fruits and vegetables as
these foods contain more bacteria than cooked foods.

Ineffective Coping related to The client will identify ways Inform the client of the possibility of alopecia from
uncertainty about treatment to cope with concerns about therapy treatments. Suggest client purchase a wig prior
of disease and prognosis disease process. to initiation of chemotherapy treatments.
Encourage the client to voice concerns and fears.
Teach the client, family members, and significant others
to monitor and report signs of infection and bleeding.
Refer to support groups, social workers, and clergy as
needed.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

uracil, diuretics, chlorpromazine hydrochloride (Thorazine),

■ AGRANULOCYTOSIS fluphenazene (Prolixin), promazene hydrochloride (Sparine),

A
and sulfonamides and their derivatives. Other causes of agranu-
severely reduced number of granulocytes (basophils, locytosis are neoplastic disease, chemotherapy, radiation therapy,
eosinophils, and neutrophils) is called agranulocytosis and bacterial and viral infection. The causative agent suppresses
(see Memory Trick). The primary cause is an adverse reaction the bone marrow, reducing the production of leukocytes.
to medication or medication toxicity, especially with administra- The client exhibits the symptoms of infection: headache,
tion of phenylbutazone (Butazolidin), chloramphenical (Chlo- fever, chills, and fatigue as well as mucous membrane ulcer-
romycetin), penicillin derivatives, cephalosporins, phenytoin ations of the nose, mouth, pharynx, vagina, and rectum. The
(Dilantin), antihistamines, vincristine (Oncovin), propythio- white blood count and neutrophils are low.

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 CHAPTER 6 Hematologic and Lymphatic Systems 181

MEMORYTRICK INFECTION CONTROL

Granulocytes
There are three types of granulocytes: basophils, The Client with Agranulocytosis
eosinophils, and neutrophils. A way to remember • Perform hand hygiene frequently and follow
the granulocyte cells is to recall G-BEN: aseptic technique when caring for the client.
• Keep client’s environment very clean.
G = Granulocytes
• The client should avoid crowds.
B = Basophils
• Screen guests so no one with a cold or any
E = Eosinophils type of infection visits the client.
N = Neutrophils • Teach client to avoid hot or cold environments.
• Ensure that the client reports any signs or
symptoms of infection.
Medical–Surgical
Management
Medical Nursing Management
The main goals of treatment are to remove the cause of Assess vital signs and monitor for temperature over 100.6°F. Aus-
the bone marrow suppression and either prevent or treat cultate lungs for crackles and wheezes. Balance periods of activity
any infection. When the client’s temperature is elevated, with periods of rest. Use strict asepsis for all procedures. Perform
blood cultures are performed. Mucosal ulcerations are thorough hand hygiene before caring for client. Screen everyone
cultured. Blood transfusions are given to provide mature coming into contact with the client for signs of infection. Encour-
leukocytes. Filgrastim (Neupogen), a human granulocyte age intake of adequate fluids. Monitor WBC count.
colony-stimulating factor, is given. Protective isolation is
instituted.
NURSING PROCESS
Pharmacological
Antibiotics specific for cultured microorganisms are given.
Assessment
Subjective Data
Diet The client may describe having extreme fatigue, weakness,
headache, chills, and fever. Inquire about all medications
A soft, bland diet high in calories, protein, and vitamins is
taken, including over-the-counter and prescription drugs.
ordered.
Objective Data
Activity Assess vital signs especially for a temperature over 100.6°F.
Periods of activity must be balanced with periods of rest to Mucosal ulcerations may be reddened. Auscultate the lungs
prevent weakness and fatigue. for crackles and wheezes.

A nursing diagnosis for a client with agranulocytosis includes the following:

NURSING DIAGNOSES PLANNING/OUTCOME NURSING INTERVENTIONS
Risk for Infection related to The client will not have signs Thoroughly cleanse hands before caring for the client.
decreased leukocyte production and symptoms of infection. Screen all persons for signs of infection before
allowing them near the client.
Monitor vital signs for signs of infection.
Use strict asepsis for all procedures.
Encourage the client to drink an adequate amount of
fluids.
Monitor WBC count.
Provide personal hygiene to prevent infection.
Provide client with periods of rest between activities.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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182 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

COAGULATION DISORDERS Medical–Surgical

Management
C oagulation disorders include disseminated intravascular
coagulation, hemophilia, and thrombocytopenia. Medical
DIC is diagnosed by the client’s symptoms and laboratory
tests. With DIC there is an increased prothrombin time,
partial thromboplastin time, thrombin time, and a decreased
■ DISSEMINATED INTRA- fibrinogen and platelet count. A laboratory test that confirms
the diagnosis is the D dimer, which measures a fibrin split
VASCULAR COAGULATION product that is released when a clot breaks.

D
The primary disease or condition must be treated. For
isseminated intravascular coagulation (DIC) is not a example, if the primary disease is an infection, an antibiotic
disease in itself but a syndrome that occurs because of a is given. If cancer is the primary disease, chemotherapy is
primary disease process or condition. A few of the conditions given.
in which DIC may occur are burns, acute leukemia, metastatic DIC is treated by administering whole blood or blood
cancer, polycythemia vera, pheochromocytoma, shock, acute
infections, septic abortion, abruptio placenta, blood transfu- products to normalize the clotting factor level. Platelets and
sion reactions, and trauma. packed red cells are given to replace those lost during hem-
DIC is a condition of alternating clotting and hem- orrhage. Cryoprecipitate or fresh-frozen plasma is given to
orrhaging. The primary disease stimulates the clotting normalize clotting factor levels.
mechanism, causing many microthrombi (very small clots)
to form and block the circulation in the arterioles and cap-
illaries. With the formation of the numerous small clots, Pharmacological
the body’s fibrinolytic process responds in an attempt to Heparin has no effect on the thrombi that are already formed
stop the clot formation, thus causing hemorrhaging (Fig- but is given to prevent the formation of more microthrombi.
ure 6-8). This can be a very serious and potentially fatal The administration of heparin is controversial because of the
condition. risk of hemorrhage. After thrombi formation is controlled with
The occlusion of blood vessels with the clots causes heparin, aminocaproic acid (Amicar) is given to stop the bleed-
infarcts and necrosis of organs and tissues. The kidneys are the ing because it stops the fibrinolytic process. Fibrinolysis is the
most commonly affected organ. process of breaking fibrin apart.
If a client with a predisposing condition develops pur-
pura (reddish purple patches on the skin indicative of hemor-
rhage), bleeding tendencies, or renal impairment, the nurse Nursing Management
assesses for DIC. Symptoms of DIC present as oozing from a Be aware of precipitating conditions. Monitor I&O closely.
venipuncture, mucus membrane, or surgical wound. The oozing Watch for purpura on the chest and abdomen, a common first
progresses rapidly into a hemorrhage within a few hours to sign. Monitor vital signs, peripheral pulses, and neurologi-
a day. The client has decreased urine output from decreased cal checks. Avoid giving injections and venipunctures when
blood flow or renal infarction. possible.

NURSING PROCESS
Primary disease
Assessment
Stimulation of clotting mechanism Subjective Data
Ask the client about previous conditions such as infectious
Microthrombi formation process Fibrinolysis processes, trauma, or cancer. Client statements of joint pain
indicate bleeding into the joint. Document recent visual
COURTESY OF DELMAR CENGAGE LEARNING

Depletion of clotting factors

changes.

Obstruction of circulation Bleeding

Objective Data
Observe and record the amount of bleeding from any wound
or body orifice. Monitor I&O closely. Purpura on the chest
Organ and tissue necrosis Hemorrhage and abdomen is a common first sign. Abdominal tenderness is
often present. Note presence of pulmonary edema, hypoten-
sion, tachycardia, absence of peripheral pulses, confusion,
Figure 6-8 Pathophysiology of DIC restlessness, convulsions, and coma.

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 CHAPTER 6 Hematologic and Lymphatic Systems 183

A nursing diagnosis for a client with DIC includes the following:

NURSING DIAGNOSES PLANNING/OUTCOME NURSING INTERVENTIONS
Risk for Injury related to altered The client will experience a minimal Monitor vital signs, peripheral pulses,
clotting factors amount of injury. neurological checks, and urine output.
Check urine and stool for the presence of blood.
Assess for abdominal bleeding by checking for
abdominal firmness or rigidity.
If abdominal bleeding is suspected, measure
the abdominal girth every 4 hours.
Assess surgical wounds and all body orifices for
bleeding and apply pressure to any oozing site.
Assess color, warmth, sensation, and
movement of extremities.
Observe for changes in mental status.
Avoid giving injections and venipunctures as
much as possible.
Observe for signs of orthostatic hypotension.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

tion (NHF, 2006). It is rare for a female to have hemophilia,

■ HEMOPHILIA but it can happen if the father has the disease and the mother

H
is a carrier (NHF, 2002a).
emophilia is an inherited bleeding disorder in which There are three classifications of hemophilia: severe (factor
there is a lack of clotting factors. Approximately 18,000 level less than 1% of normal), moderate (factor level 1% to 5% of
persons in the United States have hemophilia (CDC, 2005). normal), and mild (factor level 40% of normal). The main symp-
There are two types of hemophilia: hemophilia A is lacking tom of hemophilia is bleeding. The client with severe hemophilia
clotting factor VIII, and hemophilia B (Christmas disease) is bleeds with minor trauma to an area but can also bleed spontane-
lacking clotting factor IX, along with an absence of a plasma ously. Hemarthrosis (bleeding into the joints) occurs most fre-
protein, which results in nonformation of thromboplastin. quently, causing pain, swelling, redness, and fever. Spontaneous
The hemophilia trait is carried on the recessive X chromo- ecchymoses and bleeding from the mouth and gastrointestinal
some, so a mother is asymptomatic but can pass the trait to the and urinary tracts may occur. The most common cause of death
son, who then manifests the symptoms of hemophilia (Figure is intracranial hemorrhage. Clients with mild hemophilia will not
6-9). In the male population, hemophilia A occurs at the rate have spontaneous muscle and joint bleeding but will bleed after
of 1:5,000 and hemophilia B occurs at the rate of 1:10,000 minor or major surgery. This condition could prove fatal if the
(NHF, 2006). Genetic counseling is often advantageous for diagnosis is not determined promptly.
clients who are carriers or who have hemophilia. There is no
family history of hemophilia B in 33% of those with the disor-
der. These cases result from a new or spontaneous gene muta-
Medical–Surgical
Management
Medical
X X XY Hemophilia is diagnosed by a deficient or absent blood level
of factors VIII or IX. The prothrombin time (PT), thrombin
time, platelet count, and bleeding time are normal, but the
X X X Y XX XY partial thromboplastin time (PTT) is usually prolonged.
COURTESY OF DELMAR CENGAGE LEARNING

Female Male Female Male The National Hemophilia Foundation’s Medical and
hemophilia with not a that does Scientific Advisory Council (MASAC) recommend that
carrier hemophilia carrier not have hemophilia A be treated with Recombinant (genetically
hemophilia
engineered) factor VIII. Cryoprecipitate is not recom-
X Defective hemophilia gene mended because of the risk of hepatitis and HIV infections
(NHF, 2002a). For hemophilia B, the MASAC recommends
Recombinant factor IX concentrates. Plasma-derived factor
VIII concentrates still has the possibility of transmitting
Figure 6-9 Hemophilia Inheritance Pattern between a HIV-1, HIV-2, or hepatitis B or C, even with the use of
Female Hemophilia Carrier and a Male without Hemophilia improved viral–depleting processes (NHF, 2009). About

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184 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

spray (Stimate Nasal Spray) in clients with mild hemophilia

A. Desmopressin is not used in children under 2 years of
age, pregnant women, or in hemophilia A clients who do
Hemophilia not receive adequate Factor VIII levels with the medication
(NHF, 2009).
It is important for the client and family to under-
stand the disease process, learn how to recognize
signs and symptoms of bleeding, and be able to Nursing Management
administer treatments at home. The client should: Assess for signs of bleeding: petechiae, ecchymoses, hemate-
• Obtain medical care for trauma, cuts, edema, or mesis, melena, epistaxis, hematuria, hemarthrosis, and
pain in muscles and joints. abdominal rigidity. Note edematous or immobile joints.
Encourage client to wear Medic-Alert bracelet and avoid
• Wear a Medic-Alert tag. activities that cause trauma. Advise not to take aspirin, and to
• Not take aspirin. use an electric razor and a soft toothbrush.
• Use a soft-bristled toothbrush and carefully
perform oral hygiene.
• Prevent injuries by wearing gloves and long- NURSING PROCESS
Assessment
sleeved clothing when doing household chores
and participating in noncontact sports and
activities. Subjective Data
Assess the client for pain and ask what measures were used in
90% of hemophilia clients treated with plasma concentrates the past to relieve pain and bleeding.
in the early 1980s were infected with HIV; more than 50%
of these client have died (NHF, 2006). Objective Data
Assess the client for bleeding by checking for petechiae, ecchy-
Pharmacological moses, hematuria, hematemesis, melena, epistaxis, hemar-
Desmopressin acetate is available in a parenteral form throsis, abdominal firmness and rigidity, and frank bleeding.
(DDAVP Injection) and a highly concentrated intranasal Note edematous or immobile joints.

Nursing diagnoses for a client with hemophilia include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will relate Discuss ways to improve the safety of the client’s home
related to disease symptoms to report and environment.
process treatment methods if Advise client not to take aspirin and encourage the client to
bleeding occurs. use an electric razor and soft-bristled toothbrush.
Teach family members or significant others administration of
clotting factors for prophylactic purposes and if injury occurs.
Encourage client to wear Medic-Alert bracelet.
Refer for genetic counseling.
Refer client and family to a hemophilia treatment center.

Acute Pain related to The client will have minimal Assess the client for bruising, swelling, and joint discomfort.
bleeding into tissues and pain. Apply ice and pressure to bleeding sites.
joints
When a joint is hurting, immobilize it in a flexed position with a
supportive device.
Give analgesics as needed but not aspirin.

Risk for Injury related to The client will take Transfuse clotting factors as ordered.
altered clotting factors precautions to avoid injury. Encourage the client to avoid activities that may cause trauma.
Post emergency medical numbers in convenient places in case
of future need.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 6 Hematologic and Lymphatic Systems 185

■ THROMBOCYTOPENIA Pharmacological
Corticosteroids are given to prolong platelet life and strengthen
the capillaries. Immunosuppressive drugs, gamma globulin,
T hrombocytopenia is a decrease in the number of plate-
lets in the blood. The decrease may be related to:
• Decreased platelet production as in aplastic anemia,
and vitamin K are given.

tumors, leukemia, and chemotherapy Diet

• Decreased platelet survival as in infection or viral illnesses A high-fiber diet is eaten to prevent constipation and the need
to strain when having a bowel movement.
• Increased platelet destruction as in DIC or thrombocytopenic
purpura that is either drug induced or idiopathic (occurring Activity
without a known cause)
Activity is undertaken thoughtfully and carefully to prevent
Withdrawal of the causative drug usually allows the platelet any trauma.
count to return to normal in 1 to 2 weeks. The acute form of
idiopathic thrombocytopenic purpura (ITP) is an autoimmune
process caused by an autoantibody-destroying platelet antigen. Nursing Management
Petechiae, ecchymoses, and bleeding from mucous mem- Monitor for signs of bleeding (ecchymoses, petechiae, and
branes are observed. Bleeding may occur in internal organs. rigid abdomen). Check laboratory reports for low platelet
The platelet count is very low; the bleeding time is prolonged; count, Hgb, and Hct, and prolonged bleeding time. Encour-
Hgb and Hct is low; and bone marrow aspiration shows age a high-fiber diet to prevent constipation. Assess pain and
mostly immature platelets. administer analgesics as ordered. Monitor vital signs and
mental status.
Medical–Surgical
Management NURSING PROCESS
Medical Assessment
Transfusions of platelet concentrates are given, or apheresis
(removal of unwanted components) is performed on the cli- Subjective Data
ent’s blood to remove the autoantibodies. Ask the client about medications being taken and any recent
infection.
Surgical
A splenectomy is performed because the spleen is the primary Objective Data
site of platelet destruction. This treatment is usually reserved Observe for petechiae, ecchymoses, and any signs of blood or
until all other treatments have been unsuccessful. internal bleeding.

Nursing diagnoses for a client with thrombocytopenia include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize having Assess client’s pain on 0 (least) to 10 (most) pain scale
hemorrhage less pain. and client’s ability to cope with pain.
Administer analgesic as ordered, and note client’s
response.

Risk for Injury related to The client will have minimal Monitor client’s vital signs and neurological and mental
thrombocytopenia injury. status.
Assess client’s skin and excretions for signs of
bleeding.
Handle client very carefully when turning, assisting out of
bed, and in all other care situations.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Hodgkin’s disease and non-Hodgkin’s lymphoma (NHL).

LYMPH DISORDERS The overview and medical management of each disease are

A
presented separately. The nursing process for both diseases is
lymphoma is a tumor of the lymphatic system. Two presented together because the nursing diagnoses, goals, and
malignant lymphomas discussed in this chapter are interventions are the same.

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186 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

■ HODGKIN’S DISEASE PROFESSIONALTIP

H odgkin’s disease (Hodgkin’s lymphoma) is a rare lym-
phoma that usually arises as a painless swelling in a lymph
node. The diagnosis is confirmed when Reed-Sternberg cells
Serious HD Factors
(Hodgkin cells) are biopsied from the swollen lymph node. If a client is male, older than 45 years of age, has
There are two types of Hodgkin’s disease (HD), the classical tumors that are one-third as wide as the chest or
Hodgkin’s disease and the nodular lymphocyte predominance tumors 4 inches across, a WBC ⬎15,000, Hgb ⬍10.5,
Hodgkin disease (NLPHD). HD has an abnormal B lympho- lymphocyte count ⬍600, and a low blood albumin
cyte that is larger than normal lymphocytes. The abnormal B level, the prognosis is worse, and more intense
lymphocytes are known as Reed-Sternberg cells (Hodgkin cells) treatment is recommended.
and confirm the diagnosis when biopsied from a swollen lymph
node. NLPHD is confined to lymph nodes in the neck and
under the arm (ACS, 2009d). HD affects children and adults, but
occurs most frequently in early adulthood between the ages of
15–40 and in adults after 55 years of age (ACS, 2009d). from radiation therapy include hypothyroidism, radiation
Risk factors are mostly unknown, but reduced immune pneumonitis, immune system impairment, herpes zoster, and
function and certain infectious agents are involved. There the development of a second cancer.
is a slightly higher risk for HD in clients who had mono Generalized Hodgkin’s disease stages III and IV are
(infectious mononucleosis) caused by the Epstein-Barr virus treated with combination chemotherapy, which is administer-
(ACS, 2009d). ing a series of combined drugs over a set period. Serious late
Clients with Hodgkin’s disease most commonly have complications of chemotherapy are infertility and a secondary
painless enlarged lymph nodes in the neck, in the area above malignancy or cancer.
the clavicles, and in the groin. Lymph nodes in the mediasti-
num may also be enlarged but are not usually diagnosed until
the nodes enlarge and press on the mediastinal structures, Surgical
causing dyspnea and a cough. A chest x-ray or a computed Sometimes a laparotomy is done to see if the liver and spleen
tomography (CT) scan confirms the involvement of the medi- are involved. The rationale of performing the procedure is being
astinal lymph nodes. Other symptoms are weight loss, fatigue, questioned since the overall treatment plan is not altered.
pruritus, recurrent high fever, night sweats, anemia, thrombo-
cytopenia, and lowered resistance to infections. Pharmacological
If a client has painless, enlarged lymph nodes and the During radiation therapy, antiemetics, such as ondansetron
symptoms of an elevated temperature of 100ºF without any HCl (Zofran), are given for nausea and vomiting. Analgesics
known cause other than HD, drenching night sweats, and are given for esophagitis discomfort.
weight loss of more than 10% of the body weight in a 6-month Chemotherapy drugs are often given in combinations. The
period, more intense treatment is recommended. Hodgkin’s main chemotherapy treatment for HD is ABVD, a combination
lymphoma spreads throughout the body in a predictable pat- of 4 drugs: adriamycin (Doxorubicin), bleomycin, vinblastine
tern. From the site of the original swollen gland, the disease (Velban), and dacarbazine (DTIC). When the disease does not
spreads to nearby lymph nodes and then to other lymphatic respond to other treatments, MOPP (nitrogen mustard (Mus-
tissue in the body such as the liver, spleen, and bone marrow. targen), vincristine sulfate (Oncovin), procarbazine HCl (Matu-
The invasion of other nodes and lymphatic tissue determines lane), and prednisone (Deltasone) is used. Sometimes MOPP
the prognosis of the disease. See Table 6-5 for the Ann Arbor alternating with ABVD or ABV (adriamycin, bleomycin, and
Staging System for HD. vinblastine) are used. Zofran or Kytril are given for nausea and
Zantac for an upset stomach with MOPP. These drugs are usu-
Medical–Surgical Management ally administered intravenously or through an implanted venous
port. Allopurinol (Zyloprim) is given to prevent uric acid renal
Medical stones caused by the rapid destruction of cells during therapy.
Diagnostic tests include CBC, platelet count, bone marrow If the disease process does not respond well to chemo-
aspiration, chest x-ray, abdominal CT scan, lymphangiogram, therapy, an option for the client is a bone marrow or periph-
and lymph node biopsy. eral blood stem cell transplant with high-dose chemotherapy.
Localized Hodgkin’s disease stages I and II are treated with Rituximab (Rituxan), a monoclonal antibody, is presently in
radiation therapy. Clients with massive mediastinal involve- trial for use with HD.
ment and those who have relapsed after radiation therapy Diet
alone are treated with radiation therapy and chemotherapy.
During radiation therapy, the client may experience weight During therapy, the client is on a high-calorie, high-protein
loss, nausea and vomiting, skin reactions, esophagitis, fatigue, diet. Encourage an intake of 2,500 mL of fluid per day to pre-
and bone marrow suppression. The client’s blood count is vent the formation of renal stones.
monitored closely during therapy to check for infection and
bleeding tendencies. If the WBC level drops too low, the client Activity
will be more susceptible to infections. A decrease in RBCs and Extra rest periods may be necessary to cope with fatigue that
platelets causes a bleeding tendency. Long-term complications occurs with Hodgkin’s disease.

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 CHAPTER 6 Hematologic and Lymphatic Systems 187

Table 6-5 Ann Arbor Staging System for Hodgkin’s Disease with 5-Year Relative
Survival Rate
STAGE NODE AND ORGAN DESCRIPTION OF ANN ARBOR 5-YEAR RELATIVE
INVOLVEMENT STAGING CLASSIFICATION SURVIVAL RATE

I Cervical
nodes
Enlargement of single lymph node region (I) 90% to 95%
or of a single extralymphatic organ (IE)

Stage I

II Involvement of two or more lymph node 90% to 95%

Mediastinal regions on the same side of the diaphragm
nodes
(II) or involvement of extralymphatic organ
and one or more lymph node region on the
same side of the diaphragm (IIE)

Stage II

III Involvement of lymph node region on both 80% to 85%

Splenic Spleen sides of the diaphragm (III) plus involvement
hilar nodes
Periaortic
Splenic of the spleen (IIIS) or with involvement of
hilar nodes
nodes
Iliac Portahepatic
extralymphatic organ (IIIE) or both (IIISE)
nodes nodes
Mesenteric Celiac
nodes nodes
Inguinal
nodes
Stage III

IV Pulmonary Scattered involvement of one or more extra- Approximately 60% to 70%

infiltrates
Axillary lymphatic organs with or without involving
nodes
Liver
lymph nodes (IV)
Splenic hilar
nodes
Small
intestine
Bone

Stage IV

If an organ outside of the lymph system but next to involved lymph nodes is affected, the letter “E” is added to the
stage number, i.e., IE.

If the spleen is involved, the letter “S” is added to the stage number, i.e., IIS.

If the client has lost more than 10% of body weight in a 6-month time frame, has a temperature above 100ºF without any

COURTESY OF DELMAR CENGAGE LEARNING

known cause other than HD, and drenching night sweats, the letter “B” is added to the stage number, i.e., IIIB.

If a client has tumors that are 1/3 as wide as the chest or 4 inches across, the letter “X” is added to the stage number, i.e., IIIX.

Adapted from Overview: Hodgkin’s disease. By American Cancer Society (ACS), 2009d, retrieved May 13, 2009, from http://www.cancer.org/
docroot/CRI/content/CRI_2_ 2_1X_What_is_Hodgkins_disease_20.asp?sitearea=CRI; Ann Arbor Staging Classification for Hodgkin Disease. By CureSearch,
2001, retrieved May 13, 2009, from http://www.curesearch.org/articleprint.aspx?ArticleId=3325

estimated for 2008. The 5-year relative survival rate is 63% and
■ NON-HODGKIN’S LYMPHOMA the 10-year rate is 51% (ACS, 2007g).

N
NHL originates from the B lymphocytes and the
on-Hodgkin’s lymphoma (NHL) is more common than T lymphocytes. NHL arising from the B lymphocytes
Hodgkin’s disease and is the fifth most-common cancer occurs in the older adult population; NHL arising from
in the United States. The incidence rate for NHL has almost the T lymphocytes manifests in malignant skin diseases
doubled since the 1970s. Approximately 66,120 new cases are such as mycosis fungoides or Sezary syndrome. More men

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188 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

are affected than women. NHL does not have the Reed-
Sternberg cell present.
Nursing Management
Symptoms of NHL are enlarged painless lymph nodes in Assess for enlarged, painless lymph nodes. Monitor vital
the neck, axillary, abdominal, and inguinal areas. Other symp- signs, weight, and voice changes. Review blood test results.
toms include fever, night sweats, excessive tiredness, indiges- Encourage deep breathing and adequate fluid intake. Provide
tion, abdominal pain, loss of appetite, and bone pain. a high-calorie, high-protein diet in small, frequent meals.

Medical–Surgical
Management NURSING PROCESS
Medical Assessment
The diagnosis of NHL is confirmed by a lymph node biopsy. Subjective Data
Physicians use the same staging system as for Hodgkin’s dis-
ease. Ask if the client is experiencing pruritus, night sweats, weight
loss, decreased appetite, fever, fatigue, weakness, or chest pain.
Pharmacological
There are two different chemotherapy regimens, Objective Data
CHOP and CVP: CHOP combines cyclophosphamide Assess weight, vital signs, and for skin infections; dyspnea;
(Cytoxan), doxorubicin HCl (Adriamycin), vincristine cough; voice changes; enlarged lymph nodes in the neck,
sulfate (Oncovin), and prednisone (Deltasone); CVP axilla, and groin; and edema in the extremities. Bone scan
combines cyclophos phamide (Cytoxan), vincristine shows fractures and tumor infiltration. Review blood tests
sulfate (Oncovin), and prednisone (Deltasone). Other for hypercalcemia if bone lesions are present, and a CBC
chemotherapy drugs used are chlorambucil (Leukeran), often indicates anemia. When the client is having radiation
fludaravine (Fludara), and etoposide (VePesid). Bone or chemotherapy treatments, the assessment includes
marrow or peripheral blood stem cell transplantation is observing for dysphagia, nausea and vomiting, skin rashes,
used for HD clients who have a relapse. and alopecia.

Nursing diagnoses for a client with Hodgkin’s disease or non-Hodgkin’s lymphoma

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing Pattern The client will complete Elevate the head of the bed to assist the client’s breathing.
related to tracheobronchial activities of daily living Encourage the client to take frequent deep breaths to
obstruction from enlarged without dyspnea. expand the lungs and prevent infection; assess the client’s
mediastinal nodes breathing pattern every shift and as needed for dyspnea.

Risk for Infection related The client will remain free of Monitor the lab results for lowered WBCs.
to radiation/chemotherapy infection. Teach the client the importance of avoiding situations
treatments, decreased where there is exposure to infections.
WBCs and pruritus
Provide cool sponge baths or oral medication to relieve pruritus.
Assess the radiated skin areas for redness or breaks in the skin.
Encourage the client to report symptoms of dyspnea,
sore throat, and burning or frequency of urination.

Imbalanced Nutrition: Less The client will consume Serve attractive high-calorie, high-protein meals in a
than Body Requirements an adequate amount of a pleasant environment.
related to decreased nutritional diet. Offer six to eight smaller meals throughout the day to
appetite decrease a feeling of fullness. A soft, bland diet is more
palatable during radiation or chemotherapy treatments.
Avoid hot, spicy foods that are caustic to mucous
membranes and lead to infection.
Encourage an adequate intake of fluids to prevent
constipation and renal stones.
Weigh the client biweekly or more frequently if needed.

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Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.

CHAPTER 6 Hematologic and Lymphatic Systems 189

Nursing diagnoses for a client with Hodgkin’s disease or non-Hodgkin’s lymphoma

include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to disease The client will cope effectively Listen to the concerns of the client regarding the effect of
and therapy treatments with disease process and the disease on lifestyle, family, and finances.
therapy treatments. Encourage the family to express their concerns and discuss
effective ways to deal with the diagnosis and treatment.
Refer the client and family to clergy and social agencies
when appropriate.
Evaluation: Evaluate each outcome to determine how it has been met by the client.

PLASMA CELL DISORDER CLIENTTEACHING

T he main plasma cell disorder is myeloma. Myeloma

• Drink 3 to 4 L of fluids per day.
■ MULTIPLE MYELOMA • Exercise to decrease bone demineralization.

T
• Monitor for symptoms of hypercalcemia and
here were an estimated 19,920 new cases of multiple
notify physician if symptoms occur.
myeloma diagnosed in 2008, and an estimated 10,690
persons died from it (ACS, 2009e). More cases occur in men
older than age 65 (ACS, 2009e).
The plasma cells, mainly in bone marrow, become malig- the client is in remission because it seems to extend the
nant, crowd out normal cell production, destroy normal bone tis- remission (ACS, 2009e).
sue, and thereby cause pain. The normal production of antibodies If the serum calcium level increases above 10 mg/dL, the
is changed, making the client susceptible to infections. The first physician orders an IV of normal saline infused at a high rate
sign of myeloma is often bone pain, especially in the ribs, spine, followed by diuretics.
and pelvis. The long bones ache; joints are swollen and tender; Diet
and a low-grade fever and general malaise are present. The client
tires easily and has weakness from anemia. The weakened bones Six small meals per day are often tolerated better than the
fracture easily. The cause of myeloma is not known. usual three meals per day; nutritious meals based on the cli-
Diagnosis is made with bone marrow biopsy showing large ent’s food preferences are recommended. A fluid intake of 3
numbers of immature plasma cells and x-rays showing deminer- to 4 L per day is essential to minimize the complications of
alization and osteoporosis. Bence Jones protein is found in the excessive calcium in the blood and urine.
urine of many clients with myeloma. The client will also have Activity
hypercalcemia, hyperuricemia, anemia, and hypercalciuria.
It is important to keep the client as mobile as possible. Walk-
Medical–Surgical Management ing stimulates calcium resorption and decreases demineraliza-
tion. When the client is in bed, it is important to reposition
Medical the client frequently using a lift sheet to decrease the risk of
Multiple myeloma is not curable, so treatment is symptomatic. pathological fractures.
Intensive chemotherapy followed by autologous peripheral
blood stem cell transplantation may restore normal blood cell Nursing Management
production. Assess for bone pain. Monitor laboratory test results for hyper-
calcemia. Provide six small meals each day of client’s preferred
Surgical foods. Encourage fluid intake to 3 to 4 L per day. Encourage
A laminectomy is required if any vertebrae collapse. If the cli- ambulation. Monitor vital signs.
ent gets kidney stones from the large amount of calcium in the
blood and urine, surgery may be required. NURSING PROCESS
Pharmacological Assessment
Steroids such as prednisone and dexamethasone (Decad-
ron) along with antineoplastic drugs such as cyclophos- Subjective Data
phamide (Cytoxan), meophalan (Alkeran), vincristine The client describes constant pain that increases with move-
sulfate (Oncovin), and doxorubicin HCl (Adriamycin) ment. The pain is usually in the back, ribs, or pelvis. Achiness in
are given. Some drugs are used in combination, such the long bones and joints and general malaise also is described.
as VAD (vincristine, doxorubicin, and dexamethasone).
Pamidronate (Aredia) and zoledronic acid (Zometa), bis- Objective Data
phosphonates, are given intravenously for bone problems. Assess pain using a 0 (none) to 10 (most) pain scale. Tem-
Radiation therapy is used to treat bone pain or bone that is perature is elevated. The client’s ability to perform activities of
not responding to chemotherapy. Interferon is given when daily living is decreased. Monitor the level of blood calcium.
190 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

Nursing diagnoses for a client with multiple myeloma include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to The client will express a Assess the client’s pain level with pain scale.
disease process decrease in pain level. Administer analgesic as ordered and monitor the client’s response.

Risk for Injury related to The client will have Handle client gently and reposition the client using a lift sheet.
bone demineralization minimal injuries. Keep the client’s personal items within easy reach.

Risk for Infection related The client will have few Thoroughly cleanse hands before caring for the client.
to disease process and infections. Teach the client and family proper hand hygiene.
pharmaceutical agents Assist the client with personal hygiene as needed.
Screen visitors for signs of infections before allowing them to
visit the client.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CASE STUDY
J.J., 46, owns a hobby shop. He has had a cold for 3 weeks that has recently settled in his chest. He has been tired
lately and takes naps each evening before the evening meal. His wife noticed several bruises on his arms and
legs, but J.J. could not recall any particular injury. J.J. has gradually lost 10 pounds during the last 3 months but
has not been concerned about it. When J.J. went to the clinic for some antibiotics for his cold, the nurse prac-
titioner completed a physical assessment and ordered a chest x-ray and CBC. The nurse practitioner noticed the
WBCs were 250,000/mm3; RBCs, 4.2 million/mm3; and platelets, 100,000/mm3. After several other tests were per-
formed during the next few days, a diagnosis of chronic myelogenous leukemia (CML) was confirmed.
The following questions will guide your development of a nursing care plan for the case study.
1. List the symptoms occurring in J.J. that are typical of CML.
2. List five other typical symptoms of CML that were not stated in the case study.
3. List other diagnostic tests that could be done to confirm the diagnosis of CML.
4. List subjective and objective data the nurse would obtain about J.J.
5. Write three individualized nursing diagnoses and goals for J.J.
6. List nursing interventions for J.J.
7. List community resources specific to locale that could assist J.J. and his family during his illness with CML.
8. List discharge teaching the nurse would give to J.J. and his family.
9. List successful client outcomes for J.J.
10. List chemotherapeutic agents and side effects of the agents that may be prescribed for J.J.
11. List other medical treatments that may be ordered for J.J.
12. What measures could the nurse take to meet the emotional needs of J.J. and his family?

SUMMARY
• The main formed components of the blood are red blood • Symptoms of polycythemia vera are headache, epistaxis,
cells, white blood cells, and platelets. dizziness, tinnitus, blurred vision, fatigue, weakness,
• The lymphatic system is composed of lymph vessels that pruritus, exertional dyspnea, angina, and increased blood
drain lymph into the venous system; lymph nodes that pressure and pulse.
filter microorganisms in the body; and lymph organs, the • Polycythemia vera is treated with chemotherapeutic agents.
spleen and thymus. • DIC is not a disease but a complication of a disease or
• Sickledex and hemoglobin electrophoresis are diagnostic condition that causes the client to alternate between
tests for sickle cell anemia. forming many small clots and hemorrhaging.
• Some of the symptoms of anemia are fatigue, pallor, • Hemophilia is a recessive X chromosome inherited
exertional dyspnea, and tachycardia. bleeding disorder in which the client is lacking clotting

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 6 Hematologic and Lymphatic Systems 191

factors. The main symptom is spontaneous bleeding or • Hodgkin’s disease is diagnosed by the presence of the
bleeding caused by trauma. Reed-Sternberg cell in the swollen lymph nodes. Non-
• The two types of malignant lymphomas are Hodgkin’s Hodgkin’s lymphoma arises from the B lymphocytes and
disease and non-Hodgkin’s lymphoma. Clients with both T lymphocytes and does not have the Reed-Sternberg cell
types of lymphoma have enlarged lymph nodes. in the lymph system.

REVIEW QUESTIONS
1. A client has iron deficiency anemia. To improve iron 1. Using fingernail polish.
absorption, the nurse serves Feosol with: 2. Wearing rings.
1. milk. 3. Blood pressure checks.
2. an orange. 4. Pulse checks.
3. water. 7. A nurse examines a client’s skin and notes
4. processed cheese. multiple purplish areas randomly distributed
2. A thorough assessment of the cardiac system on a over the abdomen. The areas measure more
client with sickle cell anemia is important because: than 0.5 cm in diameter. The nurse records these
1. the heart enlarges in an attempt to provide the areas as:
oxygen needs to the body tissues. 1. purpura.
2. cells sickle more easily in the heart chambers. 2. petechiae.
3. more cardiac force is needed to pump RBCs with 3. spider angioma.
Hbg S. 4. liver disease.
4. people with sickle cell anemia are prone to 8. A Maine lobsterman was admitted to the unit with
bradycardia. an infection in his right hand that he acquired while
3. Clients with leukemia are prone to infections handling lobster bait. The nurse would most likely
because: find palpable, tender lymph nodes in the:
1. there are too many WBCs. 1. inguinal region.
2. the bone marrow is not producing WBCs. 2. supraclavicular region.
3. the bone marrow is producing too many cells. 3. periaortic region.
4. the WBCs are incapable of fighting
4. axillary region.
infections.
4. Symptoms that alert a nurse that a client may have 9. A client is at risk of developing a deep vein
DIC are: thrombosis. The nurse anticipates receiving an order
for: (Select all that apply.)
1. tinnitus and numbness and tingling in the
extremities. 1. compression stockings.
2. jaundice, palpitations, and dyspnea. 2. a sequential compression device.
3. purpura, bruising, and decreased urine output. 3. low molecular weight heparin.
4. ruddy complexion, epistaxis, and tinnitus. 4. bed rest.
5. A nurse teaches a client with non-Hodgkin’s 5. a leg massage.
lymphoma about his disease condition. He knows 6. a vitamin K injection.
that the teaching is successful when the client says: 10. What laboratory value confirms to the nurse that his
1. “I will use an electric razor.” client has DIC?
2. “I will take folic acid as prescribed.” 1. Elevated white blood count.
3. “I will apply ice and pressure to bleeding sites.” 2. Elevated platelet count.
4. “I will avoid exposure to infections.” 3. Presence of fibrin degradation products.
6. A client had the axillary lymph nodes removed. 4. Elevated hematocrit.
Which one of the following activities is avoided in
the affected arm?

REFERENCES/SUGGESTED READINGS
American Cancer Society (ACS). (2003). Cancer Facts & Figures 2003. American Cancer Society (ACS). (2007a). How is acute lymphocytic
[Online]. http://search.cancer.org/search?q=cancer+facts+and+ leukemia diagnosed? Retrieved on May 12, 2009 at http://www.
figures+&start=30&num=10&access=p&entqr=0&restrict=cancer& cancer.org/docroot/CRI/content/CRI_2_4_3X_How_Is_Acute_
output=xml_no_dtd&sort=date%3AD%3AL%3Ad1&ie=UTF-8&cl Lymphocytic_Leukemia_Diagnosed.asp?sitearea=
ient=amcancer&ud=1&site=amcancer&oe=UTF-8&proxystylesheet American Cancer Society (ACS). (2007b). Detailed Guide: Leukemia-
=amcancer&ip=71.97.143.207 Chronic lymphocytic (CLL) Monoclonal antibodies. Retrieved on

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
192 UNIT 2 Nursing Care of the Client: Oxygenation and Perfusion

May 12, 2009 at http://www.cancer.org/docroot/CRI/content/ Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds.
CRI_2_4_4X_Monoclonal_Antibodies_62.asp?sitearea= (2008). Nursing Interventions Classification (NIC) (5th ed.).
American Cancer Society (ACS). (2007c). Detailed Guide: Leukemia- St. Louis, MO: Mosby/Elsevier.
Acute myeloid (AML) Chemotherapy (AML). Retrieved on Centers for Disease Control and Prevention (CDC). (2005). Bleeding
May 12, 2009 at http://www.cancer.org/docroot/CRI/content/ disorders. Retrieved on May 12, 2009 at http://www.cdc.gov/
CRI_2_4_4x_Chemotherapy_AML.asp?sitearea= ncbddd/hbd/hemophilia.htm
American Cancer Society (ACS). (2007d). Detailed Guide: Leukemia- Daniels, R. (2009). Delmar’s guide to laboratory and diagnostic tests
Acute lymphocytic (ALL) Chemotherapy (AML). Retrieved on (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.
May 12, 2009 at http://www.cancer.org/docroot/CRI/content/ Day, M. (2001). Sickle cell crisis. Nursing2001, 31(5), 88.
CRI_2_4_4X_Chemotherapy_57.asp?sitearea= Gioia, K., Kleinert, D., & Hannon, M. (1999). What’s wrong with this
American Cancer Society (ACS). (2007e). Detailed Guide: Leukemia- patient? RN, 62(2), 43–45.
Chronic lymphocytic (CLL). What are the key statistics about Gorman, K. (1999). Sickle cell disease. AJN, 99(3), 38–43.
chronic lymphocytic leukemia? Retrieved on May 12, 2009 at Hoffman, K. (2008). Assessing the hematologic and lymphatic systems.
http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ Manuscript submitted for publication.
What_Are_the_Key_Statistics_About_Chronic_Lymphocytic_ Holcomb, S. (2001). Anemia: Pointing the way to a deeper problem.
Leukemia.asp?sitearea= Nursing2001, 31(7), 36–42.
American Cancer Society (ACS). (2007f). Detailed Guide: Leukemia- Leukemia & Lymphoma Society. (2007). Polycythemia Vera. Retrieved
Chronic lymphocytic (CLL). What is chronic lymphocytic on May 14, 2009 at http://www.leukemia-lymphoma.org/
leukemia? Retrieved on May 12, 2009 at http://www.cancer. attachments/National/br_1178803767.pdf
org/docroot/CRI/content/CRI_2_4_1X_What_Is_Chronic_ Leukemia & Lymphoma Society (LLS). (2009). Leukemia. Retrieved
Lymphocytic_Leukemia.asp?sitearea= on May 11, 2009 at http://www.leukemia-lymphoma.org/all_
American Cancer Society (ACS). (2007g). Detailed Guide: page?item_id=7026&viewmode=print
Lymphoma, non-Hodgkin type. Retrieved on May 12, 2009 at LymphomaInfo. (2009). Hodgkin’s chemotherapy – MOPP. 2009
http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ Deep Dive Media, LLC. Retrieved on May 15, 2009 at http://
What_Is_Non_Hodgkins_Lymphoma_32.asp?sitearea=CRI www.lymphomainfo.net/therapy/chemotherapy/mopp.html
American Cancer Society (ACS). (2008a). Detailed Guide: Leukemia- LymphomaInfo. (2009). Adult Hodgkin’s lymphoma: Chemotherapy.
Chronic myeloid (CML) Chemotherapy. Retrieved on May 2009 Deep Dive Media, LLC. Retrieved on May 15, 2009 at
12, 2009 at http://www.cancer.org/docroot/CRI/content/ http://www.lymphomainfo.net/hodgkins/chemo.html
CRI_2_4_4x_Chemotherapy_CML.asp?sitearea= Maningo, J. (2002). Peripheral blood stem cell transplant. Nursing2002,
American Cancer Society (ACS). (2008b). Detailed Guide: Leukemia- 32(12), 52–55.
Chronic myeloid (CML). What are the key statistics about chronic Mayo Clinic. (2009). Iron deficiency anemia. Retrieved on May 9,
myeloid leukemia (CML)? Retrieved on May 12, 2009 at http:// 2009 at http://www.mayoclinic.com/health/iron-deficiency-
www.cancer.org/docroot/CRI/content/CRI_2_4_1x_What_Are_ anemia/DS00323/METHOD=print&DS
the_Key_Statistics_About_Chronic_Myeloid_Leukemia_CML. McBrien, N. (1997). Clinical snapshot: Thrombocytopenic purpura.
asp?sitearea= AJN, 97(2), 28–29.
American Cancer Society (ACS). (2009a). Cancer Facts and Figures Mitchell, R. (1999). Sickle cell anemia. AJN, 99(5), 36–37.
2009. Retrieved on May 12, 2009 at http://www.cancer.org/ Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
downloads/STT/500809web.pdf outcomes classification (NOC) (4th ed). St. Louis, MO: Elsevier –
American Cancer Society (ACS). (2009b). Detailed Guide: Leukemia – Health Sciences Division.
Acute Myeloid (AML). What are the key statistics about acute myeloid National Hemophilia Foundation (NHF). (2002a). Bleeding disorders
leukemia (AML)? Retrieved on May 12, 2009 at http://www.cancer. information center/hemophilia A. Retrieved on May 14, 2009 at
org/docroot/CRI/content/CRI_2_4_1x_What_Are_the_Key_ http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?
Statistics_About_Acute_Myeloid_Leukemia_AML.asp?sitearea= menuid=180&contentid=45&rptname=bleeding
American Cancer Society (ACS). (2009c). Detailed Guide: Leukemia- National Hemophilia Foundation (NHF). (2002b). Bleeding
Acute myeloid (AML). What are the key statistics about childhood disorders information center/hemophilia B. Retrieved on
leukemia. Retrieved on May 12, 2009 at http://www.cancer.org/ May 14, 2009 at http://www.hemophilia.org/NHFWeb/
docroot/CRI/content/CRI_2_4_1X_What_are_the_key MainPgs/MainNHF.aspx?menuid=181&contentid=
_statistics_about_childhood_leukemia_24.asp?rnav=cri 46&rptname=bleeding
American Cancer Society (ACS). (2009d). Overview: Hodgkin’s National Hemophilia Foundation (NHF). (2007). Fast facts. Retrieved
disease. Retrieved on May 13, 2009 at http://www.cancer.org/ on May 12, 2009 at http://www.hemophilia.org/NHFWeb/
docroot/CRI/content/CRI_2_2_1X_What_is_Hodgkins_ MainPgs/MainNHF.aspx?menuid=259&contentid=476
disease_20.asp?sitearea=CRI National Hemophilia Foundation (NHF). (2009). MASAC
American Cancer Society (ACS). (2009e). Detailed Guide: Multiple recommendations concerning products licensed for the treatment
myeloma. Retrieved on May 12, 2009 at http://www.cancer.org/ of hemophilia and other bleeding disorders (MASAC Document
docroot/CRI/content/CRI_2_4_2X_What_are_the_risk #190). Retrieved November 9, 2009 at www.hemophilia.org
_factors_for_multiple_myeloma_30.asp?rnav=cri National Institutes of Health (NIH). (2009). How is pernicious anemia
Aplastic Anemia & MDS International Foundation. (2006). Aplastic diagnosed? Retrieved on May 10, 2009 at http://www.nhlbi.nih.
anemia. http://www.aamds.org/aplastic/disease_information/ gov/health/dci/Diseases/prnanmia/prnamia_diagnosis.html
about_the_diseases/aplastic_anemia.php North American Nursing Diagnosis Association International. (2010).
Atassi, K., & Harris, M. (2001). Disseminated intravascular NANDA-I nursing diagnoses: Definitions and classification 2009-2011.
coagulation. Nursing2001, 31(3), 64. Ames, IA: Wiley-Blackwell.
Barry, D., & Schaefer, J. (2003). Hemophilia forces parents to make Platt, A., Beasley, J., Miller, G., & Eckman, J. (2002). Managing sickle
a tough decision: A nurse’s child requires a venous access device cell pain . . . and all that goes with it. Nursing2002, 32(12), 32hn1–
implant. AJN, 103(1), 64A–64C. 32hn7.

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 CHAPTER 6 Hematologic and Lymphatic Systems 193

Sickle Cell Disease Association of America, Inc. (SCDAA). (2005). Stuart, B., & Viera, A. (2004). Polycythemia vera. American Family
Who is affected? Retrieved on May 10, 2009 at http://www. Physician. Retrieved on May 11, 2009 at http://www.aafp.org/afp/
sicklecelldisease.org/about_scd/affected1.phtml AFPprinter/20040501/2139.html?print=yes
Sidel, H., Ball, J., Dains, J., & Benedict, G. (2006). Mosby’s guide to Thibodeau, G., & Patton, K. (2009). Anatomy and physiology
physical examination (6th ed.). St. Louis, MO: Mosby Elsevier (7th ed.) St. Louis, MO: Mosby.
Spratto, G., & Woods, A. (2008). 2009 edition Delmar’s nurses drug Voshall, B. (2008). Caring for clients with coagulation and lymphatic
handbook. Clifton Park, NY: Delmar Cengage Learning. disorders. Manuscript submitted for publication.

RESOURCES
American Cancer Society (ACS), http://www.cancer.org National Heart, Lung, and Blood Institute,
Aplastic Anemia & MDS International Foundation, http://www.nhlbi.nih.gov/
Inc., http://www.aamds.org National Hemophilia Foundation,
Blood and Marrow Transplant Information Network, http://www.hemophilia.org
http://www.bmtinfonet.org National Marrow Donor Program,
Cancer Information Service (CIS), http://cis.nci.nih.gov/ http://www.marrow.org
Center for Sickle Cell Disease, Sickle Cell Disease Association of America, Inc.,
http://www.sicklecell.howard.edu/ http://www.sicklecelldisease.org
Cooley’s Anemia Foundation, http://www.thalassemia.org/ The Leukemia & Lymphoma Society,
Information for Sickle Cell and Thalassemic http://www.leukemia_lymphoma.org
Disorders, http://sickle.bwh.harvard.edu/ The Lymphoma Foundation,
National Cancer Institute, http://www.cancer.gov/ http://www.lymphomafoundation.org/

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 3 Digestion and Elimination
Chapter 7 Gastrointestinal System / 196

Chapter 8 Urinary System / 238

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 CHAPTER 7
Gastrointestinal System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the gastrointestinal
system:
Adult Health Nursing
• Oncology • Mental Illness
• Endocrine System • The Older Adult
• Immune System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Discuss diagnostic tests associated with the digestive system.
• Discuss components necessary for a complete assessment of the
digestive system.
• List medical and surgical management for clients with digestive
disorders.
• Describe nursing interventions for clients with digestive disorders.
• Assist with the formulation of nursing care plans for clients with
digestive disorders.

KEY TERMS
adhesion colostomy gastritis
appendicitis constipation glycogenesis
ascites diverticula glycogenolysis
calculi diverticulitis hematemesis
cholecystitis diverticulosis hemorrhoid
cholelithiasis effluent hepatitis
cirrhosis gastric ulcer ileostomy

196

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 CHAPTER 7 Gastrointestinal System 197

intussusception pancreatitis postprandial

jaundice peptic ulcer steatorrhea
ligation peristalsis stoma
melena peritonitis stomatitis
occult blood test (guaiac) polyp volvulus

amylase. The food is then swallowed as a small ball or bolus

INTRODUCTION and transported down the esophagus, a hollow, muscular
Disorders and diseases of the gastrointestinal system and tube approximately 10 inches long. Peristalsis, coordinated
accessory organs can affect not only the digestive process rhythmic contractions of the muscles, pushes the bolus
and nutrient absorption but the lifestyle of the individual through the esophagus. The cardiac sphincter, also called the
as well. lower esophageal sphincter (LES), located at the distal end of
the esophagus, relaxes and allows the food to pass into the
stomach.

ANATOMY AND PHYSIOLOGY

REVIEW Stomach
Further mechanical and chemical breakdown of the food
The digestive system, also known as the gastrointestinal (GI) occurs in the stomach, a J-shaped muscular organ located
tract or the alimentary system, is responsible for breaking down beneath the diaphragm. The stomach secretes gastric juices
complex food into simple nutrients the body can absorb and that contain hydrochloric acid (HCl) and pepsinogen, a
convert into energy (Figure 7-1). This process is known as nonactive form of the enzyme pepsin. HCl and pepsin are
digestion. responsible for beginning the breakdown of protein and
continuing the breakdown of starches. Starch digestion in
Mouth/Esophagus the stomach gradually stops because of the acidic environ-
ment. Mucus is secreted to protect the lining of the stom-
Digestion begins in the mouth, where the teeth mechanically ach. The stomach also secretes an intrinsic factor necessary
break food down into smaller pieces by chewing and mixing for vitamin B12 absorption and gastrin to stimulate HCl
it with saliva. The chemical breakdown of cooked starches release.
is begun in the mouth by the enzyme ptyalin, a salivary The peristaltic movement of the stomach mixes the par-
tially digested food and digestive enzymes into a semiliquid
mass called chyme. The chyme will not pass into the small
intestine until it is the proper consistency and particles are 1
millimeter or less. On average, the stomach empties in 3 to 4
hours. Carbohydrates are digested most readily, followed by
proteins, with fats taking the longest to pass from the stom-
Tongue
Salivary glands ach. When the chyme has reached the proper consistency, the
pyloric sphincter relaxes, releasing a portion at a time of the
Mouth
Pharynx chyme into the small intestine.
Lips

Liver
Common Esophagus
Small Intestine
bile duct The small intestine is approximately 20 to 25 feet long and
Gallbladder is responsible for absorbing nutrients from the chyme. The
small intestine also secretes digestive enzymes, mucus to
Duodenum
protect the mucosa, and hormones to aid in the absorption
Stomach of nutrients.
The chyme enters the duodenum, the first 10 to 12 inches
Jejunum
COURTESY OF DELMAR CENGAGE LEARNING

Pancreas of the small intestine. The duodenum is responsible for

Transverse colon absorbing calcium and iron as well as neutralizing the acids in
Descending colon
the chyme. Enzymes from the pancreas and bile from the liver
Ascending colon enter the duodenum from the common bile duct by way of the
Cecum Ileum ampulla of vater; it is here that fats are digested.
Appendix Sigmoid The jejunum, the middle 8 to 10 feet of the small intestine,
Rectum Anus is responsible for absorption of fats, proteins, and carbohydrates.
Vitamin B12 and bile salts are absorbed in the ileum, the distal
Figure 7-1 The Digestive System 12 feet of the small bowel.

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198 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Large Intestine • Convert glycogen to glucose when blood sugar level drops
(glycogenolysis)
The chyme enters the large intestine, also known as the colon, • Metabolize hormones
through the ileocecal valve into the cecum, a small pouch to
which the appendix is attached. The colon is approximately 4 • Break down nitrogenous wastes to urea
to 5 feet long and consists of the ascending or right colon, the • Incorporate amino acids into proteins
transverse colon, the descending or left colon, and the sigmoid • Filter blood and destroy bacteria
colon, an S-shaped segment before the rectum. The colon • Produce prothrombin and fibrinogen, which are necessary
absorbs water, electrolytes, and bile salts. for blood clotting
The last 5 inches of the large intestine comprise the rec- • Manufacture cholesterol
tum. The distal end of the rectum forms the anal canal com-
posed of muscles that control defecation. The opening to the • Produce heparin
anal canal is called the anus. • Store vitamin B12 and fat-soluble vitamins A, D, E, and K
• Detoxify poisonous substances
Accessory Organs
The digestive system also has accessory organs that aid in the Gallbladder
digestion of food. The accessory organs include the pancreas, The gallbladder is a pear-shaped sac attached to the undersur-
liver, and gallbladder (Figure 7-2). face of the liver. The liver produces bile and transports the bile
to the gallbladder through the hepatic and cystic ducts. The
Pancreas gallbladder stores and concentrates the bile until it is needed
The pancreas is a fish-shaped glandular organ 6 to 8 inches in the small intestine. When fats enter the small intestine, the
long extending from the duodenum across the abdomen gallbladder releases the bile through the cystic duct into the
behind the stomach. The pancreas has both endocrine and common bile duct and finally into the small intestine. The
exocrine functions. The endocrine functions, which include cystic duct, hepatic duct, and pancreatic duct combine to form
the production of glucagon and insulin to regulate the blood the common bile duct.
sugar level, are presented in the endocrine system chapter.
The pancreas produces three main groups of enzymes in
pancreatic juice for its exocrine function. The enzymes are:
Effects of Aging
As the body ages, several changes occur in the digestive sys-
amylase—converts carbohydrates into glucose tem (Table 7-1). It is important to educate clients about these
lipase—aids in fat digestion changes and ways they can adapt their lifestyles.
protease—breaks down protein

Liver ASSESSMENT
The liver is the largest glandular organ of the body. It is located in A thorough assessment is necessary to collect data on
the right upper quadrant of the abdomen. The liver is one of the which to make an accurate nursing diagnosis. For clients
most vascular organs, filtering 1,500 mL of blood per minute. describing GI symptoms, the assessment should include
Some of the many functions of the liver are to: the following:
• Produce and secrete bile, which emulsifies fats 1. History of the present complaint, including length and
• Convert glucose into glycogen for storage (glycogenesis) frequency of symptoms, when symptoms occur, as well
as aggravating factors
2. Medication history, including prescribed and over-the-
counter (OTC) medications, and their effectiveness.
Clients with GI symptoms frequently self-medicate
with antacids, laxatives, suppositories, and enemas.

LIFE SPAN CONSIDERATIONS

COURTESY OF DELMAR CENGAGE LEARNING

The Aging GI Tract

• Loss of elasticity and slowed motility of the GI
tract, accompanied by lack of exercise, make the
elderly prone to constipation.
• As the intestinal wall weakens, diverticuli, or
scars on the intestinal wall, can develop.
Figure 7-2 Accessory organs. Bile travels from the liver • Decreased liver mass and blood flow alter the
to the gallbladder via the hepatic and cystic ducts. The bile is pharmacokinetics of various drugs.
released into the duodenum via the common bile duct.
The pancreas releases its digestive juice into the duodenum.

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 CHAPTER 7 Gastrointestinal System 199

Table 7-1 Changes in the Digestive System with Aging

COMMON CHANGES RESULT IMPLICATIONS FOR NURSES
Decrease in peristalsis Food moves more slowly through digestive Increase fiber and fluid intake. Encourage smaller,
system. Bowel movements are more frequent meals. Offer fiber supplements.
infrequent. Increase in constipation. Feeling
full and bloated and may eat less.

Oral changes Dentures are common. Chewing is more Make sure dentures fit. Cut food into small bites.
difficult. Eating and drinking time may Teach that softer foods may be better tolerated.
be prolonged. Number of taste buds Some clients may start using more salt and
decreases. seasonings to compensate for less flavor;
monitor salt usage.

Decrease in enzyme Food is harder to digest. Increase in Encourage water between meals. Avoid foods

COURTESY OF DELMAR CENGAGE LEARNING

secretion indigestion. Intolerance to some food that are not tolerated while ensuring adequate
and seasonings. nutrient intake.

Decrease in saliva Food is more difficult to chew. Swallowing Encourage fluid intake with meals. Have clients
becomes difficult. chew food well and do two swallows with each
bite of food. Have clients sit up to eat.

3. A complete nutritional history; a note should be made

of any foods that increase or decrease symptoms. Also, ■ STOMATITIS
assess if meals aggravate symptoms or if symptoms
occur within a specific time period after a meal. Note
the fiber and fat content of the diet as well as the amount
of fluids typically consumed.
S tomatitis is a painful condition characterized by inflam-
mation and ulcerations in the mouth. Stomatitis can be
caused by infections, damage to the mucous membranes by
4. Psychosocial factors, including compliance and noncom- irritants, or chemotherapy.
pliance with health status. Meal patterns should be evalu-
ated: note whether the client eats alone, eats large meals Medical–Surgical
at regular intervals, or snacks all day.
5. Physical examination, including inspection, auscultation, Management
percussion, and palpation of the abdomen. An evaluation of Medical
the client’s ability to chew and swallow is also important. Cultures may be done to determine whether an infectious
6. Bowel elimination patterns, including frequency, process is present.
consistency, and amounts of bowel movements.
7. Evaluation of diagnostic data, including laboratory Pharmacological
analysis and radiologic and endoscopic examinations.
Refer to Box 7-1, Questions to Ask and Observations to Because the client’s mouth can be sore, topical anesthetics
Make When Collecting Data, for guidance in completing such as xylocaine may be used. Analgesics may also be
client gastrointestinal assessments. ordered. If an infection is present, the appropriate medication
is ordered.

COMMON DIAGNOSTIC TESTS Diet

Dietary restrictions are based on what the client is able to
Commonly used diagnostic tests for clients with digestive tolerate. Bland, soft foods or liquids are usually tolerated best.
disorders are listed in Table 7-2. As the sores heal, the diet may be advanced as tolerated. It is
important to monitor dietary intake because caloric and fluid
intake may be poor as a result of discomfort.
DISORDERS OF THE
GASTROINTESTINAL TRACT Nursing Management
D isorders of the gastrointestinal tract include stomatitis, esoph-
ageal varices, gastroesophageal reflux disease, gastritis,
ulcers, appendicitis, diverticulosis and diverticulitis, inflamma-
Monitor caloric and fluid intake for adequacy. Encourage
the client to eat soft, bland foods and liquids. Assess for
mouth discomfort and check mouth for inflammation and
tory bowel disease, irritable bowel syndrome, intestinal obstruc- ulcerations. Provide oral care and administer medications as
tion, hernias, peritonitis, hemorrhoids, and constipation. ordered.

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200 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Table 7-2 Common Diagnostic Tests for Gastrointestinal Disorders

Laboratory Tests Radiologic Studies
• Complete blood count (CBC) • Barium swallow
• Prothrombin time (PT) • Upper gastrointestinal tract (UGI) with small bowel
• Partial thromboplastin time (PTT) follow-through
• Bilirubin • Abdominal x-rays
• Albumin • CT scans
• Globulin • Ultrasound
• Total protein • Barium enema
• Alkaline phosphatase • Gallbladder series
• Lactate hydrogenase (LDH-5)
Other
• Gamma-glutamyl transpeptidase (GGT or GGTP)
• Flexible sigmoidoscopy
• Aspartate aminotransferase (AST/SGOT)
• Esophagogastroduodenoscopy (EGD)
• Alanine aminotransferase (ALT/SGPT)
• Endoscopic retrograde cholangiopancreatogram (ERCP)
• Cholesterol
• Colonoscopy
• Triglycerides
• Esophageal motility studies (manometry)
• Amylase
• Gastric secretion analysis

COURTESY OF DELMAR CENGAGE LEARNING

• Carcinoembryonic antigen (CEA)
• Liver biopsy
• HAA, now called hepatitis B surface antigen (HBsAG)
• Peritoneal aspiration
• Stool O & P
• Stool occult blood (guaiac)
• Fecal occult blood test (FOBT)
• Hemocult

NURSING PROCESS Objective Data

Observations include inflamed mucosa of the mouth with
Assessment ulcerations frequently present.
Subjective Data
Clients usually describe pain in the mouth and difficulty
swallowing.

Nursing diagnoses for a client with stomatitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize increase in Assess the client frequently for discomfort.
Stomatitis comfort within 1 hour of initiation of Administer medications such as topical xylocaine and
treatment. analgesics as ordered.
Allow for rest periods as indicated.

Imbalanced Nutrition: The client will maintain caloric intake Monitor daily caloric intake and consult with the
Less than Body of 1,500 calories per day within dietitian to assist with food selection.
Requirements related to 48 hours of treatment initiation. Administer IV fluids as ordered and monitor I&O.
inadequate caloric and The client will maintain a fluid intake
fluid intake of 2,000 mL per day within 48 hours
of treatment initiation.

Impaired Oral Mucous The client will have less inflammation Monitor the stomatitis every shift to assess status of
Membranes related to and a decrease in the size of the condition.
stomatitis ulcers by 36 hours after treatment Provide oral care every 4 hours.
initiation.
Administer medications as ordered to combat the infection.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 7 Gastrointestinal System 201

BOX 7-1 QUESTIONS TO ASK AND OBSERVATIONS TO MAKE WHEN COLLECTING DATA
Subjective Data Are you hoarse in the morning?
Do you wear dentures? If yes, do they Do you have difficulty breathing in the
fit properly? morning?
Do you consume alcohol? Do you cough in the morning? During the
Obtain a history of alcohol use/abuse. night?
How much alcohol do you consume in a week? Do any foods irritate your stomach, cause
Do you smoke cigarettes, cigars, or a pipe? indigestion, belching, or bloating? Do you take
Do you chew tobacco? any medications to relieve stomach discomfort,
Do you smoke, inhale, or ingest illicit drugs? pain, or indigestion?
Do you have pain or discomfort in your mouth? Do you take NSAIDs?
Do you have difficulty swallowing? What do you think causes the discomfort, pain,
What kind of foods and liquids do you consume? or indigestion?
Do you consume acidic foods? What relieves the discomfort, pain, or indigestion?
What is your ideal weight? Do you have unexplained Do you notice more discomfort or pain at one
weight loss? Weight gain? time more than another?
Have you ever vomited bloody stomach contents? Have you missed work because of stomach
Have you vomited stomach contents that look like discomfort, pain, or indigestion?
coffee grounds?
Are you easily fatigued? Objective Data
Describe your energy level now compared to Inspect the oral mucosa for ulcers or lesions.
6 months ago. Assess the mucous membranes for dryness,
Do you have a history of liver disease? cracked lips, erythema, bleeding, and presence
Do your bowel movements appear black and appearance of saliva.
and tarry? Assess the surface of the tongue.
Are your bowel movements constipated, Inspect the gingiva for redness and swelling.
watery? Assess the teeth for caries and firmness within
Do you have diarrhea? Persistent or occasional? the gums.
Have you passed blood clots in your stool? Assess vital signs.
Have you ever experienced bloody Guaiac all stools for occult blood.
diarrhea alternating with normal bowel movements? Observe for hematemesis and melena.
Do you experience heartburn? How often do you Assess and measure amount of blood vomited.
have heartburn? Assess lab data for H & H, liver profiles,
Do you take any OTC medications to treat the albumin, pre-albumin, bilirubin, WBCs, and
heartburn? Do you get relief from these medications? neutrophils.
Do you have heartburn, acid regurgitation into the Assess the skin and sclera for presence
throat or mouth, or increased salivation after bending of jaundice.
over to tie your shoes or retrieve something from the Weigh the client every day and evaluate BMI.
floor? Assess for recent weight loss and/or weight gain.
Do you have increased difficulty swallowing when Assess eating habits for types of food/beverages
lying down, bending over, or straining? consumed, and time and frequency of meals.
Have you experienced a burning sensation in the Assess breath odor for halitosis.
chest, throat, or behind the sternum? Assess voice for hoarseness.
Do you belch frequently? Assess for frequent belching.
Do you have a burning or squeezing pain when Assess breath sounds for cough and wheezing.
swallowing? Inspect the abdomen for distention.
Have you experienced the sensation of food being Assess for presence of bowel sounds.
caught in your throat or like you are choking? Assess for presence and location of abdominal
Have others mentioned that you frequently have bad pain.
breath? Assess for rebound abdominal tenderness.
Do you have frequent chest pain? Describe the chest Keep client NPO as ordered.
pain. How long does it last? Monitor I&O.
Is the chest pain related to any particular Maintain IV fluids for hydration.
activity? Does it seem to occur after a heavy meal?

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202 UNIT 3 Nursing Care of the Client: Digestion and Elimination

A
■ ESOPHAGEAL VARICES

A
Esophagus
varix is an enlarged, tortuous vein or, occasionally, an
artery. Although varices can occur in any part of the Varix
digestive system, they occur most frequently in the distal veins
of the esophagus. The varices are often associated with cirrhosis
of the liver or any other condition that causes chronic obstruc- B
tion of drainage from the esophageal veins into the portal veins.
Swelling of the veins causes the walls to weaken, making them
prone to ulceration and bleeding. Anything that causes increased
abdominal venous pressure, such as sneezing, coughing, vomit- O-ring
ing, the Valsalva maneuver, swallowing large, poorly chewed
pieces of food, and the erosion of vessel walls by gastric acid, C
can cause the varices to rupture.
Varices have no symptoms, so clients may not be aware of

COURTESY OF DELMAR CENGAGE LEARNING

them until they start bleeding. Death may ensue rapidly if the
hemorrhaging varix is not treated immediately.

Medical–Surgical
O-ring

Management
Medical
The varices may be treated with sclerotherapy, ligation, or Figure 7-3 Banding of an Esophageal Varix; A, Varix; B,
balloon tamponade. Sclerotherapy is a procedure in which a Insertion of Tube with O-Ring; C, O-Ring is Placed around the Varix
caustic substance is injected into the varix. An esophagogas-
troduodenoscopy (EGD) is performed and a sclerosing agent is blood to bypass the liver and relieve pressure in the portal vein.
injected through a special needle. Several treatments are neces- This procedure is done in x-ray and is used with clients who are
sary to cause formation of scar tissue and to stop the bleeding. too unstable for surgery (also refer to Figure 7-9.)
After the bleeding has stopped and the client has stabilized, the
remaining treatments may be done on an outpatient basis. Pharmacological
Complications to sclerotherapy include mediastinal Octreotide (Sandostatin) is given by IV to help control the
inflammation secondary to extra esophageal injection, perfo- bleeding by decreasing blood flow to the gut, thus lowering
ration, ulceration, stricture secondary to scar formation, and pressure in the portal system. Analgesics may be necessary fol-
rebleeding. lowing sclerotherapy if clients have chest discomfort. Clients
Esophageal ligation, also called banding, involves plac- should avoid NSAIDs, aspirin, and all anticoagulants. Sucralfate
ing a rubber band, tie, or O-ring on the varix (Figure 7-3). An (Carafate) liquid may be given to coat the esophagus, protecting
EGD is performed to guide the placement of the bands. The it from erosion by gastric acid. IV rehydration as well as blood
complications include rebleeding and stricture formation. transfusions may be necessary for clients with active bleeding.
In a case where varices are actively bleeding, a three- or
four-lumen balloon tamponade, known as a Minnesota or
Sengstaken-Blakemore tube, is passed into the esophagus. Activity
The balloon is then inflated in the esophagus to put direct If varices are bleeding or have recently bled, the client should
pressure onto the bleeding varices. The balloon is periodically remain on bed rest. If no active bleeding is present, the client
deflated to prevent necrosis of the esophageal tissue. Isotonic may be ambulatory but should avoid strenuous exercise.
saline lavages also are administered through the tube. During
Nursing Management
the procedure, the client must be kept NPO with the head of
the bed elevated 30 to 45 degrees. Complications include
perforation of the esophagus from the balloon pressure and Monitor vital signs. Explain tests and procedures. Allow time
necrosis of the surrounding tissue. for client to express fears and concerns about the varices.
Check laboratory test results for changes. Explain reasons to
Surgical avoid strenuous activity. Assess for nausea and dizziness.
A portosystemic shunt is performed to relieve the pressure on
the esophageal veins by redirecting blood from the portal vein
to the inferior mesenteric vein. Some of the blood bypasses NURSING PROCESS
the liver and reenters the circulatory system (Figure 7-4).
A nonsurgical but invasive procedure, transjugular intrahe- Assessment
patic portosystemic shunt (TIPS), may also be performed. With
this procedure, the right internal jugular vein is used to place a Subjective Data
cannula into the hepatic and portal veins. A connection is made Assessment includes history of liver disease or alcohol abuse
through the liver tissue between the hepatic and portal veins. and nausea. With esophageal varices there is no abdominal pain.
A stent is placed in the connection. This allows some of the The symptom of abdominal pain helps distinguish esophageal

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 CHAPTER 7 Gastrointestinal System 203

Esophagus

Liver

Stomach
A B

Spleen
Portal vein Porto-
Systemic
Shunt
Inferior Splenic vein
mesenteric
vein Kidney

COURTESY OF DELMAR CENGAGE LEARNING

Superior
mesenteric vein
Left renal vein

Inferior
vena cava

Figure 7-4 A, Normal Circulation of Abdominal Organs; B, An Example of a Portosystemic Shunt (May be Performed in Clients
with Elevated Portal Vein Pressure That Is Resistant to Medical Management)

varices from bleeding gastric ulcers, which generally do cause pain vomiting blood. Review hemoglobin and hematocrit (H & H)
that worsens after eating (Movius, 2006). to evaluate anemia and liver profile for elevated bilirubin and
globulin levels and a decrease in albumin.
If cirrhosis of the liver is present, jaundice, a yellowing of
Objective Data the skin, mucous membranes, and sclerae of the eyes, is pres-
Assessment includes testing stools for occult blood (guaiac) ent. Jaundice results when the liver is unable to fully remove
and melena (black, sticky, tar-like stools containing partially bilirubin from the blood. Nutritional status may be poor if the
broken-down blood), and assessing for hematemesis, or client abuses alcohol.

Nursing diagnoses for a client with esophageal varices include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Deficient Fluid The client will maintain Monitor vital signs every 4 hours including orthostatic blood
Volume related to adequate fluid volume. pressures. Orthostatic blood pressure is obtained by taking
bleeding esophageal the blood pressure when the client is lying down and then
varices (if the varices are when standing. A 20 mm Hg difference in blood pressures
not actively bleeding) from lying to standing would indicate a change in fluid volume,
possibly indicating varix bleeding.
Monitor for nausea and dizziness.
Monitor H & H every 4 to 8 hours as ordered. A decrease in
H & H values would indicate bleeding.

Deficient Fluid Volume The client will maintain an Monitor H & H.

related to bleeding H & H within normal limits. Frequently monitor vital signs. Administer IV fluids, electrolyte
esophageal varices and The client’s blood pressure will replacement, and blood transfusions as ordered.
gastric loss from vomiting be within 20 mm Hg of baseline
with no orthostatic changes.

(Continues)

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204 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with esophageal varices include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to change The client will discuss Explain all tests and procedures to decrease anxiety. Allow
in health status, threat of concerns about health status. client to express fears and concerns regarding condition.
death

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ GASTROESOPHAGEAL Nursing Management

REFLUX DISEASE Encourage client to avoid foods that increase the symptoms
(e.g., caffeine, milk products, alcohol, and fatty foods). Obtain

I n gastroesophageal reflux disease (GERD), gastric secretions

flow upward into the esophagus, damaging the tissues. An
inability of the lower esophageal sphincter (LES) to fully close
diet history from client. Observe for melena and signs of dis-
comfort or pain.

contributes to this condition. Environmental and physical fac-

tors contribute to decreased pressure in the LES. Fatty foods, caf-
feine, nicotine, calcium channel blockers, and NSAIDs decrease
■ GASTRITIS
the tightness of the sphincter. Symptoms include belching, dys-
phagia, esophagitis, epigastric pain, heartburn, flatulence, mel-
ena, and bleeding. Diagnosis is made by symptoms, a 24-hour
G astritis is an inflammation of the stomach mucosa occur-
ring when the stomach has been exposed to irritating
substances such as medications, smoke, food allergens, or toxic
pH monitoring, and an esophageal motility test. An endoscopy chemicals. Another contributing factor to gastritis is impaired
determines the extent of esophagitis and rules out a malignancy. mucosal defenses, which occur when the epithelial cells of the
Medical–Surgical Management stomach are not able to secrete an adequate quantity or quality of
mucus to protect the stomach. The presence of the bacteria Heli-
Medical cobactor pylori (H. pylori) has also been associated with gastritis.
GERD is generally treated conservatively with diet and medi-
cations. Clients are encouraged to lose weight if they are
overweight. Medical–Surgical Management
Surgical Medical
Diagnosis of gastritis is based on history and symptoms. An
A fundoplication is done to alleviate symptoms. A fundoplica- UGI or EGD is done to help diagnose the condition. If H. pylori
tion is a laparoscopic procedure in which the LES is tightened is suspected, a biopsy is obtained during an EGD and a culture
by wrapping and suturing the fundus of the stomach around is performed.
the esophagus.
Pharmacological Pharmacological
GERD is treated conservatively with antacids, H2 receptor Treatment for gastritis is primarily pharmacological involving
antagonists, proton pump inhibitors, cytoprotective agents, antacids and histamine (H2) receptor antagonists (also call
and gastrointestinal motility agents. H2 blockers). A proton pump inhibitor such as omeprazole
(Prilosec) or prostaglandins is used. If H. pylori is present,
Diet bismuth preparations are used to inhibit H. pylori growth and
A low-fat, high-protein diet is recommended. The client is antibiotics to eliminate the bacteria (Table 7-3).
encouraged to avoid caffeine, milk products, alcohol, pepper- NSAIDs such as ibuprofen (Motrin) and indomethacin
mint, licorice, and spicy foods. (Indocin) have been shown to compromise mucosal defenses
and increase acid secretion. Clients who are on NSAIDs
chronically, such as clients with arthritis, need to be evaluated
to determine whether other analgesics would be effective or if
CLIENTTEACHING a prostaglandin should be taken with the NSAIDs.
GERD
Diet
• Lose weight as needed. Although studies have shown that dietary modifications have
• Avoid fatty foods, alcohol, nicotine, caffeine, little impact on the rate of gastritis healing, some modifica-
and spicy foods. tions are indicated. Any foods that aggravate symptoms are
• Take medications as instructed. eliminated. Also, foods that increase acid secretions, such as
milk, coffee, decaffeinated coffee, tea, colas, and chocolate,
• Elevate head of the bed 2 to 4 inches on blocks.
should be consumed only in small amounts or eliminated if
• Avoid wearing constrictive clothing. possible. Eating before bedtime is avoided because it increases
nocturnal acid secretions.

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 CHAPTER 7 Gastrointestinal System 205

Table 7-3 Medications Used for Ulcers and Gastritis

MEDICATION PURPOSE NURSING IMPLICATIONS
Antacids Seal impaired mucosa. Antacids containing aluminum hydroxide may
• aluminum hydroxide (Amphogel) Neutralize acids. cause constipation. Antacids containing
• aluminum hydroxide and magnesium magnesium hydroxide may cause diarrhea;
hydroxide (Maalox) monitor serum electrolytes; do not give with
• dihydroxyaluminum sodium carbonate other meds.
(Rolaids)

H2 Receptor Antagonists Decrease gastric acid Do not give within 1 hour of antacids.
• ranitadine HCl (Zantac) secretion.
• cimetidine (Tagamet)

Proton Pump Inhibitor Stop gastric acid secretion. Give with food. Suspend granules in an acid
• omeprazole (Prilosec) liquid. Takes 4 days to achieve blood level.

Prostaglandins Decrease gastric acid Give when NSAIDs need to be continued.

• misoprostol (Cytotec) secretion.
Enhance mucosal defenses.

Bismuth Compounds Enhance mucosal barriers. Do not give within 1 hour of H2 blockers.
• bismuth subsalicylate (Pepto-Bismol) Inhibit H. pylori growth.

COURTESY OF DELMAR CENGAGE LEARNING

Antibiotics Eliminate H. pylori. Some antibiotics will cause N/V if taken with
• ampicillin (Omnipen) alcohol. Do not give with antacids or meals with
• metronidazole (Flagyl) the exception of Flagyl, which must be taken
with food. Clients are usually placed on two
different antibiotics simultaneously.

Health Promotion NURSING PROCESS

Smoking and alcohol aggravate the mucosal lining of the
stomach and significantly impair gastritis healing. Smoking
and alcohol consumption are minimized or eliminated if
Assessment
possible. Subjective Data
Clients with gastritis may have no symptoms or may describe
epigastric pain or burning, or nausea. They may also state that
Nursing Management certain foods aggravate symptoms.
Encourage client to minimize or eliminate smoking and alco-
hol consumption (if applicable) and any foods that aggravate Objective Data
symptoms. Teach client about medications. Stools may test positive for blood.

Nursing diagnoses for a client with gastritis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related The client will experience less Administer medications and provide diet as ordered.
to gastric acid on pain within 24 hours of onset Assess client for improvement of symptoms.
inflammation of treatment as identified by
pain scale. Implement education about lifestyle changes.

Deficient Knowledge The client will verbalize Educate regarding medication regimen and lifestyle changes.
related to condition, understanding of condition and If the client smokes or drinks alcohol, provide information on
therapy, and symptoms of symptoms of complications smoking and drinking cessation.
potential complications and will comply with treatment
regimen. Discuss dietary modifications.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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206 UNIT 3 Nursing Care of the Client: Digestion and Elimination

A vagotomy eliminates the complications of the more aggres-

■ ULCERS sive surgeries, such as gastrectomies.
If the ulcer continues to bleed or if the ulcer has per-
P eptic ulcers are erosions that form in the esophagus,
stomach, or duodenum resulting from an acid/pepsin
imbalance. Gastric ulcers refer to erosions in the stomach
forated, the client is taken to surgery and a gastrectomy is
performed. The portion of the stomach or duodenum that is
perforated is removed and the bowel is reconnected with an
and are correlated to exposure to irritants such as NSAIDs, anastomosis.
smoking, alcohol, food allergens, toxic chemicals, H. pylori Complications from gastrectomies include gastric dump-
infections, and impaired mucosal defenses. Impaired mucosal ing in which the stomach experiences postprandial (after
defenses occur when the epithelial cells of the stomach are eating) rapid gastric emptying. Clients experience abdominal
not able to secrete an adequate quantity or quality of mucus pain, nausea, vomiting, explosive diarrhea, weakness, and
to protect the stomach. dizziness. Clients with gastric dumping have malabsorption
Clients with gastric ulcers frequently complain of pain 1 to of nutrients because the food passes too quickly to permit
2 hours after eating. Eating may not relieve pain or may even absorption, thus leading to malnutrition. In addition, many
increase pain. Weight loss is common. Risk factors include clients with significant symptoms limit dietary intake to avoid
alcohol use, stress, and NSAID use. symptoms, compounding the malnutrition and weight loss
Stress ulcers are a type of gastric ulcer that form when issues.
gastritis becomes erosive and starts bleeding. As the name Management of gastric dumping includes small, frequent
implies, stress ulcers occur in clients whose bodies are expe- meals of high fiber and high protein and avoidance of simple
riencing stress, such as clients who have experienced major carbohydrates.
surgery, trauma, burns, chemotherapy, or radiation therapy.
Clients with chronic respiratory disorders also experience Pharmacological
stress ulcers because hypoxia can lead to impaired mucosa.
Bleeding may be massive resulting in significant blood loss Treatment of ulcers is primarily pharmacological involving
or can be slow and insidious. Because of the multiple sites of antacids, histamine (H2) receptor antagonists (also called
bleeding, stress ulcers are difficult to manage. H2 blockers), proton pump inhibitors, or prostaglandins. If
Duodenal ulcers refer to ulcers in the duodenum. Incidents H. pylori is present, bismuth preparations are generally used
of duodenal ulcers have been correlated to a high secretion to inhibit its growth and antibiotics to eliminate the bacteria
of HCl. Clients with duodenal ulcers frequently complain of (refer to Table 7-3).
pain 2 to 4 hours after eating. Nocturnal pain may be present, NSAIDs such as ibuprofen (Motrin) and indomethacin
occurring between midnight and 3:00 a.m. Eating frequently (Indocin) have been shown to compromise mucosal defenses
relieves symptoms. Weight gain is common. Risk factors and increase acid secretion. For clients who are on NSAIDs
include a history of pulmonary disease, cirrhosis, chronic pan- chronically, such as clients with arthritis, one needs to evalu-
creatitis, and/or chronic renal failure. ate whether other analgesics would be effective or whether a
If an ulcer erodes through a blood vessel, the client prostaglandin should be taken with the NSAIDs.
may experience a life-threatening hemorrhage. A perforation
occurs if the ulcer erodes through the wall of the stomach or Diet
small intestine resulting in gastric or intestinal contents entering Although studies have shown that dietary modifications have
the abdominal cavity and causing peritonitis. little impact on the rate of ulcer healing, some modifications
Diagnosis of ulcers is based on symptoms, history, and an are indicated. Foods that aggravate symptoms are eliminated.
UGI or EGD performed to visualize the ulcer. If an H. pylori Also, foods that increase acid secretions, such as milk, coffee,
infection is suspected, a biopsy is obtained during an EGD and decaffeinated coffee, tea, colas, and chocolate, should be con-
a culture is performed. sumed only in small amounts or eliminated if possible. Eating
close to bedtime is avoided because it increases nocturnal acid
Medical–Surgical secretions.
Management Health Promotion
Medical Smoking and alcohol aggravate the mucosal lining of the
If an ulcer bleeds, an EGD may be performed, and the ulcer stomach and duodenum and significantly impair ulcer healing.
is either injected with epinephrine to cause vasoconstriction Smokers also experience a higher ulcer recurrence rate. Stress
or a special electrical probe is used to cauterize or burn the has been shown to increase the rate of peptic ulcers. Although
tissue that is bleeding. A nasogastric (NG) tube is inserted the type or severity of stress may not be significant, the cli-
to remove gastric contents and blood, and iced isotonic ent’s interpretation of the events as stressful is. Clients need
saline is instilled to help cause vasoconstriction and stop the to develop mechanisms for reducing stress such as exercise,
bleeding. biofeedback, and relaxation.

Surgical Nursing Management

The most commonly performed surgery for peptic ulcers is a Encourage lifestyle changes when necessary regarding smok-
vagotomy, in which a section of the vagus nerve is cut removing ing, alcohol, and stress. Teach relaxation techniques. Monitor
vagal innervation to the fundus of the stomach. This elimi- weight and laboratory test results. Discourage having a bedtime
nates the production of hydrochloric acid, decreases function snack to prevent acid secretions at night. Assess pain including
of the gastrin hormone, and slows motility of the stomach. relationship to eating a meal.

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 CHAPTER 7 Gastrointestinal System 207

also have a history of pulmonary disease, cirrhosis, chronic

NURSING PROCESS pancreatitis, and/or chronic renal failure.
Assessment A client who is actively bleeding from an ulcer will expe-
rience an acute onset of epigastric pain, shortness of breath,
Subjective Data and nausea.
Clients with gastric ulcers are often asymptomatic or may
describe epigastric pain or burning 1 to 2 hours after eating, Objective Data
and nausea or bloating. Clients may experience an increase of Clients with gastric ulcers may show a weight loss and stools
symptoms when they eat and therefore may decrease dietary may test positive for blood. An H & H may show anemia.
intake. When questioned about lifestyle, NSAID usage, stress, Clients with duodenal ulcers may show a weight gain and
smoking, and alcohol use may be discovered. stools may test positive for blood. An H & H may show anemia.
Clients with duodenal ulcers may exhibit no symptoms The client who is actively bleeding from an ulcer will
or may complain of pain 2 to 4 hours after eating. Eating will show signs of shock: pale clammy skin, an elevated pulse
frequently decrease symptoms, so clients will often eat more rate, and a drop in blood pressure. The client may also have
frequently. When questioned about lifestyle, stress, smoking, hematemesis. Laboratory tests show a low H & H and stools
and alcohol consumption may be discovered. The client may test positive for blood.

Nursing diagnoses for a client with ulcers include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will experience less Assess clients for decrease of pain.
gastric acid on ulcerated pain within 24 hours of onset Administer medications as ordered.
mucosa of treatment as identified on
pain scale. Assess for elevated BP.

Deficient Knowledge The client will verbalize Identify client’s learning style and provide information
related to condition, understanding of factors in a manner compatible with the learning style. Educate
therapy, and symptoms related to condition and regarding medication regimen, lifestyle changes, and signs
of complications symptoms of complications. and symptoms of possible complications.
Client will comply with If indicated, provide client with smoking cessation
treatment regimen. information and stress reduction techniques such as
exercise and biofeedback.

Deficient Fluid Volume The client will exhibit normal Check vital signs every 4 hours and PRN including
related to bleeding ulcer fluid volume as evidenced orthostatic blood pressure.
by stable H & H and blood Monitor for dizziness and nausea.
pressure within 20 mm Hg of
baseline. Check stool for blood.
Administer IV fluids, electrolyte replacement, and blood
transfusions as ordered.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

show a WBC >10,000/mm3 and neutrophils >75%. An ele-

■ APPENDICITIS vated temperature indicates infection. Rebound tenderness in
the right lower quadrant (RLQ) of the abdomen (at McBur-
A ppendicitis is the inflammation of the vermiform
appendix, a 10-cm small, slender tube attached to the
cecum. The appendix may be inflamed, gangrenous, or rup-
ney’s point) is a positive diagnostic finding. An appendectomy
is performed along with other abdominal surgeries as a preven-
tive measure.
tured. If the opening to the appendix becomes blocked with
feces, the E. coli multiply in the appendix and infection devel-
ops with pus formation. If it ruptures, fecal content spills into
the abdominal cavity causing peritonitis, which may be fatal. Surgical
It is most common in young adults, but can occur at any age A surgical procedure called an appendectomy is necessary
(Atassi, 2002a). A barium enema or an ultrasound is ordered before the appendix ruptures. Appendectomies are the most
to confirm inflammation in the appendiceal area. common emergency surgery and require a hospital stay of
a few days if the appendix has ruptured. If no rupture has
Medical–Surgical Management occurred, a laparoscopic appendectomy, in which the appen-
dix is removed through a scope, may be done. This requires
Early diagnosis and treatment are necessary for the best client only a small incision and allows the client to be discharged
outcome. A white blood count and differential will usually 24 hours after the surgery.

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208 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Pharmacological Nursing Management

Preoperatively, no analgesics are administered so that symp- Assess pain. Keep client NPO. Monitor vital signs, especially
toms will not be masked by the medication. Fluids and elec- temperature. Assess bowel sounds. Monitor the results of the
trolytes may need to be replaced before surgery. Antibiotics CBC, especially WBC and neutrophils. Postoperatively, encour-
are usually given preoperatively. Postoperatively, analgesics age client to turn, cough, and deep breathe every 2 hours.
are administered for relief of incisional discomfort. Antibiot- Encourage ambulation. Advance diet from liquid to regular as
ics are usually given postoperatively, especially if a perforation bowel function returns.
is present.
NURSING PROCESS
Diet
Preoperatively and initially postoperatively, the client is NPO. Assessment
If a perforation with peritonitis occurred, the client is kept Subjective Data
NPO longer, and an NG tube is inserted until bowel sounds
return. Clear liquids and then full liquids and finally a regular Clients with appendicitis describe abdominal pain, typi-
diet is given as normal bowel function returns. cally located in the RLQ around McBurney’s point (halfway
between the umbilicus and the right iliac crest). Clients also
complain of anorexia (a loss of appetite) and nausea.
Activity
Initially postoperatively, the client is encouraged to turn, Objective Data
cough, and deep breathe every 2 hours. Next, the client is Clients may have vomiting and fever. Bowel sounds may be
encouraged to increase ambulation gradually. Activity restric- diminished or absent. Rebound tenderness, pain that occurs
tions depend on the severity of the appendicitis. Driving, when fingers are pressed into the RLQ and then released
exercise, and lifting will be limited for a few weeks to allow for suddenly, may be present. A CBC will show WBCs elevated
incisional healing. ⬎ 10,000/mm3 with neutrophils ⬎ 75%.

Nursing diagnoses for a client with appendicitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related The client will experience Preoperatively, monitor client’s pain and check abdomen for
to appendicitis/ a decrease in pain as rigidity.
appendectomy evidenced by improved Provide an ice pack to help relieve pain as ordered; never use
mobility and as identified on heat.
pain scale.
Postoperatively, give analgesics as ordered and medicate prior
to activities such as ambulation.
Teach client to use a pillow to splint the incision when coughing.
If client is having difficulty passing flatus, administer enemas or
a rectal tube as ordered, and encourage ambulation.

Impaired Skin Integrity The client will verbalize Administer antibiotics as ordered.
related to the abdominal signs and symptoms of Educate the client that incision may be left open to the air
incision infection and factors that after 24 hours; that showers may be taken, per physician
enhance wound healing, by instruction; and signs and symptoms of infection and activity
discharge. restrictions.
If adhesive strips are present, leave in place until they no
longer cover the incision (approximately 10 days to 2 weeks).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

fiber is believed to contribute to the formation of the pouches.

■ DIVERTICULOSIS AND Diverticulosis affects >50% of the elderly population (Marrs,
DIVERTICULITIS 2006). It is asymptomatic unless perforation or hemorrhage
occur.

D iverticula are saclike protrusions of the intestinal wall.

Diverticulosis refers to a condition of the colon in
which multiple diverticula are present (Figure 7-5). The exact
Diverticulitis refers to the inflammation of one or more
diverticula generally in the sigmoid colon. It is a complication
of diverticulosis and is thought to be caused by stool impacted
cause of diverticulosis is not known; however, a diet low in in the diverticula.

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 CHAPTER 7 Gastrointestinal System 209

Perforation
Hemorrhage

COURTESY OF DELMAR CENGAGE LEARNING

Figure 7-5 Diverticula in the sigmoid colon. Diverticulosis is
almost always located in the descending or sigmoid colon. Ascending colostomy Transverse colostomy

Medical–Surgical Management
Medical
Diverticulosis is typically asymptomatic and needs no interven-
tion. Most cases of diverticulitis are treated with analgesics, anti-
biotics, bed rest, NPO to rest the bowel, and IV fluid hydration.
A barium enema or abdominal ultrasound is usually
ordered when diverticulitis is suspected. A flexible sigmoidos-
copy is also performed.

COURTESY OF DELMAR CENGAGE LEARNING

Surgical
If bleeding or perforation of the diverticula occurs, or if an
abscess forms, surgery is required to remove the affected por-
tion of the bowel. A colon resection is performed. A colos-
tomy may be required. A colostomy is a surgically created
opening from the colon through the abdominal wall to relieve
Descending colostomy Sigmoid colostomy
either a disease or functional problem in the large intestine.
Stool consistency depends on the placement of the stoma
(surgical opening between a cavity and the surface of the body) in Figure 7-6 Colostomy Sites (Blue Area Is Colon Removed)
the colon. A colostomy is named for the part of the colon where
it is located. An ascending colostomy takes its name from the If surgery is performed, the client is NPO until bowel
ascending colon and would be on the right side of the abdomen. sounds return. The client is then started on clear liquids,
It has a liquid output. A transverse colostomy would be more advanced to full liquids as more bowel function returns, and then
toward the midline of the abdomen and has a pasty liquid output. finally advanced to a regular diet. A high-fiber diet is encouraged
A descending colostomy or sigmoid colostomy has a more solid for clients once the diverticulitis episode has resolved.
output. Figure 7-6 shows the different colostomy sites.
If a large amount of inflammation is present, a temporary
colostomy is performed to allow the colon to heal. The colon Activity
is reconnected at a later time. Sometimes a permanent colos- For clients experiencing diverticulitis, bed rest and decreased
tomy needs to be performed. mobility are encouraged to allow the bowel to rest. In clients
who have had a bowel resection, activity will gradually be
Pharmacological progressed postoperatively.
Clients who have been identified as having diverticulosis are usu-
Stoma/Ostomy Management
ally placed on fiber supplements or stool softeners. Clients with
diverticulitis are treated with sulfa antibiotics and other antimi-
crobial agents. Analgesics also are ordered for discomfort.
Assessment
Provide the client with an opportunity to ask questions and
Diet begin coping with a possible altered body image. Before
A high-fiber diet is believed to help reduce the occurrence ostomy surgery, the surgeon and the enterostomal (ET) nurse
of diverticulosis and diverticulitis. Clients experiencing talk with the client and explain the reason for the surgery
diverticulitis will be NPO to rest the bowel. Once the diver- and the possibilities of ostomy surgery. Choosing the site or
ticulitis begins healing, the client is placed on clear liquids and placement of the stoma depends on the type of ostomy being
then advanced to a bland, low-residue diet while the diver- created, the lifestyle of the client, and the contours of the
ticulitis heals. client’s abdomen.

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210 UNIT 3 Nursing Care of the Client: Digestion and Elimination

On return from surgery, the new stoma is edematous and want to look at or touch the stoma. The family may have to help
ranges from deep red to dusky in color. The color of the stoma with care and be supportive until the client can assume the care.
is checked with a penlight and documented at least once per
shift. Color is important because it reveals the status of the Appliances
blood supply to the stoma. If blood supply to the stoma is If the client has only one bowel movement per day, a closed
inadequate, the stoma will turn black. Notify the physician if appliance that is taken off and emptied once a day is all that is
the stoma becomes black. needed. If the client has several stools per day, an open-ended
Immediately after surgery there may be a small amount drainable appliance is best.
of serosanguineous drainage in the appliance, the stool-collec- For ileostomies, the one- or two-piece open-end appliance
tion device. When the appliance is changed and the stoma is offers ease in emptying. Effluent usually varies from liquid to
cleaned or touched when swollen, a small amount of bleeding pasty, so an appliance that can be drained several times per day
may occur. Reassure the client that a small amount of bleeding without taking it off is important. A skin barrier is also neces-
is normal. Bowel function is checked every shift to monitor sary for the ileostomy or any ostomy with liquid output.
for any obstruction or ileus. Bowel sounds, distention, and
abdominal tenderness are checked every 4 hours. Irrigation
Irrigation is a means of regulating some colostomies. Descending
Complications or sigmoid colostomies are irrigated daily or every other day for
Hemorrhage Bleeding or hemorrhage may occur at the control of evacuation. After irrigation, the client may wear a small
incision site or stoma site. It is important to check the incision security appliance or a gauze pad over the stoma the rest of the
and stoma site for bleeding and to check the blood pressure day. The disadvantage of irrigation is that it takes about an hour
and pulse frequently after surgery. or more to perform. The decision to irrigate is made by the client,
with the consent of the surgeon, after healing has taken place. To
Infection The risk of infection around the stoma is great irrigate a colostomy, a cone tip is needed on the end of the irriga-
because of the presence of stool around the new suture line. tion catheter. Using the cone on the tip of the tubing prevents the
end of the tube from poking into the side of the bowel and injuring
Hernia A hernia is the most frequent complication of an
the bowel and helps hold the fluid in the bowel. The cone needs
ostomy and is caused when a loop of bowel pushes up through
to be lubricated liberally with water-soluble lubricating jelly.
the muscle next to the stoma and under the skin.
Obstruction Obstruction of the bowel ostomy may occur as Support Person
a complication after surgery. Ileostomy clients are instructed Upon discharge, the client and family receive the telephone
to chew their food well before swallowing because large pieces number of the hospital and unit where treatment was received
of food such as an olive or large piece of meat may get caught so they may call if questions arise. Seeing the ET nurse again in 4
at the opening of the ostomy. to 6 weeks is sometimes recommended to check how the client
is doing with ostomy care. If there is a local stoma support group,
Prolapse The bowel may sometimes telescope out through the a person from the group may call or visit the client at home and
stoma, resembling an elephant’s trunk. If the bowel continues to invite the client and family to come to the group sessions.
work, this is not an emergency. The physician or ET nurse may Having ostomy surgery is no reason to stop any life activity.
be able to replace the bowel back into the abdomen; if not, the People with ostomies live full, active, productive lives.
mucosa of the bowel may become injured, so the prolapse is
corrected surgically. Prolapse can be frightening for the client,
and its possibility is discussed in postoperative teaching. Nursing Management
Assess bowel sounds frequently. Monitor severity of symp-
Electrolyte Imbalance An ileostomy with a high output toms such as pain, diarrhea, constipation, abdominal dis-
of effluent can cause electrolyte imbalances by loss of large tention, anorexia, nausea, vomiting, and fever. Check CBC
amounts of potassium and protein. The client may have dif- reports for increased WBC and low H & H. Explain all tests
ficulty learning to cope with an appliance that is always filling and treatments and answer questions.
and the need to take in enough fluid, protein, and potassium
to replace the lost nutrients.
Skin Excoriation The skin around a high-output ostomy NURSING PROCESS
may become excoriated if an appliance that protects the skin
cannot be found. Ileostomy effluent contains digestive juices Assessment
that, if left on the skin, will start to digest the skin, resulting Diverticulosis often has no symptoms, and therefore, clients
in red, open areas. To prevent this problem, correct appliance may not be aware they have it.
fitting that will stay in place is important for these clients.
Subjective Data
Discharge Teaching for Clients with diverticulitis frequently describe left lower abdomi-
nal pain, constipation or diarrhea, bloating, anorexia, and nausea.
the Ostomy Client Objective Data
Assessment Assessment shows abdominal distention with tenderness on
As the client prepares to go home, it is important to assess the palpation, decreased bowel sounds, fever, vomiting, and stools
client’s or the family’s ability to handle ostomy care at home. The that test positive for blood. A CBC will show an increased
client may still be dealing with an altered body image and not WBC and, if bleeding is present, a low H & H.

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 CHAPTER 7 Gastrointestinal System 211

Nursing diagnoses for a client with diverticulosis or diverticulitis include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize a Encourage bed rest to allow healing.
diverticulitis decrease in pain within 24 Maintain client as NPO.
hours after intervention as
measured by the pain scale. Administer analgesics and antibiotics as ordered.

Risk for Infection related The client will verbalize Monitor vital signs and pain level every 4 hours and assess
to abscess formation or understanding of signs abdomen every 4 hours for increased tenderness and distention.
perforation and symptoms of possible Educate the client to notify staff of chills, shortness of breath,
complications. or increasing pain.

Anxiety related to The client will verbalize fears Explain all tests and treatments to decrease the client’s
possible surgery related to surgery and exhibit anxiety level. Answer all concerns and questions.
decreased anxiety regarding Allow the client to verbalize fears and concerns.
the procedure and follow-up
treatment. If a colostomy is planned, arrange a consult with an
enterostomal therapist to help answer concerns.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Diverticulitis
W.D. is a 67-year-old man admitted to the hospital with abdominal pain that started 2 days ago. The pain
has been increasing in intensity and is now accompanied by nausea and anorexia. Physical assessment
reveals temperature 101.7°F, pulse 96, respirations 24, and blood pressure of 162/90. W.D.’s abdomen is
tender on palpation. He is in obvious discomfort and is unable to lie on his back. W.D. states he has not
been eating any food or drinking adequate fluids for 24 hours. Skin turgor is poor. An abdominal ultra-
sound is ordered and identifies diverticulitis. An IV of D5 1/2 NS with 20 mEq KCl, droperidol (Inapsine) IV
for nausea, meperidine (Demerol) IM for pain, and IV antibiotics are ordered. W.D. is placed on I&O, bed
rest with bathroom privileges, and is made NPO. W.D. states that he does not understand why all this is
being done. His first two voidings are 50 mL each and very concentrated (dark-gold colored).

NURSING DIAGNOSIS 1 Deficient Knowledge related to diagnosis and treatment regimen, as

evidenced by W.D.’s statement that he does not understand why all this is being done
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Disease Process Teaching: Disease Process
Knowledge: Treatment Regimen Teaching: Individual

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

W.D. will verbalize Assess W.D.’s knowledge level of Helps client relate new informa-
understanding of treatment plan. diverticulosis/diverticulitis. tion and integrate it into his
behavior.
Assess W.D.’s learning style Increases understanding and
and present information in a retention.
compatible manner.
Monitor for signs of pain and They impair learning.
fatigue.
Answer questions and reinforce Reinforces the new information
information. learned.
(Continues)
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212 UNIT 3 Nursing Care of the Client: Digestion and Elimination

SAMPLE NURSING CARE PLAN (Continued)

EVALUATION
W.D. verbalizes understanding of the disease process and treatment regimen.

NURSING DIAGNOSIS 2 Acute Pain related to diverticulitis as evidenced by tender abdomen

Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Comfort Control Pain Management
Pain Control Medication Management
PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
W.D. will verbalize a decrease Assess pain by the use of a scale of 1 Provides objective measure of the
in pain within 24 hours of pain (no pain) to 10 (extreme pain). client’s perceived discomfort and
intervention. effectiveness of analgesics.
Medicate with analgesics as Provides pain relief.
ordered.
Encourage W.D. to request Provides better control of pain.
analgesics before pain becomes
intense.
Monitor effectiveness of the Provides a measure of
pain medication by reassessing analgesic effectiveness.
the pain 45 minutes after the
analgesic is given.

EVALUATION
W.D. demonstrates adequate pain relief as demonstrated by a decrease in pain scale.

NURSING DIAGNOSIS 3
Deficient Fluid Volume related to not eating any food or drinking adequate fluids for 24 hours as evidenced by low urine output and poor skin turgor
NOC: Fluid Balance, Hydration
NIC: Fluid/Electrolyte Management, Fluid Monitoring

NURSING GOAL
W.D. will demonstrate adequate hydration through balanced I&O,
improved skin turgor, and normalized electrolyte values within 24
hours of interventions.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Monitor I&O every shift. 1. Provides information on W.D.’s hydration.
2. Provide frequent oral care while NPO. 2. Helps to keep oral mucosa moist and clean.
3. Administer IV fluids as ordered. 3. Provides needed hydration while NPO.
4. Assess oral mucosa and skin turgor. 4. Provides information on hydration status.
5. Monitor electrolyte values from laboratory reports and notify team 5. Provides information on electrolyte balance and tracks
leader and/or MD of abnormal findings. trends while values normalize.

EVALUATION
Did W.D. demonstrate adequate hydration by evidence of balanced
I&O, moist oral mucosa, good skin turgor, and electrolytes within
normal limits?

Concept Care Map 7-1

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 CHAPTER 7 Gastrointestinal System 213

■ INFLAMMATORY BOWEL Medical–Surgical

DISEASE Management
I nflammatory bowel disease (IBD) is the term used to
describe Crohn’s disease and ulcerative colitis (UC), which
are diseases characterized by inflammation and ulcerations of
Medical
Treatment for Crohn’s disease and UC is similar. Crohn’s dis-
ease, however, is more debilitating because it involves more of
the bowel (Table 7-4). The symptoms of IBD are not confined the GI tract. UC is more limited but can still produce signifi-
to the bowel but can affect many of the body’s systems, such cant symptoms.
as uveitis and inflammatory process in the eye (Cox, Evans, An endoscopy done on a UC client reveals continu-
Withers, and Titmuss, 2008). Potential extraintestinal mani- ous mucosal inflammation and ulceration, loss of mucosal
festations may be found in other internal organs, eyes, blood, vascularity, diffuse erythema, and often purulent exudate.
skin, and musculoskeletal system. Thirty percent of IBD cli- Any granuloma found in the biopsy confirms Crohn’s disease
ents have at least one extraintestinal manifestation (Rayhorn (Rayhorn & Rayhorn, 2002). The goals of treatment are to
& Rayhorn, 2002). control inflammation, relieve symptoms, maintain fluid and
Crohn’s disease is characterized by lesions that affect electrolyte balance, provide adequate nutrition, and prevent
the entire thickness of the bowel and can occur anywhere complications.
throughout the colon and small intestine. Symptoms include
abdominal pain, diarrhea that usually does not contain blood, Surgical
fever, anorexia, weight loss, and steatorrhea (fatty stools). In severe cases of UC resistant to medical management, the
Electrolyte imbalance, iron-deficiency anemia, and amino colon is removed and an ileostomy is performed, curing the
acid malabsorption occur when the disease involves the disease. An ileostomy is an opening created in the small
jejunum and the ileum. Long-term complications of Crohn’s intestine (ileum). The output from an ileostomy is a thin
disease include bowel obstructions, fistulas, abscesses, and liquid, usually of a yellowish-green color. This thin output
perforation. The risk for colorectal cancer, although not as is called effluent. It generally has no odor, and it may get
high as in UC, is still increased. There is malabsorption of fat thicker in time as the body adapts to the need to retain
and fat-soluble vitamins. moisture. Many ileostomies have almost constant effluent
UC is characterized by mucosal lesions occurring output. The Kock continent ileostomy has a pouch made
typically in the rectal area and sigmoid colon and pro- inside the abdomen to hold the effluent until the client is
gressing throughout the colon. Symptoms include fever, ready to empty the pouch. Figure 7-7 illustrates a Kock con-
anorexia, weight loss, cramping, spasms, abdominal pain, tinent ileostomy.
and bloody diarrhea. Long-term complications include Most clients with Crohn’s disease need surgery at some
fissures, abscesses, and an increased risk for colorectal point to repair the structural damage caused by scarring.
cancer. Intestinal obstructions and perforations may also occur in
The gold standard for diagnosing IBD is an endoscopic Crohn’s disease, necessitating further surgery. Surgical inter-
examination with a biopsy. vention, however, does not cure the disease.

Table 7-4 Comparison of Crohn’s disease and ulcerative colitis

PARAMETER CROHN’S DISEASE ULCERATIVE COLITIS (UC)
Involvement Patchy areas. Can involve small Starts in lower colon and spreads
and large intestine. progressively throughout colon. Affects
only the colon.

Tissue affected Affects entire thickness of bowel. Affects mucosal lining of bowel.

Long-term complications Intestinal obstruction, fistulas, Fissures, abscesses, increased risk for
abscesses, perforations; cancer colorectal cancer.
risk increases with age.

Surgical intervention Usually needed at some point to Ileostomy performed in approximately 20% of
repair structural damage. Does not cases to remove the colon. Cures the
cure or limit the progress of the disease.
COURTESY OF DELMAR CENGAGE LEARNING

disease.

Cause Unknown: possibly altered immune Unknown: possibly enteric bacterium E. coli.
state.

Stools 3 to 4 semisoft/day; rarely bloody; 15 to 20 liquid/day; blood present; no

steatorrhea and mucus present. steatorrhea.

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214 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Ileum
Abdominal CLIENTTEACHING
wall
IBD
• Schedule a colon cancer screening regularly.
• When taking oral corticosteroids, strictly adhere to
the prescribed schedule.

COURTESY OF DELMAR CENGAGE LEARNING

Stoma Ileal pouch Health Promotion
Although stress has not been shown to exacerbate the symp-
toms of Crohn’s disease or UC, the impact on the client’s
lifestyle can be significant, especially with Crohn’s disease.
Support groups can be beneficial. Encourage clients to develop
mechanisms to help them cope with the disease process. Exer-
cise, meditation, and biofeedback may be helpful.
Figure 7-7 Kock Continent Ileostomy

Pharmacological Nursing Management

Treatment for both UC and Crohn’s disease includes 5-ASA Assess the abdomen for tenderness, distention, and bowel
compounds such as sulfasalazine (Azulfidine) or salicylates such sounds. Monitor weight, vital signs, and stools. Maintain
as mesalamine (Rowasa) or olsalazine sodium (Dipentum). If an accurate I&O and calorie count. Provide high-calorie,
inflammation is severe, corticosteroids also are administered. high-protein small, frequent meals and snacks. Encourage
In cases resistant to the 5-ASA compounds and corticosteroids, verbalization of feelings.
immunosuppressors are used. If an infection is present, anti-
biotics are administered. According to Rayhorn and Rayhorn
(2002), clients are seldom given antidiarrheal medications NURSING PROCESS
because they may predispose the client to toxic megacolon.
Clients need IV fluid and electrolyte replacement during
severe flare-ups. In the most severe cases, clients are placed on
Assessment
total parenteral nutrition (TPN) to allow for complete bowel Subjective Data
rest and to improve nutritional status. Clients describe mild abdominal spasms and cramping,
which may increase to severe abdominal pain, nausea, and
Diet anorexia. Clients with UC have an urge to defecate with the
Protein and calorie malnutrition is a concern in clients with cramping.
IBD. Because of the severe cramping, pain, and diarrhea
brought on by foods, these clients typically put themselves on Objective Data
a very restrictive diet that is not nutritionally balanced. Clients Clients have abdominal tenderness on palpation, guarding, dis-
with Crohn’s disease may also have malabsorption of iron and tention, weight loss, diarrhea, an elevated WBC count, and fever.
vitamin B12. In clients with Crohn’s disease, steatorrhea and iron-deficiency
Nutritional support includes modifying the diet to elimi- anemia may be present. In clients with UC, stools may be posi-
nate foods that exacerbate symptoms while maintaining a tive for blood and the H & H may be low. The serum potassium,
balanced diet. A high-calorie, low-residue, high-protein, low- magnesium, and albumin levels are usually low. Because Crohn’s
fat diet is recommended (Rayhorn & Rayhorn, 2002). disease is so debilitating, clients may become depressed.

Nursing diagnoses for a client with Crohn’s disease or UC include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: The client will demonstrate Monitor I&O every shift; caloric count and weight daily.
Less than Body adequate nutritional status as Administer IV fluid and electrolyte replacement as ordered.
Requirements related exhibited by maintaining weight
to postprandial pain, within range for height and body Provide high-calorie, high-protein supplements as ordered
bowel hypermobility, and type. along with small, frequent meals.
decreased absorption Administer TPN, a high-calorie and nutrient-dense IV
solution, as ordered. Closely monitor lab reports for
electrolytes and glucose level.

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 CHAPTER 7 Gastrointestinal System 215

Nursing diagnoses for a client with Crohn’s disease or UC include

the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Deficient Fluid The client will exhibit adequate Administer 5-ASA compounds, corticosteroids, and
Volume related to hydration as evidenced by immunosuppressors as ordered.
diarrhea and altered electrolytes within normal range, Monitor I&O every shift.
intake moist mucous membranes, and
I&O nearly equal within 48 hours Administer IV fluid and electrolyte rehydration as ordered.
of intervention. The frequency
and amount of diarrhea will
decrease within 48 hours of
intervention.

Powerlessness related The client will verbalize a plan to Provide client with information on national organizations
to impairment in lifestyle seek support, by discharge. and local support groups. Arrange social work consult if
secondary to disease needed.
process Allow client to verbalize feelings.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

• When abdominal pain or discomfort begins, there

■ IRRITABLE BOWEL is a change in how often the client has a bowel
SYNDROME movement.

I
• When abdominal pain or discomfort begins, there
rritable bowel syndrome (IBS) refers to a group of symp- is a change in the form of the stool or the way it
toms—cramping, abdominal pain, bloating, constipation, looks.
or diarrhea. Some clients have both constipation and diarrhea
which alternate in appearance. There is no organic cause, but
the movement of feces and gas through the colon and the Medical-Surgical
absorption of fluids are affected. When feces stay in the colon
too long and too much water is absorbed, constipation results. Management
When feces is pushed through the colon too fast by spasms, Medical
little water is absorbed and diarrhea results. Spasms also
temporarily trap gas or feces, preventing them from moving The goal of treatment is to relieve the symptoms. Foods
forward, and therefore causing pain. that make the symptoms worse are eliminated from the diet.
The colon seems to be more sensitive and reactive espe- Increasing dietary fiber is often helpful. Anxiety-reducing
cially to certain foods and stress. Since the colon is partly measures often relieve symptoms. If the client has severe
controlled by the autonomic nervous system, it responds to anxiety or depression, counseling may be required.
stress. It may contract too much or too little, and too much
water or too little water may be absorbed. Pharmacological
In the United States, one in five persons has IBS, making Anticholinergic medications are administered before meals.
it one of the most common gastrointestinal disorders. Only Clients with constipation may be given tegaserod maleate
a small proportion of people seek medical treatment, while (Zelnorm), usually for 4 weeks. Bulk-forming psyllium hydro-
most will treat the symptoms themselves. IBS occurs more philic muciloid (Metamucil) may also be used.
frequently in women than in men, and usually begins around Clients who primarily have diarrhea and have not
age 20 (NIDDK, 2009b). responded to other therapies may be given alosetron hydro-
There is no diagnostic test for IBS, but clients presenting chloride (Lotronex). It should be used with caution because
with the aforementioned symptoms often undergo testing it can have serious side effects, such as severe constipation or
to rule out other disorders. Criteria for a diagnosis of IBS decreased blood flow to the colon.
include:
Diet
1. Abdominal pain or discomfort for at least 12 weeks
The client is instructed to eliminate from the diet those foods
(not necessarily consecutive) out of the previous 12
that aggravate the symptoms and discomfort. Foods often
months.
associated with making IBS symptoms worse include wheat,
2. At least two of the following three features must be rye, barley, chocolate, milk products, alcohol, and caffeinated
present: drinks. Foods high in fiber such as bran, cereal, beans, fruits,
• Abdominal pain or discomfort is relieved by having a and vegetables may reduce symptoms. Large meals cause
bowel movement. cramping and diarrhea.

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216 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Activity NURSING PROCESS

Regular exercise may help relieve symptoms. Seldom is weight
loss a problem. Assessment
Subjective Data
Nursing Management
Some clients describe cramping, abdominal pain, and diarrhea
during or soon after a meal, others complain of constipation,
Encourage the client to write down what is eaten, what symp- and still others report alternating diarrhea and constipation.
toms are present and when they occur, and which foods always Abdominal fullness, gas, and bloating also often occur.
make the client feel bad. Then eliminate those foods causing
symptoms or making the client feel bad. Suggest that the client Objective Data
eat five or six small meals instead of three large meals each day. The client’s stools will be either very loose (diarrhea) or very
Encourage the client to exercise regularly and practice stress- hard and difficult to pass (constipation). Mucus may be passed
relieving measures such as progressive relaxation or guided with the bowel movement. No weight loss, bleeding, or fever is
imagery. associated with IBS.

Nursing diagnoses for a client with irritable bowel syndrome include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Diarrhea related to The client will have normally Encourage frequent meals. Add high-fiber foods gradually
rapid movement of formed stools. to meals.
feces through the colon Teach client to eliminate gas-forming foods and other foods
with too little fluid being causing symptoms from the diet.
absorbed
Teach stress-reducing measures.

Constipation related to The client will have regularly Encourage increased fluid intake unless contraindicated, and
delayed movement of passed, soft, formed stools. increase consumption of high-fiber foods.
feces through the colon Encourage regular exercise such as walking.
with too much fluid being
absorbed Administer medications as prescribed.
Teach stress-reducing measures.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ INTESTINAL OBSTRUCTION Telescoping of bowel

A n intestinal obstruction occurs when the contents can-

not pass through the intestine. Obstructions occur in the
large or the small intestine, with most occurring in the ileum.
A

Obstructions may be mechanical, neurogenic, or vascular in

origin.
A mechanical obstruction may be a partial or complete
obstruction caused by a tumor; fecal impaction; hernia; vol-
vulus, a twisting of the bowel on itself; intussusception, a Intussusception
telescoping of the bowel where the bowel slides inside itself
(Figure 7-8); or adhesions, scar tissue in the abdomen
from previous surgeries or disease process such as Crohn’s B
disease.
COURTESY OF DELMAR CENGAGE LEARNING

180-degree twisting of bowel

A neurogenic obstruction, known as a paralytic ileus,
occurs when nerve transmission to the bowel is interrupted by
trauma, infection, or medications, resulting in a portion of the
bowel being paralyzed.
A vascular obstruction occurs when blood flow to a por-
tion of the bowel is interrupted, as in atherosclerosis, and that
portion of the bowel becomes necrotic. Volvulus
When the small intestine becomes obstructed, large
amounts of fluid, bacteria, and swallowed air build up in the Figure 7-8 Bowel obstructions can be caused by A, an
bowel proximal to the obstruction. The normal process of intussusception; or B, a volvulus.

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 CHAPTER 7 Gastrointestinal System 217

secretion and absorption of the electrolyte-rich fluid is inter- Activity

rupted. Distention and poor absorption occur when water
and salts move from the circulatory system to the lumen of the In cases of paralytic ileus, ambulation is encouraged to help
intestine. bowel function return. Encourage clients who have had a
An abdominal x-ray and a barium enema or UGI with bowel resection to turn, cough, and deep breathe every 2 hours
small bowel follow-through are ordered when a bowel obstruc- initially postoperatively. Activity is progressed the next day.
tion is suspected.
Nursing Management
Medical–Surgical Assess abdomen for tenderness, distention, and bowel sounds.
Management Monitor vomiting for fecal material. Assess weight daily. Accu-
rately record I&O and limit ice chips when NPO. Check labora-
Medical tory reports for low sodium and potassium and elevated BUN,
amylase, and H & H.
Treatment of the obstruction depends on the cause and loca-
tion. Some can be treated medically by inserting an NG tube for
decompression, providing IV fluids for rehydration, and treat-
ing the cause, such as the use of enemas for fecal impaction. NURSING PROCESS
Surgical Assessment
Most bowel obstructions require surgery. A bowel resection is Subjective Data
performed to remove the portion of the bowel affected by the Clients report symptoms of colicky abdominal pain, nausea,
obstruction. constipation, and bloating.

Pharmacological Objective Data

Nonnarcotic analgesics are used to avoid the intestinal motil- Objective assessment includes abdominal distention and
ity decrease caused by opioids. Antibiotics also are ordered. tenderness on palpation. Vomiting temporarily relieves the
abdominal pain. Vomitus may include fecal material, which is
Diet a poor prognostic sign (Lynch and Sarazine, 2006).
Clients are kept NPO until the obstruction is cleared and then Laboratory analysis demonstrates decreased levels of
slowly progressed from a clear liquid diet to a regular diet as sodium and potassium, elevated BUN, elevated amylase, and
more bowel function returns. elevated H & H caused by hemoconcentration.

Nursing diagnoses for a client with intestinal obstruction include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Fluid Volume The client will exhibit adequate Monitor I&O every shift.
related to vomiting, shift hydration within 48 hours Administer IV fluid and electrolyte replacements as ordered.
in fluids, and NPO status of initiation of treatment as
evidenced by moist mucous Allow limited ice chips to prevent further electrolyte
membranes, electrolytes imbalance in clients with NG tubes.
within normal limits, and I&O Assess weight daily.
approximately equal.

Acute Pain related to The client will verbalize Administer nonnarcotic analgesics as ordered.
distention, edema, or increased comfort within In clients with a paralytic ileus, encourage ambulation to
ischemia 1 hour of analgesic encourage return of bowel function.
administration as measured on
pain scale. Maintain and monitor NG tube as ordered for abdominal
decompression. Check bowel sounds every 4 hours or PRN.

Deficient Knowledge The client will verbalize Identify client’s learning style and present information in a
related to disease treatment course, possible manner compatible with learning style. Include intestinal
process, treatment complications, and possible decompression, need for ambulation, need for good oral
regimen, and possible need for surgery. care due to fecal drainage, and surgery.
surgery

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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218 UNIT 3 Nursing Care of the Client: Digestion and Elimination

with it by reducing it when needed. Clients who are a poor

■ HERNIAS surgical risk may use a truss, a device that applies pressure

A
to the hernia, thus keeping the intestine in the abdominal
hernia occurs when the wall of a muscle weakens and cavity.
the intestine protrudes through the muscle wall. Hernias
that do not return to the abdominal cavity with rest or manipula- Surgical
tion and cause complete bowel obstruction are said to be incarcer- Hernias are repaired with surgery called herniorrhaphy. The
ated. If the blood supply to the hernia is cut off, the hernia is said surgery is typically performed on an outpatient basis, with
to be strangulated. Immediate surgery is required to restore blood clients going home the same day. If the surgery is more com-
flow. If not done, gangrene develops, which may be fatal. plicated because the hernia is incarcerated, the client may stay
Several types of hernias exist. In an umbilical hernia, a por- overnight. If the hernia is strangulated, a bowel resection may
tion of the bowel protrudes through the umbilicus. In children, be required.
these generally resolve on their own once the child begins to walk. Surgical repair of a hiatal hernia involves reinforcing the
Umbilical hernias most commonly occur in multiparous women esophagus with a portion of the stomach. The surgery is per-
or in adults with cirrhosis and ascites (abnormal accumulation of formed laparoscopically, with the client remaining in the hos-
fluid in the peritoneal cavity). Because of a high risk for strangula- pital 3 to 5 days postoperatively. Initially, the client will have
tion in adults with umbilical hernias, surgery is usually performed. an NG tube. The NG tube is removed 24 to 48 hours later and
Abdominal hernias occur in the midline of the abdo- the diet gradually progressed to a soft diet.
men between the umbilicus and the xyphoid process. Most
are asymptomatic, with a few causing pain on exertion that Diet
resolves with reclining and rest. Inguinal hernias, the most
common hernia, occur in the groin area. Inguinal hernias Clients with hiatal hernias modify their dietary patterns by
frequently occur after activities, such as lifting, that increase eating small frequent meals. Clients are encouraged not to eat
intraabdominal pressure; they subside with relaxation. Pain after the evening meal, lie down for 2 hours after eating, or
is located lower than in the abdominal hernia. Femoral her- consume aggravating foods.
nias occur when the intestine pushes into the passageway
carrying blood vessels and nerves to the legs and are more
common in women than in men. A hiatal hernia occurs when
Nursing Management
a portion of the stomach protrudes into the mediastinal Assess abdomen for bowel sounds and bulge in abdominal
cavity through the diaphragm. Symptoms of hiatal hernias wall. Encourage client with hernia to eat small, frequent meals
include indigestion and heartburn, especially after eating a and avoid lying down for 2 hours after eating.
large meal.
Upon evaluation and recommendation of a physician,
some hernias can be reduced or pushed back into place. This NURSING PROCESS
can be accomplished by having the client recline, applying
direct pressure to the hernia, and, in some cases, having the Assessment
client exhale to decrease intraabdominal pressure. The nurse Subjective Data
should never try to reduce a hernia.
Clients may describe pain at the site of the hernia.
Medical–Surgical Management Objective Data
Medical Assessment may show a bulge through the abdominal wall. If
Some hernias have no symptoms or minimal symptoms, so the hernia is strangulated, the client will have the symptoms of
clients may not be aware they have one or may learn to live a bowel obstruction.

Nursing diagnoses for a client with a hernia include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will experience Administer analgesics as ordered.
tissue edema less pain within 1 hour of Evaluate aggravating activities (e.g., straining to have a bowel
intervention as measured on movement) and provide information on modification if indicated.
the pain scale.
Educate regarding signs of complications and when to notify
staff of symptoms.

Ineffective The client will have minimal Assess abdomen for bowel sounds every 4 hours.
Tissue Perfusion tissue necrosis. Insert NG tube to decrease abdominal distention as ordered.
(Gastrointestinal) related
to strangulation Administer IV hydration as ordered.
Prepare client for surgery as ordered. Keep client NPO.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 7 Gastrointestinal System 219

breathe shallowly with peritoneal inflammation, pulmonary

■ PERITONITIS hygiene is important. Activity is increased postoperatively, as
soon as tolerated, to increase lung expansion and to encour-
P eritonitis is the inflammation of the peritoneum, the
membranous covering of the abdomen. Peritonitis is
caused by irritating substances such as feces, gastric acids,
age bowel function return. Exercise, lifting, and driving are
restricted until the incision heals.
bacteria, or blood in the abdominal cavity. A ruptured portion
of the digestive system (such as the appendix), a ruptured
tubal pregnancy, or invasion of tumors through the gastric wall
Nursing Management
can lead to peritonitis. Peritonitis is a serious, life-threatening Assess vital signs and administer antipyretics as ordered.
condition. Complications of peritonitis include adhesions Monitor I&O, signs of dehydration, and fluid and electro-
(scar tissue), paralytic ileus, and pneumonia. lyte replacement. Provide comfort measures (cool cloth,
oral hygiene, back rub). Maintain patency of NG tube.
Medical–Surgical
Encourage coughing and deep breathing and teach inci-
sion splinting. Keep client in semi-Fowler’s position to help
Management localize purulent exudate. Follow surgical asepsis for wound
care. Empty drainage devices as required. If drainage does
Surgical not flow into a device, change dressings frequently to keep
Treatment is primarily surgical with repair of the cause and irri- drainage off the skin. If the wound is still draining when the
gation of the abdominal cavity with saline and antibiotic solutions. client is discharged, teach client/family aseptic technique
Drains are left in the abdomen for several days postoperatively to for changing dressings.
allow any remaining fluid to drain. Because bowel function usu-
ally stops as a result of the irritating substances, an NG tube is
placed to decompress the abdomen and relieve nausea.
NURSING PROCESS
Pharmacological
Analgesics are ordered postoperatively for discomfort. If an Assessment
ileus develops, nonnarcotic analgesics are ordered. Antibiotics Subjective Data
are ordered preoperatively and postoperatively.
Clients describe abdominal pain, nausea, and constipation.
Diet
Clients are NPO preoperatively and postoperatively until Objective Data
bowel sounds return. Clients are then placed on a clear liquid Assessment reveals vomiting, absent bowel sounds, a tense or
diet and slowly progressed to a regular diet as more bowel distended abdomen with tenderness on palpation, shallow and
function returns. rapid respirations, weak and rapid pulse, dry mucous mem-
branes, low urine output, fever, and limited mobility because
Activity of pain. Laboratory analysis will show an increased WBC. If
Preoperatively, clients are placed on bed rest and encouraged the client is bleeding, the H & H will be low. Sodium, potas-
to turn, cough, and deep breathe. Because clients tend to sium, and chloride may be low.

Nursing diagnoses for a client with peritonitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Fluid Volume The client will maintain Monitor I&O every shift. Monitor for signs of dehydration:
related to gastric losses hydration as indicated by an dry mucous membranes, poor skin turgor, and low urine
and restricted intake I&O that is nearly equal and output.
electrolytes within normal Monitor electrolytes as ordered. Administer IV rehydration
limits. and electrolyte replacement as ordered.

Hyperthermia related to The client will maintain Assess VS including temperature every 4 hours. Administer
inflammatory process and temperature within normal antipyretics as ordered; probably rectal suppositories due
dehydration limits. to NPO status.
Monitor for dehydration: decrease in urine output, dry
mucous membranes, and poor skin turgor.
Provide comfort measures: cool cloth to the head
or neck, assistance to turn, and a back rub with
cooling lotion.

(Continues)

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220 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with peritonitis include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will have less pain Administer analgesics as ordered.
abdominal distention and improved mobility within Encourage activity such as coughing and deep breathing
1 hour of receiving analgesics after analgesics. Teach splinting of incision for cough and
as measured on the pain scale. deep breathing.
Monitor NG tube to decompress abdomen. Maintain
patency of NG tube.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

decrease swelling. Fiber supplements and stool softeners are

■ HEMORRHOIDS ordered to keep bowel movements soft.

H emorrhoids are swollen vascular tissues in the rectal area.

They may be internal or external. Hemorrhoids may be
caused by straining with constipation or sitting on the toilet (read-
Diet
Bowel movements are kept soft with a high-fiber diet of 20 to
ing) for an extended time. Hemorrhoids frequently occur with 30 grams of fiber per day and at least 2,500 mL of fluid intake
pregnancy. Hemorrhoids can cause burning, pruritis, and pain daily.
with defecation. At times, they can bleed, leading to anemia.
Nursing Management
Medical–Surgical Management Teach client to modify bowel habits (sit on toilet only for
short periods), increase fiber in diet to 20 or 30 grams per
Medical day, and increase fluid intake to 2,500 mL per day. Provide sitz
Sitz baths or warm compresses on the rectal area for 20 min- baths several times a day or teach client how to do it.
utes, 4 times a day, often helps decrease swelling.
Surgical NURSING PROCESS
If bleeding continues despite medical intervention, or if dis-
comfort is significant, hemorrhoids can be surgically removed Assessment
by a hemorrhoidectomy. For external hemorrhoids, surgery is
performed on an outpatient basis by placing a band around the Subjective Data
hemorrhoid as for esophageal varices, allowing it to necrose Clients describe rectal burning, pain, and pruritis with bowel
and fall off. For internal hemorrhoids, sclerotherapy, cryo- movements; constipation; and, occasionally, bright red bleeding.
therapy, or laser is performed. This usually requires that the A dietary history is obtained to determine fiber and fluid intake.
patient stay overnight in the hospital. Hemorrhoids can recur
after surgical removal if the cause is not eliminated.
Objective Data
Pharmacological If hemorrhoids are external, they can be visualized during a
Treatment includes the administration of creams and sup- physical examination. If chronic bleeding is present, labora-
positories to decrease inflammation, some with cortisone to tory analysis may show a low H & H.

Nursing diagnoses for a client with hemorrhoids include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize Provide sitz baths or warm compresses for 20 minutes, 4 times
edema and inflammation a decrease in discomfort a day. Administer creams and suppositories as ordered.
of swollen vascular within 48 hours of initiation Increase fiber and fluids in diet to keep stools soft to avoid straining.
tissues of treatment.

Deficient Knowledge The client will be able to Determine client’s learning style and present information in a
related to diet, causes of verbalize treatment regimen manner compatible with learning style.
condition, treatment, and and long-term management Educate client about increasing fiber in diet to 20 to
potential complications of hemorrhoids. 30 grams per day, increasing fluid intake to 2,500 mL per
day, causes of hemorrhoids, possible complications such as
anemia, and modification of bowel habits (such as not sitting
on the toilet for long periods).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 7 Gastrointestinal System 221

■ CONSTIPATION LIFE SPAN CONSIDERATIONS

C onstipation is characterized by hard, infrequent stools

that are difficult and/or painful to pass. Constipation can
be caused by tumors, low-fiber diet, inactivity, some diseases
Constipation in the Older Client
The slowing of peristalsis, which is part of the
that interfere with the mechanical functioning of the bowel aging process, leads to constipation in the older
(such as multiple sclerosis), or some medications (such as client. An increase in dietary fiber and fluid intake
narcotics, antidepressants, or anti-Parkinson drugs). (water) helps to prevent constipation. A regular
schedule for bowel evacuation also helps.
Medical–Surgical
Management
Pharmacological Nursing Management
Assess dietary intake of fiber and fluids and activity/exercise
Fiber supplements and stool softeners are ordered. Laxatives level. Review medications client is taking for any causing con-
and enemas may be ordered, but long-term use is avoided stipation. Encourage regular schedule for bowel evacuation.
because they interrupt normal bowel function. If constipation
is caused by medications the client is taking, the client should
discuss other options with the physician, such as modifying NURSING PROCESS
the dosage or changing medications.
Assessment
Diet Subjective Data
Fiber is increased to 20 to 30 grams per day. Fluid intake is Clients describe infrequent, difficult to pass stools. Dietary
increased to 2,500 mL per day. assessment of fiber and fluids usually reveals inadequate
intake. Ask client to describe activity/exercise level.
Activity
Increase activity level if possible because exercise, such as Objective Data
walking, increases motility in the colon. Bowel movements are hard-formed.

Nursing diagnoses for a client with constipation include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Constipation related to The client will have soft Encourage client to increase fiber in the diet to 20 to 30 grams a
inadequate intake of fiber stools every other day by one day and fluid intake to 2,500 mL a day.
and fluids week from intervention. Administer fiber supplements and stool softeners as ordered.
Determine fluid preferences of client and always have fluids at
client’s bedside within reach.
Help the client establish a regular schedule for bowel
movements, usually 30 minutes after a meal.

Deficient Knowledge The client will be able to Assess client’s learning style and present information in a
related to dietary select a menu high in fiber manner compatible with learning style.
sources of fiber and the and fluids utilizing nutrients Teach client about foods that are high in fiber (fruits,
importance of adequate from the food pyramid within vegetables, whole grains) as well as importance of fluid
fluid intake and exercise 48 hours and verbalize the intake.
need for adequate exercise.
Discuss with client the importance of exercise in maintaining
bowel function.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

DISORDERS OF THE ■ CIRRHOSIS

ACCESSORY ORGANS
C irrhosis refers to the chronic, degenerative changes in

D
the liver cells and thickening of surrounding tissue that
isorders of the accessory organs include cirrhosis, hepa- result from the liver repairing itself after chronic inflammation.
titis, pancreatitis, and cholecystitis/cholelithiasis.

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222 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Causes of cirrhosis include chronic hepatitis, repeated Surgical

exposure to toxic substances, disease processes (such as
sclerosing cholangitis and hemochromatosis), cancer, and If the client continues to develop ascites after medical treat-
chronic alcohol abuse. Alcohol abuse accounts for most cases ment, a LeVeen or Denver peritoneal venous shunt is used.
of cirrhosis. The pressure-regulated shunt is implanted in the peritoneal
Because the liver is responsible for so many functions, cavity and threaded through the subcutaneous tissue into the
complications of cirrhosis can be significant and include mal- superior vena cava, returning the fluid back to the vascular
nutrition, hypoglycemia, clotting disorders, jaundice, portal system. As fluid pressure builds in the peritoneal cavity, a valve
hypertension, ascites, hepatic encephalopathy, and hepato- opens and drains the fluid into the superior vena cava.
renal syndrome. If esophageal varices are present, an EGD with sclero-
Liver dysfunction causes several organ-related complica- therapy or banding is done to prevent hemorrhage (refer to
tions. Malnutrition results from the liver’s inability to absorb Figure 7-3).
fat and fat-soluble vitamins and leads to muscle wasting, If portal hypertension cannot be controlled with medi-
weight loss, and fatigue. Hypoglycemia occurs when the liver cations, a portosystemic shunt or a transjugular intrahepatic
is unable to perform glycogenolysis efficiently. When the liver portosystemic shunt (TIPS) may be performed. The shunt
is not able to produce sufficient amounts of prothrombin and redirects the blood flow, thereby relieving the portal hyperten-
fibrinogen, clotting disorders arise. sion, and decreases the risk of rupturing distended veins in the
Portal hypertension results when blood flow through the esophagus (Figure 7-9).
cirrhotic liver is inhibited, resulting in blood backflowing in
the portal vein. Portal hypertension leads to distention of the Pharmacological
esophageal veins, resulting in esophageal varices; distention of A potassium-sparing diuretic, such as spironolactone (Aldac-
rectal veins, resulting in hemorrhoids; and distention of the tone), decreases ascites and pleural effusion. Lactulose (Cholac)
splenic vein, resulting in splenomegaly. moves ammonia from the blood into the bowel. The lactulose
Because the liver is responsible for metabolizing medica- acts as a laxative and causes the body to excrete the stool con-
tions, clients frequently become intolerant to some medica- taining ammonia. Tap water enemas may also be ordered to
tions. Jaundice, a yellow discoloration of the skin, is usually help the body eliminate the ammonia.
present. Jaundice occurs when the liver is unable to convert Propranolol hydrochloride (Inderal), an antihyperten-
bilirubin, an end product of red blood cell breakdown, into a sive medication, is ordered to lower portal hypertension. All
water-soluble form that can be excreted in the bile. The extra unnecessary medications are avoided because the liver cannot
bilirubin collects in areas that contain elastin, such as the metabolize them.
sclera of the eyes, the skin, and the nail beds.
Fluid accumulates in the pleural cavity in the form of Hepatic vein
pleural effusions. Fluid may also accumulate in the peritoneal
cavity. This condition is called ascites. The cause of ascites is
the congestion of blood in the portal system. Liver
Hepatic encephalopathy is a condition in which ammonia
accumulates in the brain. Fluid is pulled into the extracellular
compartment, accelerating brain stem herniation. Confusion, A
lethargy, and/or coma may occur. Symptoms of impending
hepatic encephalopathy are disorientation and asterixis (liver Portal vein
flap), a flapping tremor of the hands. When the client extends
the arms and hands in front of the body, the hands rapidly flex
and extend.
Hepatorenal syndrome is a complication of cirrhosis in
which the client goes into renal failure. Symptoms include
oliguria (diminished production of urine), azotemia (excess
nitrogen in the blood), anorexia, fatigue, and weakness.
Cirrhosis is a form of end-stage liver disease for which there
is no cure. The process of cirrhosis can be slowed by removing
the cause (i.e., abstaining from alcohol), but the damage cannot
be reversed. Clients in end-stage liver disease are evaluated to
determine whether they qualify for a liver transplant.
COURTESY OF DELMAR CENGAGE LEARNING

Medical–Surgical Placement of stent

Management
Medical
The physician performs a paracentesis to remove the fluid
from the abdomen and relieve pressure on the diaphragm and Figure 7-9 A, Blood Flow before TIPS; B, TIPS is performed
lungs. A small incision is made and a trochar inserted into the in radiology on clients deemed too unstable for the surgery
abdomen to drain the fluid. Albumin may be infused at the necessary for a portosystemic shunt. A stent is placed to redirect
same time to pull excess fluid back into the vascular system. the blood flow.

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 CHAPTER 7 Gastrointestinal System 223

Diet Nursing Management

Clients with cirrhosis are placed on a low-protein diet, usually Monitor vital signs and mental status. Restrict fluid intake as
40 grams per day. If ascites is present, sodium will also be ordered. Accurately record I&O. Weigh client daily and mea-
restricted to 2 grams or less per day to decrease the amount of sure abdominal girth. Provide low-sodium, low-protein diet.
fluid retained by the body. Fluids also are restricted to 1,000 Turn client every 2 hours and monitor for redness and skin
mL to 2,000 mL per day depending on the severity of fluid breakdown. Assist with or provide frequent oral hygiene.
accumulation.

Activity NURSING PROCESS

Because fatigue is such a common symptom of cirrhosis, the
client’s tolerance for activity will be diminished. Plan rest peri- Assessment
ods during the day, and schedule activities between rests.
Subjective Data
Clients describe fatigue, nausea, anorexia, weakness, and
SAFETY indigestion.

Cirrhosis Objective Data

Assessment shows ascites, jaundice, enlarged liver and spleen,
If hepatic encephalopathy is present, precautions
petechiae (small bruises on the skin), vomiting, weight loss,
are taken to ensure the client’s safety, such as fever, epistaxis, and decreased breath sounds. Lethargy, con-
elevating bedrails and allowing the client to fusion, or coma is present if encephalopathy has occurred.
ambulate only with assistance, especially if the Laboratory analysis includes a CBC, which will demonstrate
client’s gait is unsteady. low WBCs, RBCs, Hgb, and platelets. A liver panel will show an
elevated bilirubin, alkaline phosphatase, GGT, ALT, and AST.
Albumin will be low. PT, PTT, and clotting times will be delayed.

Nursing diagnoses for a client with cirrhosis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Thought The client will experience an Administer tap water enemas and lactulose as ordered to
Processes related to improved level of orientation eliminate ammonia-rich stools. An NG tube may be placed
elevated serum ammonia within 48 hours of initiation of to give lactulose if the client is comatose. Monitor ammonia
level and hepatic coma treatment. level.
Elevate bedrails to prevent injury.
As coma lessens, reorient client frequently.

Excess Fluid Volume The client will have less Weigh daily. Educate client to notify physician of weight gain
related to ascites ascites by discharge. of 1½ lbs or more in 1 week.
Measure abdominal girth daily.
Restrict fluid to 1,000 to 2,000 mL per day depending on the
severity of the ascites. Provide low-sodium diet of 500 to
2,000 mg a day depending on severity of the ascites.
Teach client how to measure fluids and calculate sodium in diet.
If a paracentesis is done, check vital signs every 15 minutes
during the procedure and after the procedure until the vitals
are stable. The amount of fluid removed from the abdomen is
measured and sent to the laboratory.

Risk for Impaired Skin The client will not experience Provide egg crate mattress. Turn client every 2 hours.
Integrity related to skin breakdown while Monitor skin closely for redness and skin breakdown.
accumulation of bile salts hospitalized.
in skin, poor skin turgor, Apply lotion to skin frequently, especially to pressure areas.
ascites, and edema Assist with ADLs to promote good hygiene and conserve
client’s energy.

(Continues)

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224 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with cirrhosis include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: The client will eat a balanced Offer small, high-calorie meals frequently.
Less than Body diet of 1,500 calories a day. Offer high-nutrient supplements if client is unable to maintain
Requirements related to adequate caloric intake. Assist and encourage client to eat.
inadequate diet, anorexia,
or vomiting Provide frequent oral hygiene.
Observe for changes in mental status that would interfere
with caloric intake (e.g., increased lethargy).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

homosexuals, IV drug users, travelers to countries with poor

■ HEPATITIS sanitation conditions, and laboratory workers who handle
live hepatitis A virus (CDC, 2009). HBV vaccine is recom-
H epatitis is a chronic or acute inflammation of the liver
caused by a virus, bacteria, drugs, alcohol abuse, or other
toxic substances. There is a diffuse inflammatory reaction with
mended as a routine vaccination for all 0 to 18 years olds
and for those in high-risk groups (CDC, 2009). The Food
and Drug Administration approved a combined hepatitis A
liver cells degenerating and dying. The functions of the liver and B vaccine in September 2001. It is recommended for
slow down. Because viral infections are the most common persons younger than age 18 years and those in a high-risk
cause of hepatitis, emphasis will be placed on viral hepatitis group.
within the chapter.
Researchers are still learning about the viruses that cause
hepatitis. Seven viruses are known to cause hepatitis: A, B, C, Diet
D, E, F, and G. Diet modifications include decreasing fat intake to decrease
Dustia (2005) describes hepatitis F as similar to hepa- the amount of bile needed in the digestive tract. A low-protein
titis A and E and hepatitis G usually as a coinfection with diet is needed if the client’s liver is no longer able to metabo-
hepatitis C. Hepatitis F has no serologic test and is diagnosed lize the protein. Anorexia is a common symptom that can be
by seeing the virus with an electron microscope. Hepatitis treated with small, frequent, high-calorie meals. Fluids are
G is transmitted by blood. Most clients have no symptoms, restricted if the client retains fluids. No alcoholic beverages are
and 90% to 100% develop chronic infection. The viruses recommended for at least 1 year or longer.
are similar and have almost identical signs and symptoms.
Incubation period, mode of transmission, treatment and
prognosis vary. See Table 7-5 for a summary of hepatitis Activity
viruses A–E. Bed rest is usually recommended for the first several weeks,
generally at home unless the serum bilirubin is greater than
Medical–Surgical
10 mg/dL or the PT is prolonged. If either occurs, hospital-
ization is usually recommended. Once bed rest is no longer
Management necessary, activity is increased gradually because fatigue will
be present for up to several months. Rest periods are included
Treatment is focused on resting the liver and early detection throughout the day.
of complications. The liver is rested by modifying the diet so
that less bile is needed to digest the food. Treatment is related
to the signs and symptoms present and the prevention of
transmission.
Nursing Management
Follow Standard Precautions with all clients and Enteric
Precautions for hepatitis A and E. Teach clients to always
Pharmacological follow proper hand hygiene. For hepatitis A and E, be careful
Antiemetics such as hydroxyzine hydrochloride (Atarax, also about consuming contaminated food and/or water. Hepa-
Vistaril) or trimethobenzamide hydrochloride (Tigan) are titis B spreads through blood and body fluids. Health care
given before meals for nausea. IV hydration with vitamin C for workers are at risk for hepatitis B and C. Most clients with
healing may be ordered. A vitamin B complex also is ordered hepatitis have flu-like symptoms, weight loss, hepatomegaly,
to help clients absorb fat-soluble vitamins. Vitamin K may be jaundice, dark yellow urine, and light stools. Monitor labora-
ordered if clotting time is prolonged. All unnecessary medica- tory test results for increased levels of bilirubin, GGT, AST,
tions, especially sedatives, are avoided. ALT, LDH, and alkaline phosphatase. Clotting time and PT
Those exposed to hepatitis B by needle puncture or sex- are prolonged. Encourage low-fat, low-protein, high-calorie
ual contact should have hepatitis B immunoglobin (HBIG). frequent small meals and fluid intake of 2,500 to 3,000 mL
Vaccines for hepatitis A (HAV) and hepatitis B (HBV) are daily. Bed rest is important for the first several weeks and
available. HAV vaccine is recommended for persons 2 years then a gradual increase in activity with rest periods several
of age and older at risk for exposure to hepatitis A such as times a day.

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 CHAPTER 7 Gastrointestinal System 225

Table 7-5 Comparison of Different Types of Viral Hepatitis

A B C D E
Etiologic Hepatitis A virus Hepatitis B virus Hepatitis C virus Hepatitis D virus Hepatitis E virus
Agent (HAV) (HBV) (HCV) (HDV) (HEV)

Transmission Fecal-oral; Blood or body Blood Only persons Oral-fecal route;

contaminated fluids from infected with hepatitis B contaminated
water or food; person can get hepatitis water; person to
person to person D; blood and person uncommon
blood products;
needlesticks;
seldom sexual;
rarely perinatal

Risk Groups Household/sexual Intravenous drug Blood transfusions Needle sharing; Mainly travel to
contact with users; sexual/ or organ needlesticks countries where
infected person; household contact transplants prior endemic
international with infected to 1992; sharing
travelers person; infants needles; exposure
born to infected to blood and blood
mothers; health care products
workers; multiple
sex partners

Incubation 15–50 days 45–160 days 14–180 days 15–60 days 15–60 days
Period

Infectious Usually less than 2 Before symptoms Before symptoms Not determined Not determined
Period months appear; lifetime if appear; lifetime if
chronic chronic

Diagnostic IgM anti-HAV HBsAg EIA-3; RIBA serum IgG anti-HDV and/ None available
Tests ALT increased 10x; or Igm anti-HDV
HCVRNA-PCR

Symptoms Flu-like; jaundice; Flu-like; may have 80% have no Flu-like; may have Abdominal pain;
dark yellow urine; jaundice; dark symptoms; flu-like jaundice; dark anorexia; dark
light colored stools yellow urine; light yellow urine; light yellow urine;
colored stools colored stools jaundice; fever

Prevention Standard Standard Standard Standard Precau- Standard

Precautions; Precautions; Precautions; tions; reduce Precautions; be
Enteric reduce risk reduce risk risk behaviors; sure water safe
Precautions; behaviors; behaviors; no hepatitis B when traveling; no
hepatitis A vaccine hepatitis B vaccine vaccine vaccine; if client vaccine
(entire series); (entire series); already has
immune globulin immune globulin hepatitis B, no
(for short term) (for short term) prevention for
hepatitis D

Treatment Immune globulin Immune globulin Peginterferon Alpha interferon None given
within 2 weeks of (HBIg); alpha alfa-2a (Pegasys);
exposure interferon; ribavirin (Virazole)
Iamivudine
(Epivir-HBV);
adefovirdipivoxil
(Hepsera)

(Continues)

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226 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Table 7-5 Comparison of Different Types of Viral Hepatitis (Continued)

A B C D E
Prognosis Rarely fatal; no No cure; may 75% to 85% have Low risk of No evidence of
chronicity; resolves become chronic chronic infection; chronicity chronicity
on its own in 70% develop
several weeks chronic liver
disease

Data from Viral Hepatitis A. By Centers for Disease Control and Prevention (CDC), 2009a, retrieved from www.cdc.gov/ncidod/diseases/hepatitis/a/fact.
htm; Viral Hepatitis B. By CDC, 2009b, retrieved from www.cdc.gov/ncidod/diseases/hepatitis/b/fact.htm; Viral Hepatitis C. By CDC, 2009c, retrieved from
www.cdc.gov/ncidod/diseases/hepatitis/c/fact.htm; Viral Hepatitis D. By CDC, 2009d, retrieved from www.cdc.gov/ncidod/diseases/hepatitis/slideset/
hep-d.htm; Viral Hepatitis E. By CDC, 2009e, retreived from www.cdc.gov/ncidod/diseases/hepatitis/slideset/hep-e.htm; Peginterferon alfa-2a plus ribavirin
for chronic hepatitis C virus infection, by M. W. Fried, M. L. Shiffman, et al., 2002e, New England Journal of Medicine, 347(13), 975; Resolution of chronic
delta hepatitis after 12 years of interferon alpha therapy. By D. T. Lau, D. E. Kleiner, Y. Park, A. M. DiBisceglie, & J. H. Hoofnagle, 1999, Gastroenterology,
117(5), 1229-33; What I need to know about hepatitis C. By NIDDK, 2006, retrieved from www.niddk.nih.gov/health/digest/pubs/hep/hepc/hepc.htm; Viral
hepatitis A to E and Beyond. By National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 2008a, retrieved from www.niddk.nih.gov/health/
digest/pubs/hep/hepa-e/hepa-e.htm; What I need to know about hepatitis A. By NIDDK, 2008b, retrieved from www.niddk.nih.gov/health/digest/pubs/
hep/hepa/hepa.htm; What I need to know about hepatitis B. By NIDDK, 2008c, retrieved from www.niddk.nih.gov/health/digest/ pubs/hep/hepb/hepb.htm;
Speaking out about the silent epidemic, by S. Parini, 2001, Nursing 2001, 31(3), 36–42; FDA approves new treatment for chronic hepatitis B. By U.S. Food
and Drug Administration, 2002, retrieved from www.fda.gov/bbs/topics/ANSWERS/2002/ANS01163.html.

Laboratory analysis shows an increased level of bilirubin,

NURSING PROCESS GGT, AST, ALT, LDH, and alkaline phosphatase. Clotting time
Assessment and PT are prolonged. Specific hepatitis test is elevated (refer
to Table 7-5).
Subjective Data
Symptoms include fatigue, anorexia, photophobia, nausea, CRITICAL THINKING
headaches, abdominal pain, generalized muscle aches, chills,
pruritis, and bloating. Hepatitis and Lifestyle

What lifestyle changes are necessary with a diag-

Objective Data nosis of hepatitis A, B, C, or D?
The client may have weight loss, hepatomegaly, fever, jaun-
dice, dark amber urine, and clay-colored stools.

Nursing diagnoses for a client with hepatitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will be able to Assess client’s learning style and present information in a
related to disease explain disease process, manner compatible with learning style.
process, treatment incubation period, and Educate about disease process and incubation period.
regimen, and mode of mode of transmission, by
transmission discharge. The client will Teach proper hand hygiene technique and emphasize
practice precautions to importance of washing hands after using the bathroom.
prevent spread of disease. Emphasize that client cannot donate blood.
The client will be able to Emphasize importance of follow-up laboratory analysis.
select a menu using foods
from the food guide pyramid Instruct in selection of low-fat, low-protein diet.
and maintain a low-fat, For clients with hepatitis A, teach client to disinfect articles
low-protein diet. contaminated with feces (such as the toilet), not to prepare
food for others, and not to share articles such as eating
utensils or toothbrushes.
For clients with hepatitis B, teach to avoid sexual contact until
they test negative for HBsAg or their partners are immunized
with the HBV vaccine.

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 CHAPTER 7 Gastrointestinal System 227

Nursing diagnoses for a client with hepatitis include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
For clients with hepatitis C, teach that it is unknown whether it
can be transmitted through sexual contact, so precautions are
recommended until more is known.

Imbalanced Nutrition: The client will maintain a Monitor I&O every shift. Weigh daily.
Less than Body caloric intake of Offer small, frequent, high-calorie, low-fat meals. Encourage
Requirements related to 2,000 calories/day. low-protein diet of 40 gm of protein.
inadequate caloric intake,
fat intolerance, nausea, Monitor daily calorie count.
and vomiting Offer largest meal in morning, as food tends to be tolerated
better in the morning. Encourage fluid intake of 2,500 to
3,000 mL daily.
Note color and consistency of stools and color of urine.
Administer antiemetic 30 minutes before meals as ordered.

Fatigue related to The client will verbalize Educate client regarding reasons for fatigue and that fatigue
decreased energy plan to modify activity, by may be present for several months.
production and altered discharge. Encourage client to maintain bed rest for several weeks. Advise
body chemistry client that when resuming normal activity, rest periods should
be included until stamina returns.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

nausea and vomiting are present, antiemetics are ordered.

■ PANCREATITIS Meperidine (Demerol) is ordered for analgesia because
morphine sulfate may cause spasms of the sphincter of
P ancreatitis is an acute or chronic inflammation of the
pancreas caused when pancreatic enzymes digest the
lining of the pancreas. Pancreatitis occurs when obstruction
Oddi. Atropine sulfate or propantheline bromide (Pro-
Banthine) is ordered to decrease pancreatic activity. Ant-
acids or an H2 receptor antagonist is ordered to prevent
of the pancreatic duct occurs as a result of gallstones, tumors, stress ulcers.
exposure to chemicals or alcohol, or injury to the pancreas. In
severe cases, the pancreas can hemorrhage, resulting in a life- Diet
threatening condition.
Clients are kept NPO while the serum amylase level is
elevated to decrease the demand for digestive enzymes in the
Medical–Surgical bowel. An NG tube is inserted to decrease pancreatic activity
and to prevent nausea, vomiting, and abdominal distention.
Management As the serum amylase level begins to decrease, clients are
started on clear liquids and slowly advanced to a bland, low-
Medical fat, high-protein, high-carbohydrate diet. No coffee or alcohol
Treatment depends on the cause of the pancreatitis. If the pan- is allowed.
creatitis results from exposure to chemical or alcohol abuse, IV rehydration is necessary while the client is NPO. If the
treatment is primarily medical. An NG tube is inserted to rest pancreatitis is severe and the client must be NPO for a pro-
the bowel and relieve abdominal distention. longed period, TPN, a high-calorie, high-nutrient IV solution,
is administered.
Surgical
If the pancreatitis is caused by structural changes such as Activity
gallstones, an endoscopic retrograde cholangiopancreatogram Clients are generally placed on bed rest to decrease metabolic
(ERCP) with stone removal is performed. Surgery to relieve rate. Activity is increased as the serum amylase decreases.
the pancreatic duct obstruction is necessary in cases where
tumors or injury are the causes of the pancreatitis.
Nursing Management
Monitor and maintain NG tube. Weigh client daily and main-
Pharmacological tain client on bed rest. Assess pain and administer an analgesic.
Insulin is administered if the client’s pancreas is unable to Monitor vital signs. Provide personal hygiene. Assess and
secrete enough to maintain normal blood sugar level. If maintain IV hydration and TPN if ordered. Accurately record

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228 UNIT 3 Nursing Care of the Client: Digestion and Elimination

I&O. Monitor laboratory results, especially serum amylase, or lying in a fetal position. Nausea and anorexia are also
bilirubin, electrolytes, and H & H. present.

NURSING PROCESS Objective Data

Assessment includes steatorrhea, vomiting, low-grade fever,
Assessment tachycardia, and jaundice. Laboratory analysis shows an
elevated serum amylase followed by an elevated urine amy-
Subjective Data lase and serum lipase, leukocytosis, and an increased Hct.
Clients describe excruciating epigastric pain that radi- Glucose, alkaline phosphatase, and bilirubin may also be
ates to the back. Pain may decrease by leaning forward elevated.

Nursing diagnoses for a client with pancreatitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize a Monitor NG tube to decompress the abdomen.
inflammation and edema decrease in pain as evidenced Position client in most comfortable position.
of the pancreas by pain scale by 1 hour after
initiation of interventions. Assess pain for increasing severity that would indicate
worsening pancreatitis.
Administer analgesics as ordered and monitor for relief.
Monitor serum amylase, WBCs, and H & H for signs of
increasing severity of pancreatitis or hemorrhage.

Imbalanced Nutrition: The client will experience no Monitor I&O every shift.
Less than Body further weight loss during Administer IV rehydration or TPN as ordered.
Requirements related hospitalization.
to NPO status, nausea, Weigh client daily.
vomiting, and altered Maintain bed rest to decrease the metabolic rate.
ability to digest nutrients Insert NG tube to decompress the abdomen as ordered.

Risk for Deficient Fluid The client will maintain Monitor I&O every shift.
Volume related to adequate hydration as Administer IV hydration or TPN as ordered.
vomiting, NG tube, or evidenced by I&O that is
hemorrhage nearly equal, electrolytes Monitor electrolyte levels and H & H as ordered.
within normal limits, and moist
mucous membranes.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Ultrasound of the gallbladder is ordered if gallstones are

■ CHOLECYSTITIS AND suspected.
CHOLELITHIASIS
Medical–Surgical
C holecystitis is an inflammation of the gallbladder. In
>90% of the cases, gallstones are present. Cholelithiasis
Management
In asymptomatic clients, no intervention is necessary.
is the presence of gallstones or calculi (concentration of min-
eral salts) in the gallbladder. Not all gallstones cause cholecys- Medical
titis. Some gallstones pass out of the gallbladder and into the
duodenum with the client unaware of the stones. Sometimes If stones are lodged in the common bile duct, an ERCP is
gallstones migrate into the cystic or common bile duct causing performed.
an obstruction that, in turn, leads to cholecystitis. The exact
cause of the formation of these stones is not known. Surgical
These two diseases are more common in multiparous A sphincterotomy, an incision in the ampulla of vater, is
women, age 45 and older; obese people; those who use birth performed to enlarge the opening of the common bile duct.
control pills or control cholesterol with gemfibrozil (Lopid); Stones are then removed or crushed. If the stones are too large
and people with a history of a disease of the small intes- or in the case of clients with repeated episodes of cholelithiasis,
tine such as Crohn’s disease. Also, clients on sudden weight a cholecystectomy, the surgical removal of the gallbladder, is
reduction diets that are low in fat will cause the bile to pool in performed. The cholecystectomy is performed laparoscopi-
the gallbladder, increasing the risk for gallstone formation. cally or by making a large abdominal incision.

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 CHAPTER 7 Gastrointestinal System 229

Laparoscopic cholecystectomies have become the surgery encouraged to turn, cough, and deep breathe every 2 hours
of choice for cholelithiasis and cholecystitis. The gallbladder initially after surgery. On the day after surgery, the client
is removed by making four small incisions and extracting the is assisted out of bed and encouraged to gradually increase
gallbladder through an endoscope. If the cholecystectomy is activity. Clients who have a laparoscopic cholecystectomy are
performed laparoscopically, it is more difficult to perform an ambulated within hours of returning from the recovery room.
exploration of the common bile duct, especially in clients with Clients usually leave the hospital later on the day of surgery,
cholecystitis. An ERCP may need to be performed if stones but may stay overnight depending on their overall condition
remain in the common bile duct (CBD). Clients are ready for (University of Michigan Health System, 2009). Clients return
discharge 24 hours after the surgery. to normal activities within 4-5 days and typically return to
The cholecystectomy can also be performed by making a previous activity level 2 weeks after surgery. Clients who have
large abdominal incision. A cholangiogram can be performed an incision restrict lifting, driving, and exercise until incisional
easily, and therefore this type of procedure is more common in healing is complete, usually 4 to 6 weeks.
clients with much inflammation of the gallbladder. If damage
has occurred to the CBD from severe inflammation or a stone,
a T-tube will be left in place to allow the bile to drain into a Nursing Management
collection bag. This allows the CBD to heal. Clients are typi- Monitor vital signs and bowel sounds. Assess pain, nausea, and
cally ready for discharge 3 to 7 days after surgery. vomiting and administer analgesic and/or antiemetic. Prepare
for surgery by teaching deep breathing, coughing, splinting
Pharmacological incision, incentive spirometry use, and leg exercises. Monitor
In acute cholecystitis, analgesics are ordered to relieve discomfort. and maintain NG tube if used. Accurately record I&O.
Meperidine (Demerol) is preferred because morphine sulfate is
believed to increase sphincter spasms. IV hydration is ordered
if the client is unable to maintain hydration. Antiemetics are
ordered for nausea and vomiting. In clients who have surgery, NURSING PROCESS
analgesics are ordered after surgery to control discomfort.
Assessment
Diet Subjective Data
In clients with mild or moderate symptoms, a clear liquid diet Clients describe pain in the right upper quadrant radiating to
to rest the bowel, followed by small frequent meals low in fat, the right scapular area that occurs 2 to 4 hours after a meal
may resolve the symptoms. containing significant amounts of fat, nausea, flatulence, and
If clients are to have surgery, they will be NPO before indigestion.
surgery and initially after surgery until bowel sounds return.
They are started on clear liquids first and then advanced, as
tolerated, to a regular diet. Objective Data
Assessment shows vomiting, occasionally a fever, jaun-
Activity dice, steatorrhea, clay-colored stools, and dark amber urine.
In acute cases of cholecystitis, bed rest is recommended to Laboratory analysis shows increased alkaline phosphatase,
decrease metabolic rate. If surgery is performed, the client is GGT, WBCs, and bilirubin.

Nursing diagnoses for a client with cholecystitis and cholelithiasis include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will experience Keep client NPO or on a clear liquid diet as ordered.
inflammation or blocked less pain as evidenced by Administer analgesics as ordered.
bile duct pain scale within 1 hour of
initiation of treatment. Monitor NG tube to decompress the abdomen as ordered.
Observe for jaundice and bile flow obstruction.

Ineffective Breathing The client will demonstrate Assist client to cough and breathe deeply every 2 hours.
Pattern related to appropriate breathing pattern Teach use of incentive spirometer.
decreased lung expansion and will not have respiratory Teach splinting techniques for comfort and to facilitate breathing.
because of pain complications while
hospitalized. Turn client every 2 hours and ambulate as soon as indicated.

Risk for Deficient Fluid The client will maintain Monitor I&O every shift including NG drainage and T-tube
Volume related to nausea, adequate hydration as drainage if present.
NG tube, NPO, or bile evidenced by I&O that is Administer IV hydration as ordered.
drainage nearly equal and moist
mucous membranes. Maintain patency of NG tube.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
230 UNIT 3 Nursing Care of the Client: Digestion and Elimination

surgery, clients require a soft diet or, in some cases, nutritional

NEOPLASMS OF THE supplements to allow the surgical area to heal. Tube feedings,
either by a feeding tube or by a gastrostomy tube (a special
GASTROINTESTINAL SYSTEM tube inserted through the abdomen into the stomach), are

N eoplasms of the gastrointestinal system may occur

anyplace in the GI system. Signs, symptoms, and
treatment vary according to where the cancer occurs. Oral
frequently needed in clients who have undergone a radical neck
dissection.

cancer, colorectal cancer, and liver cancer are discussed Activity

following.
If the surgery is minor, no activity restrictions are neces-
sary. If surgery is extensive, postoperatively, the client
will need to turn, cough, and deep breathe. Activity is
■ ORAL CANCER increased postoperatively. Clients receiving radiation treat-

O ral cancer refers to cancers of the lips, tongue, oral cav-

ity, and pharynx. According to the American Cancer
Society (ACS, 2009), 35,720 new cases are expected that
ments frequently experience fatigue and need scheduled
rest periods.

year. Risk factors are tobacco use and excessive consumption Other Therapies
of alcohol. Symptoms include a mouth sore that bleeds easily
and does not heal, a lump, or difficulty chewing, swallowing, In cases where the lesion cannot be surgically removed, radia-
or moving tongue or jaw. On the lips, the cancer may be a tion and/or radium implants is/are used. High-energy radia-
growth. tion is used to destroy cancer cells. Clients may experience
irritated skin, swallowing difficulties, dry mouth, nausea, diar-
Medical–Surgical rhea, hair loss, or fatigue. Radiation is usually administered
daily for a specified period. If radium implants are used, a
Management radioactive capsule is implanted into the area.
Surgical
Treatment is primarily surgical and involves removal of the Nursing Management
cancer with excision of tissue and lymph nodes surrounding Encourage all clients to refrain from tobacco use and exces-
the cancer. In cases of cancer involving the pharynx, a radical sive alcohol consumption. Maintain feeding tube and admin-
neck dissection is performed, which requires reconstruction ister tube feedings as ordered. Preoperatively, teach client
of the pharynx. Clients undergoing radical neck dissection to turn, cough, and deep breathe, and encourage client to
frequently have a tracheostomy. practice postoperatively. Weigh client daily and accurately
record I&O.
Pharmacological
Chemotherapy is not effective against most oral cancers and
is, therefore, used only in the most severe cases with metasta- NURSING PROCESS
ses. Medications ordered are based on the client’s symptoms.
If the client is experiencing side effects from the radiation such Assessment
as nausea, antiemetics are ordered. Subjective Data
If a client has surgery, analgesics are ordered postopera- Clients describe a sore throat, difficulty swallowing, or a pain-
tively. Analgesics are also ordered if the cancer has progressed ful area in the mouth.
and is causing discomfort.

Diet Objective Data

Because the surgery is in the oral area, it may be difficult to Assessment reveals a sore or lesion of the lips or in the oral
maintain adequate nutrition. Depending on the extent of the cavity, and hoarseness.

Nursing diagnoses for a client with oral cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fear related to diagnosis The client will verbalize fear Allow client time alone and with significant others and client
and long-term prognosis and express plan to cope with and family to express fears and concerns.
diagnosis. Answer questions.
Encourage contact with support system (e.g., clergy).
Discuss past experiences with stress and individual
responses to those situations.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 7 Gastrointestinal System 231

Nursing diagnoses for a client with oral cancer include the

following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: The client will maintain weight Monitor I&O every shift.
Less than Body while hospitalized. Weigh client daily.
Requirements related to
oral surgery or radical Administer tube feedings and IV rehydration as ordered and
neck dissection introduce fluids, when indicated.
Monitor for aspiration.

Disturbed Body Image The client will verbalize Allow client time to verbalize feelings. Answer questions.
related to disfiguring feelings regarding surgery and Discuss options (e.g., plastic surgery or makeup).
surgery altered body image.
Provide information on support groups.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Cancer
■ COLORECTAL CANCER

C olorectal cancer is the third most common site of new

cancers and deaths in the United States (ACS, 2009).
Almost all colorectal cancers arise from polyps, an abnormal
Polyp

Submucosa

growth of tissue that protrudes into the colon. Risk factors for Muscularis
colorectal cancer include age 50 or older, history of polyps, Serosa
family history of polyps and/or colorectal cancer, a history of
ulcerative colitis, and a diet high in fat and low in fiber. Class A colorectal cancer
Prognosis is very good if the cancer is caught in the early
stages. Recommended routine screenings for early detection
include fecal occult blood testing and colonoscopy depending Cancer
on personal and family history.
A colonoscopy or barium enema may demonstrate the
disease. A CBC may show anemia if the cancer is bleeding. A
CEA may be effective in detecting recurrent cancer but is not
a valid screening test. Signs and symptoms include a change in
bowel habits, guaiac-positive stools, and abdominal pain. Class B colorectal cancer

Medical–Surgical

COURTESY OF DELMAR CENGAGE LEARNING

Cancer
Management
Surgical
Treatment is surgical to remove the cancer. In class A tumors,
a colonoscopy is performed with a polypectomy, the removal
of the polyp. In class B or C tumors, a colon resection is done Lymph nodes
Class C colorectal cancer with cancer
(Figure 7-10). In some cases, a colostomy, either temporary or
permanent, is performed. In class D tumors, surgery is done Figure 7-10 Classes of Colorectal Cancer
only to relieve symptoms (e.g., bowel obstruction). Follow-up
colonoscopies must be performed throughout the client’s life
to monitor for recurrence of the disease. Diet
Preoperatively, the client is NPO. Postoperatively, the client
Pharmacological is NPO and an NG tube is in place until bowel sounds return.
The client is then started on a clear liquid diet and progressed
In cases of class B, C, and D tumors, chemotherapy is given
to a high-fiber, low-fat diet.
after the surgery. Side effects of chemotherapy include nau-
sea, vomiting, weight loss, hair loss, fatigue, and dry skin.
Medications to combat some side effects of the chemo- Activity
therapy are ordered. Immunotherapy as an adjunct therapy Postoperatively, the client is encouraged to turn, cough, and
for class C and D tumors is ordered to boost the immune deep breathe every 2 hours. The client is ambulated the next
system. day and activity is progressed.

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232 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Other Therapies NURSING PROCESS

No significant benefits have been found with the use of radia-
tion on colorectal cancer; however, radiation may be used on
metastatic sites in class D tumors.
Assessment
Subjective Data
Nursing Management Clients describe a change in bowel habits and possibly abdom-
inal pain.
Encourage all clients to have recommended routine screen-
ings, fecal occult blood test, and colonoscopy, based on their
personal and family history. Prepare client for side effects Objective Data
(hair loss, fatigue, nausea, and dry skin) when chemotherapy Stools may be guaiac positive for blood. An H & H may show
is used. Postoperatively, maintain the NG tube. Assess bowel anemia.
sounds. Encourage turning, coughing, deep breathing, use of
incentive spirometer, leg exercises, and ambulation.

Nursing diagnoses for a client with colorectal cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fear related to diagnosis The client will verbalize fear Allow client time alone and with significant others and allow
and long-term prognosis and express plan to cope with client and family to express fears and concerns.
diagnosis. Answer questions and encourage contact with support
system (e.g., clergy).
Discuss past experiences with stress and identify individual
responses to those situations.

Deficient Knowledge The client will be able to Determine client’s learning style and present information in a
related to disease explain disease process, manner compatible with the learning style.
process, treatment treatment, and follow-up care. Educate client regarding disease process and discuss
options, and follow-up treatment options.
Recognize that information may need to be presented more
than once.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

obese cases rose 24% and morbidly obese cases with a BMI of
■ LIVER CANCER >40 and 50 increased 50% and 75%, respectively.
A 1990 study by Blumberg and Mellis reported that 78%
P rimary liver cancer is rare. Most liver tumors are meta-
static from other sites in the body. Most cases of primary
liver cancer are asymptomatic until later stages. Risk factors
of preoperative bariatric clients felt health care professionals
“always” or “usually” treated them with disrespect. Another
study 12 years later in 2002 by Kaminsky and Gadaleta
for primary liver cancer include a history of cirrhosis, hepatitis revealed very similar results. Kaminsky and Gadaleta con-
B, and exposure to toxic chemicals. cluded their results were because health care providers do not
A primary liver tumor can be removed surgically if the dis- understand the disease of obesity, its causes, or the medical
ease is not extensive. Metastases cannot be surgically removed consequences if not treated. Little data suggest that health care
and are usually treated with chemotherapy and radiation. providers’ attitudes affected their delivery of care. In other
Obesity words, the medical/nursing care was provided but the “caring”
attitude was not perceived. Clients having bariatric surgery
According to the National Heart Lung and Blood Institute deserve respect for privacy and deserve kind, compassionate
(NHLBI), the body mass index (BMI) measures body fat in rela- care. To provide clients with compassionate, quality care,
tion to an individual’s height and weight. The BMI determines health care providers may desire to analyze personal attitudes
an individual’s weight according to categories of underweight, toward obesity and take appropriate steps to care for each
normal weight, overweight, or obese. According to the World individual as a valued person of worth.
Health Organization, an individual is overweight with a BMI of The obese client presents challenges to the health care
30 or greater and morbidly obese with a BMI of 40 or greater. provider. The extra soft tissue makes it difficult to assess
The NHLBI website provides a formula to automatically calcu- heart and lung sounds, and significant abnormalities can be
late an individual’s BMI: http://www.nhlbisupport.com/bmi/ missed. A nurse needs the appropriate equipment to assess
The National Center for Health Statistics (2007) reported and care for the obese client, such as an extra large blood
that more than one third of adult Americans (>72 million pressure cuff to obtain an accurate reading. A blood pressure
people) were obese in 2005 to 2006 (Ogden, Carrol, McDow- cuff that is too small gives an elevated reading. An echocar-
ell, & Flegal, 2007). Between 2000 and 2005, the number of diograph may be more accurate than an EKG. Fatigue and

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 7 Gastrointestinal System 233

nutritional counseling and exercise to assist the overweight

SAFETY client. If these interventions do not work and the client desires
to lose weight, the health care provider makes a referral to a
Weight Limitations with Equipment bariatrician (a specialist in the treatment of obesity and obese
diseases).
When caring for an obese client, consider the Bariatric surgery may be a client option and includes a
weight limits on equipment such as stretchers, restrictive or malabsorptive surgery. The laparoscopic adjustable
toilets, and bedside commodes. If these weight gastric band is a restrictive surgery. A band is placed laproscopi-
limitations are not considered, staff and clients are cally around the proximal stomach distal to the gastroesophagel
at risk for injury (Wolf, 2008). junction as shown in Figure 7-11A. A tube is connected to the
band and threaded through the abdomen to the abdominal
wall, where it is connected to an access port. The access port is
anchored to the fascia. Throughout the next year, the physician
lethargy along with nausea and vomiting are possible symp- injects saline into the access port to restrict the stomach size so
toms of a cardiac or glycemic emergency (Wolf, 2008). the client loses weight.
Obese clients have more difficulty breathing and present The Roux-en-Y gastric bypass is a malabsorptive surgery.
issues with intubation. A guided ultrasonography assists A section of the stomach close to the gastroesophageal junc-
with IV insertion, and an extra long needle is used for cen- tion is divided from the remaining stomach by stapling along
tral venous catheter placement. Obese clients are at risk for the dividing line as shown in Figure 7-11B. A section of the
rapid skin breakdown, hypercoagulopathy leading to venous jejunum is anastomosed to the stomach pouch. The remaining
thromboembolism, and pulmonary emboli after surgery. stomach, duodenum, and proximal jejunum are anastomosed
Pneumonia is a risk because of immobility, difficulty tak- distally on the jejunum. Weight loss occurs for 2 reasons: the
ing deep breaths, and extra soft tissue on the chest (Wolf, restricted stomach area cannot hold as much food and the
2008). Signs of hypoxia are lethargy, mental status changes, bypassed bowel section cannot absorb as many calories and
and restlessness. Regular-size stretchers are not safe because nutrients from ingested food. Thus, it is called a malabsorptive
the client makes the stretcher top-heavy and causes it to tip surgery. This surgery bypasses the part of the small intestine
over. Skin pressure sores also may occur from the side rails. that absorbs calcium, iron, and other nutrients placing the
Therefore, bariatric stretchers and beds provide stability client at risk for chronic nutritional deficits and vitamin B12
and client safety. anemias. After the surgery, the client is placed on multivitamin
and mineral supplements.
Medical-Surgical Nursing Management
Management Postoperatively the nurse maintains the client’s oxygen satu-
Health care professionals are reluctant to discuss weight loss ration at 92% by administering 2 to 4 L of oxygen by nasal
with clients. In a national study of adults with a BMI of ⱖ30 cannula or, if client tolerates it, room air. Encourage the client
only 42% reported that a health care provider discussed the to use the incentive spirometer every 2 hours. The head of
need for weight loss (Calonge, 2004). The health care pro- the bed is elevated to 45° to enhance breathing. If the client
vider could suggest a monitored weight-loss program with uses a continuous positive airway pressure device (CPAP),

Roux-en-Y gastic bypass

Esophagus Bypassed portion

of stomach
Esophaqus

Proximal pouch
of stomach
Laproscopic
adjustable band
Stomach “Short” intestinal
Roux limb

Abdominal Pylorus
muscles
Duodenum
COURTESY OF DELMAR CENGAGE LEARNING

Access port

Duodenum

A B

Figure 7-11 Types of Bariatric Surgery; A, Laparoscopic Adjustable Gastric Banding; B, Roux-en-Y Gastric Bypass

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
234 UNIT 3 Nursing Care of the Client: Digestion and Elimination

continue using it in the hospital. The nurse assesses pain Postoperative complications are nausea and dumping
regularly, monitors PCA use, and obtains appropriate orders syndrome. The nurse assesses for abdominal distension,
to manage pain (Sammons, 2002). If an NG tube is in place, diarrhea, cramping, hypotension, flushing, and tachycardia
the nurse does not reposition the NG tube as the movement indicating symptoms of dumping syndrome that last 20 to
may damage the suture line. The client takes sips of water and, 30 minutes. Dumping syndrome is a common side effect
if tolerated, slowly progresses to eating very small portions of caused by eating simple sugars. It is a benign problem that
pureed food or juices. The nurse teaches diet modifications possibly can be modified by decreasing the ingestion of
and exercise to assist the client in controlling weight. Weight simple sugar.
loss is a lifetime challenge.

CASE STUDY
R.J. is a 52-year-old woman admitted to the hospital with acute abdominal pain. R.J. complains of right upper
quadrant pain radiating to the back. She has had previous episodes, usually occurring about 2 hours after eat-
ing. This episode, however, is not resolving. R.J. also complains of nausea. Her vital signs are BP 152/88 mm Hg,
pulse 92 beats/min, and respirations 24 breaths/min and shallow. R.J. is a slightly obese female who states she has
recently been dieting to lose weight. Laboratory analysis includes a CBC with slightly elevated WBCs, elevated
bilirubin, and elevated alkaline phosphatase. An IV is started, and R.J. is given meperidine (Demerol) IM for pain.
R.J. has been made NPO. An ultrasound of the gallbladder is ordered.
The following questions will guide your development of a nursing care plan for this case study.
1. List subjective and objective data a nurse would want to obtain about R.J.
2. List risk factors other than those R.J. has that would put a client at risk for developing cholecystitis.
3. List two nursing diagnoses and goals for R.J.
4. The ERCP is successful in removing the CBD stone. The decision is made to perform a laparoscopic cholecystectomy.
What teaching will R.J. need?
5. Why is meperidine (Demerol) the medication of choice for pain control?
6. List at least three successful outcomes for R.J.

SUMMARY
• The gastrointestinal system is a complex system composed • Inflammatory bowel disease includes both Crohn’s
of the digestive tract as well as accessory organs. disease and ulcerative colitis. IBD can lead to
• Disorders of the GI tract affect the breakdown and nutritional imbalances, bowel obstructions,
absorption of nutrients, breakdown of wastes and alterations in the structure of the intestine, and
by-products, and the lifestyle of the individual. affected lifestyle.
• Because the liver is responsible for so many functions in • Bowel obstructions have multiple causes and can lead
the body, disorders of the liver can affect other systems to electrolyte imbalances, dehydration, and possibly
significantly. sepsis.
• Peptic ulcers may be either gastric or duodenal. H. pylori is • Viral hepatitis is a concern for health care professionals at
a common cause of ulcers and can be treated with risk for exposure. Standard precautions must be used to
antibiotics. prevent the transmission of the virus.
• Diverticulosis is a commonly occurring disorder in the • Colorectal cancer is one of the most preventable forms of
United States and is believed to be caused by a low-fiber diet. cancer if routine screenings are performed.

REVIEW QUESTIONS
1. A client with a bleeding esophageal varix: 4. will not need follow-up once the bleeding has
1. should be encouraged to vomit the blood to stopped.
decrease abdominal distention and pressure. 2. A client with a perforated duodenal ulcer:
2. should have an NG tube placed to suction blood 1. requires an EGD to repair the perforation.
from the stomach. 2. may need diet modification after surgery.
3. should have the Minnesota tube deflated every 3. will have a vagotomy performed.
4 hours. 4. may experience an increased risk for cholecystitis.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 7 Gastrointestinal System 235

3. Clients with hepatitis C: 3. consider a referral for surgical intervention.

1. should be instructed that all the mechanisms of 4. participate in vigorous exercise.
transmission are not known. 8. A nurse gave dietary instructions to a client recently
2. will have a negative HCV if they are a carrier. diagnosed with ulcerative colitis. What dietary
3. should be instructed that recombinant interferon choice indicates the client understands the
alpha-2b will cure the hepatitis C. appropriate foods to eat? (Select all that apply.)
4. are not contagious until symptoms develop. 1. Apple.
4. Crohn’s disease: 2. Lettuce salad.
1. can be cured by removing the colon. 3. Refined pasta.
2. usually causes clients to gain weight from the 4. Chunky peanut butter.
slower metabolism of nutrients. 5. Cream of asparagus soup.
3. can be a debilitating disease leading to 6. Cottage cheese.
depression. 9. A client is returning to the unit with a bowel
4. is cured as long as the clients remain on 5-ASA resection from an intestinal obstruction. What is
compounds. the nurse’s first action when the client returns to the
5. Hernias are a protrusion through the muscle room?
wall and: 1. Encourage ambulation to stimulate the return of
1. can be easily reduced by the nurse applying bowel function.
gentle pressure. 2. Connect NG tube to suction to decompress the
2. are benign occurrences that do not need any abdomen.
intervention. 3. Identify client’s learning style and teach
3. can lead to bowel obstructions. information in a manner compatible with
4. are caused by a lack of exercise. learning style.
6. Postoperative care of clients who have undergone 4. Assess for pain and administer an analgesic as
gastric bypass surgery includes: ordered.
1. immobilization of abdominal wound to stabilize 10. A client is admitted to the unit with the diagnosis of
the incision areas. a peptic ulcer. When assessing the client, the nurse
2. keeping the head of the bed flat to avoid stressing would most likely find:
the incision. 1. epigastric pain that increases when the stomach is
3. allowing only sips of fluids and small amounts of empty.
food in soft consistency. 2. stools that are fatty and foul smelling.
4. bed rest to prevent complications from surgery in 3. alternating episodes of diarrhea and
obese patients. constipation.
7. An excessively overweight client expressing a desire 4. pain in the upper quadrant radiating to the right
to lose weight must be advised initially to: scapular area that occurs 2–4 hours after eating
1. decrease caloric intake. fatty foods.
2. follow a weight loss diet and increase activity level.

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Centers for Disease Control and Prevention (CDC). (2001). FDA Krumberger, J. (2002). When the liver fails. RN, 65(2), 26–29.
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hepatitis D. Retrieved May 28, 2009 from www.cdc.gov/ncidod/ Nursing2001, 31(9), 46–48.
diseases/hepatitis/slideset/hep-d.htm Lynch, B., & Sarazine, J. (2006). A guide to understanding malignant
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diseases/hepatitis/slideset/hep-e/htm McConnell, E. (2001a). Administering total parenteral nutrition.
Chene, B., & Decker, A. (2001). Battling hepatitis C. RN, 64(4), 54–58. Nursing2001, 31(11), 17.
Clinical Rounds. (2003). Acetaminophen linked to most liver failure McConnell, E. (2001b). Myths & facts . . . about dysphagia.
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Cox, C., Evans, P., Withers, T., & Titmuss, K. (2008). The importance Marrs, J. (2006). Abdominal complaints: Diverticular disease. Clinical
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Nursing, 6(9), 32–40. Mehta, M. (2003). Assessing the abdomen. Nursing2003, 33(5),
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(2nd ed.). Clifton Park, NY: Delmar Cengage Learning. Metheny, N., & Titler, M. (2001). Assessing placement of feeding
Day, M. (2008). Fight back against inflammatory bowel disease. tubes. AJN, 101(5), 36–45.
Nursing2008, 38(11), 34–42. Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
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Clifton Park, NY: Delmar Cengage Learning. National Cancer Institute. (2008b). U.S. National Institutes of Health:
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Framp, A. (2006). Diffuse gastric cancer. Retrieved from http://www.cancer.gov/cancertopics/types/stomach
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 CHAPTER 7 Gastrointestinal System 237

National Institute of Diabetes and Digestive and Kidney Diseases. Sammons, D. (2002). Roux-en-Y gastric bypass. American Journal of
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RESOURCES
American Liver Foundation, National Institute of Diabetes and Digestive and
http://go.liverfoundation.org/ Kidney Diseases, http://www2.niddk.nih.gov/
Crohn and Colitis Foundation of America, Inc., United Ostomy Associations of America — Ostomy,
www.ccfa.org Colostomy, http://www.uoaa.org/
Hepatitis Foundation International (HFI), www.hepfi.org
National Digestive Diseases Information Clearing-
house (NDDIC), http://digestive.niddk.nih.gov/

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 8
Urinary System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the urinary system:
Adult Health Nursing • Reproductive System
• Cardiovascular System • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe the anatomy and physiology of the urinary system.
• Relate diagnostic test results to urinary disorders.
• Discuss the pros and cons of peritoneal dialysis/hemodialysis and kidney trans-
plantation, including lifestyle changes for the client receiving dialysis.
• List four drug classifications and two examples of each used in the
treatment of urinary disorders.
• State two changes in the urinary system related to the normal aging process.
• Compare and contrast acute and chronic renal failure, including nursing care.
• Assist in formulating a nursing care plan for clients with urinary disorders.

KEY TERMS
anasarca ileal conduit pyuria
azotemia intravesical renal colic
cachectic litholapaxy residual urine
calculus lithotripsy retroperitoneal
cystitis micturition stress incontinence
dialysate nephrotoxic urge incontinence
dialysis nocturia urgency
dysuria nocturnal enuresis urinary incontinence (UI)
erythropoiesis oliguria urinary retention
fulguration overflow incontinence urolithiasis
glomerular filtration rate (GFR) polyuria
hematuria pyelonephritis

238

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 CHAPTER 8 Urinary System 239

(Figure 8-2). Urine normally consists of 95% water; the

INTRODUCTION nitrogenous waste products of protein, which are urea, uric
Urology is the study of disorders of the urinary system. The acid, and creatinine; the excessive electrolytes sodium, cal-
National Kidney Foundation estimates that more than 26 cium, potassium, and phosphates; bile pigments; hormones;
million Americans have chronic kidney disease and more and metabolized drugs and toxins. Urine moves steadily
than 26 million more are at increased risk (National Kidney by peristalsis through the ureters into the urinary bladder
Foundation [NKF], 2008). Disorders of the urinary system (Figure 8-3). The urine remains in the urinary bladder until
may seriously affect an individual’s health and, thereby, affect capacity has been reached (about 500 mL) or until the body
the lives of family members. Clients are treated by a urolo- feels the urgency or desire to urinate (about 250 mL). The
gist, specialist in urinary tract disorders, or a nephrologist, urine is then expelled from the bladder through the urethra,
specialist in structure, function, and diseases of the kidney. which is shorter in females than in males. Micturition, the
According to the National Kidney Foundation (2009b), process of expelling urine from the urinary bladder, is also
the warning signs of kidney disease are: called urination or voiding.
The kidneys are located beneath the false ribs, in the
• Burning or difficulty during urination retroperitoneal space (behind the peritoneum outside
• Increase in the frequency of urination, especially at night the peritoneal cavity) of the abdominal cavity. The kid-
(nocturia) neys also assist in acid–base balance, raise blood pressure
• Passage of bloody appearing urine by secreting the enzyme renin, and produce the hormone
• Puffiness around the eyes, or swelling of the hands and erythropoietin, which is responsible for erythropoiesis
feet, especially in children (the production of red blood cells and their release by the
• Pain in the small of the back just below the ribs (not red bone marrow).
aggravated by movement) Within the kidneys are microscopic units called nephrons,
which are responsible for urine formation (Figure 8-4). The
• High blood pressure nephron winds into the cortex and medulla of the kidney.
Each nephron includes a renal corpuscle, which consists of a
glomerulus, a ball-like network of capillaries formed from an
ANATOMY AND PHYSIOLOGY arteriole and held within a cuplike Bowman’s capsule. The Bow-
REVIEW man’s capsule is attached to a long, intricate, ultrathin looped
and coiled tubular structure called the renal tubule. Continuing
The urinary system consists of two kidneys, two ureters on from the glomerulus is an arteriole that forms a capillary
(upper urinary tract), a urinary bladder, and a urethra (lower network around the tubule. Blood flowing through this system
urinary tract) (Figure 8-1). The kidneys manufacture urine is collected by venioles.

Kidneys

Kidneys

Ureters

Ureter

Bladder
Bladder
Urogenital
diaphragm
Urethral
sphincter
muscle
COURTESY OF DELMAR CENGAGE LEARNING

Urethra
Urethra

A B

Figure 8-1 Urinary Tract; A, Female; B, Male

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240 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Renal
pyramid

Renal column
Minor calyces

Renal
Major calyces papilla

Renal
pelvis
Renal
Minor capsule
calyx (peeled back)

COURTESY OF DELMAR CENGAGE LEARNING

Ureter

Cortex Medulla

Figure 8-2 The Internal Anatomy of the Kidney

Detrusor muscle the capillaries of the glomerulus and into the Bowman’s
in wall of bladder capsule (glomerulofiltration). This occurs because of the
high capillary blood pressure within the glomerulus. The
Ureter Openings of
ureters
glomerular basement membrane assists with the process of
into bladder filtration. The glomerular filtration rate (GFR) is the
amount of fluid filtered from the blood into the capsule
per minute and an accurate measure of the functioning
status of the kidneys. The material filtered from the blood
is called glomerular filtrate, which contains water, elec-
trolytes, glucose, various toxic substances, waste products
(urea and creatinine), and just about everything else in
the blood except large protein molecules and blood cells.
As the filtrate passes through the first parts of the tubular
Trigone
structure, various substances such as necessary amounts
of electrolytes, glucose, and water are reabsorbed (tubular
Opening into reabsorption) back into the circulatory system through the
COURTESY OF DELMAR CENGAGE LEARNING

urethra Prostate gland capillaries or into the interstitial fluid. Tubular secretion
then removes certain ions, nitrogen waste products, and
External urethral
Internal urethral
drugs from the blood in the capillaries and adds it to the
sphincter filtrate. The remaining filtrate—water, urea, excess electro-
sphincter
lytes, toxic substances, and wastes, all of which constitute
urine—continues through the tubules into the collecting
Urethra duct, which collects urine from many nephrons. The urine
passes from the collecting duct into the pelvis of the kidney,
Figure 8-3 The Anatomy of the Urinary Bladder then through the ureter into the bladder and out of the
body through the urethra. The kidneys process about 200
Most of the contents of the blood, except for large quarts of blood a day to eliminate 2 quarts of waste prod-
molecules and blood cells, are forced out of the blood from ucts and extra water as urine (NIDDK, 2006).

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 CHAPTER 8 Urinary System 241

Distal convoluted tubule

Proximal convoluted tubule Collecting Table 8-1 Urinary Terms
duct
TERMS DEFINITION
Juxtaglomerular
apparatus Anuria Cessation of urine production or
urine output <100 mL/day
Efferent
arteriole Dysuria Painful or difficult urination
Hematuria Blood in the urine
Afferent Nocturia Excessive urination at night
arteriole
Oliguria Diminished capacity to form
Glomerular and excrete urine (<500 mL/

COURTESY OF DELMAR CENGAGE LEARNING

capsule day)
Glomerulus
Polyuria Excreting an abnormally large
quantity of urine
Urgency Feeling the need to urinate im-
mediately
Cortex
Interlobular Medulla
artery
CRITICAL THINKING

Interlobular Clinical Setting Activity:

vein
Urinalysis Results
COURTESY OF DELMAR CENGAGE LEARNING

Peritubular
capillaries Research and evaluate the urinalysis results of a
client in the clinical setting. Were abnormal results
Loop of Henle
detected? If so, what course of treatment was
ordered for the client? What nursing interventions
To minor should be implemented?
calyx

Figure 8-4 The Anatomy of a Nephron

Next, the client can describe the urine and urination pat-
tern. Is there difficulty starting the stream? Is there urgency,
frequency, incontinence, or hematuria? Does the bladder
ASSESSMENT feel empty after voiding? Does the client have pruritis or dry
skin?
Assessment of the urinary system is included in the base-
line data for all clients. The client may be reluctant to
discuss urinary problems. Assist the individual to relax
by asking open-ended questions, using familiar terms,
Objective Data
and making sure the client understands the medical terms If edema is present, ask the client if it is always present or if
(Table 8-1). it disappears during the night. Monitor I&O and vital signs,
A more in-depth assessment is performed when clients and palpate the client’s bladder for retention. Weigh the cli-
are at high risk for renal disease because of exposure to neph- ent. Assess mucous membranes for moisture and the skin for
rotoxins; an altered health state such as diabetes mellitus, dryness and uremic frost. Evaluate urine for color, clarity, and
pregnancy, or hypertension; trauma, dehydration, or fluid odor. Review diagnostic tests.
retention, which can compromise renal function; and those
with suspected or active renal disease.
Changes with Aging
The following changes are found in the urinary system as a
Subjective Data result of aging:
Ask the client to describe how the symptoms developed and 1. Nephrons decrease, resulting in decreased filtration and
progressed. Is there pain? Is it sharp or a dull ache? Constant gradual decrease in excretory and reabsorptive func-
or intermittent? Does it radiate to the groin, genital area, or tions of renal tubules.
leg? Is the pain associated with urination? Have headaches 2. Glomerular filtration rate decreases, resulting in
been experienced? decreased renal clearance of drugs.

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242 UNIT 3 Nursing Care of the Client: Digestion and Elimination

8. Incidence of stress incontinence increases in females.

BOX 8-1 QUESTIONS TO ASK AND 9. The prostate may enlarge, causing frequency or drib-
OBSERVATIONS TO MAKE WHEN bling in males.
COLLECTING DATA
Subjective Data
Do you have any urinary health problems?
COMMON DIAGNOSTIC TESTS
Commonly used diagnostic tests for clients with symptoms of
Do you have any family members with any urinary
urinary system disorders are listed in Table 8-2.
health problems?
How do you view your overall urinary health?
What was different today than any other day that IMPAIRED URINARY
brought you here? ELIMINATION

D
How often do you urinate in the day and at night?
isorders in this category include urinary retention and
Are you urinating as much as you are drinking? urinary incontinence.
How many glasses of water do you drink a day?
Does it ever hurt or burn when you urinate? ■ URINARY RETENTION

A
Do you leak urine when you cough or exercise?
person who is unable to void when there is an urge to
Do you have trouble starting your urine stream? void has urinary retention. This creates urinary stasis
Does your urine have a strong odor or appear dark and increases the possibility of infection. The urine may over-
yellow? flow the bladder’s capacity, causing incontinence.
A variety of causes include a response to stress; benign
Do you ever see blood in your urine? prostatic hypertrophy (BPH), obstruction of the urethra by
Are you experiencing sleep disturbances? calculi (concentration of mineral salts, known as stones),
tumor, or infection; interference with the sphincter muscles
Do you experience shortness of breath on exertion?
during surgery; or as a side effect of medications or perineal
Objective Data trauma.
Check vital signs The client may experience discomfort and anxiety from
urinary retention. Frequency of urination and voiding small
Inspect color, odor, and consistency of the urine amounts may also occur. A distended bladder can be palpated
Observe client for signs of anorexia above the symphysis.
Treatment may include urinary analgesics and antispas-
Observe client’s activity tolerance and for signs of modics to help the client relax. Cholinergic medications such
fatigue as bethanechol chloride (Urecholine) may be ordered to pro-
Assess client for nausea and/or metallic taste in the mote detrusor muscle contraction and bladder emptying. A
mouth urinary catheter may be used to empty the bladder, or surgery
may be performed to remove any obstruction.
Assess skin condition for pruritus When a client is unable to void, check for residual
Measure and record intake and output urine. Immediately after the client voids, use a bladder scan
or insert an intermittent straight catheter, if ordered, and
Weigh client daily measure the urine output. The bladder scan is preferred
Monitor client for impaired cognition because it reduces the risk of urinary tract infection (UTI).
The urine left in the bladder, residual urine, should be less
Report diagnostic test results than 50 mL.

3. Blood urea nitrogen (BUN) increases 20% by age 70. ■ URINARY INCONTINENCE

U
The creatinine clearance test is a better index than the
BUN of renal function in the elderly. rinary incontinence (UI) is the involuntary loss of
urine from the bladder. UI may be a complication of
4. Sodium-conserving ability is diminished. urinary tract problems or neurologic disorders and may be
5. Bladder capacity decreases, causing increased frequency permanent or temporary. Medications such as sedatives, hyp-
of urination and nocturia. notics, diuretics, anticholinergics, antipsychotics, and alpha
6. Renal function increases when the client is lying antagonists may be associated with UI.
down, sometimes causing a need to void shortly after More than 25 million men and women in the United
going to bed. States experience UI, with women twice as often as men
(National Association for Continence, 2008). This is not
7. Bladder and perineal muscles weaken, resulting in just a physiological problem but also affects the client’s emo-
inability to empty the bladder. This results in residual
tional, psychological, and social well-being. UI can occur in
urine and predisposes the elderly to cystitis.
clients of any age but is more common in older adults. All

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 CHAPTER 8 Urinary System 243

types of incontinence can be treated at any age. Keeping the

Table 8-2 Common Diagnostic Tests perineal area dry and intact is a goal for all clients. UI is clas-
for Urinary System Disorders sified as stress, urge, overflow, total, or nocturnal enuresis.
URINALYSIS
Urinalysis
Stress Incontinence
Stress incontinence is the most common type of incon-
Color Bilirubin tinence. It is not a disease or a natural, inevitable effect of
Odor Glucose aging. Anyone can be affected; however, women are more
likely to have this condition than men. In stress inconti-
Albumin (protein) Specific gravity nence there is leakage of urine when a person does anything
Acetone (ketone) Bacteria that strains the pelvic floor, such as coughing, laughing, jog-
ging, dancing, sneezing, lifting, making a quick movement,
RBCs Casts or even walking. Medical management depends on the
WBCs pH underlying cause. Treatment may include bladder retraining,
medicines such as conjugated estrogens (Premarin Vaginal
Culture and sensitivity (C & S) Cream), or surgery. Surgery may be necessary to restore the
Creatinine clearance support of the pelvic floor muscles or to reconstruct the
sphincter but is used after other treatments are unsuccessful.
Residual urine (postvoiding residual urine) Another possible treatment is having collagen injected into
the tissues surrounding the urethra thus causing the urethra
BLOOD TESTS to close enough to prevent urine from leaking out. The pro-
cedure is done in a nonsurgical outpatient setting. Surgical
Blood urea nitrogen (BUN)
procedures include internal mesh support of the urethra,
Serum creatinine formation of a urethral sling to elevate and compress the
urethra, and implantation of an artificial sphincter. Several
Antistreptolysin O titer (ASO titer)
support prostheses and external barriers are available.
Serum electrolytes The client can be taught pelvic floor exercises (Kegel
Sodium Calcium exercises) to strengthen the muscles, thereby preventing
Potassium Phosphorus
or minimizing stress incontinence. Kegel exercises involve
having the client tighten the pelvic floor muscles to stop the
Chloride Uric acid flow of urine when urinating, and then releasing the muscles
to start the flow of urine again. Once the client can do this,
URINE TESTS the exercise may be done anytime, anyplace. Practicing the
exercise 10 times, 7 or 8 times a day strengthens the pelvic
Voiding cystourethrography floor muscles.
Kidney-ureter-bladder (KUB) x-ray
Computed tomography (CT; spiral CT)
CLIENTTEACHING
Magnetic resonance imaging (MRI)
Performing Pelvic Muscle Exercises
Intravenous pyelogram (IVP)
(Kegel Exercises)
Renal angiography
The nurse instructs the client to do the following
Renal scan when learning Kegel exercises:
Ultrasound • To learn how to control the pelvic floor muscles,
Portable ultrasonic bladder scan tighten the pelvic floor muscles to stop the flow
of urine when urinating.
Retrograde pyelogram
• Then, release the pelvic floor muscles to start
the flow of urine again.
URODYNAMIC TESTS
• Now, practice (without urinating) tightening
Uroflowmetry and holding the pelvic floor muscles for a count
of 3 to 5 seconds and then release the muscles.
Cystometrogram (CMG)
• Perform each contraction 10 times, three times
Urethra pressure profile (UPP) daily.
COURTESY OF DELMAR CENGAGE LEARNING

ENDOSCOPIC EXAMS • This exercise can be done anytime, anyplace.

• Develop a schedule or routine to remember to
Cystoscopy do daily Kegel exercises (e.g., when drinking
Biopsy morning coffee, working at the kitchen sink,
waiting at a stoplight).
Renal biopsy

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244 UNIT 3 Nursing Care of the Client: Digestion and Elimination

LIFE SPAN CONSIDERATIONS MEMORYTRICK

Elderly Clients and UTIs DRIP
• Elderly clients are more prone to UTIs because There are several causes of incontinence that can be
of incomplete emptying of the bladder, fecal reversed or corrected. A memory trick to easily identify
incontinence with perineal soiling, and a
the reversible causes of incontinence is DRIP:
decrease in urine acidity.
D = Delirium (a new onset of delirium)
• Incomplete emptying of the bladder in women
is caused by bladder or uterine prolapse or loss R = Restriction (restricted mobility)
of pelvic muscle tone; in men it is caused by an I = Infection (a new infection)
enlarged prostate gland. P = Polyuria (increase in urination as seen in
• In elderly clients, sometimes the only sign of a diabetes)
UTI or urosepsis is new onset of mental changes
or confusion (National Institutes of Health,
2006).
channel between an abdominal stoma and the bladder. Cli-
ents can then empty their bladder with a catheter.

Bladder retraining begins with assessing the client’s void-

ing pattern and encouraging the client to void 30 minutes
Nocturnal Enuresis
before the projected time of incontinence. The schedule is Incontinence that occurs during sleep is called nocturnal
extended until the client can stay dry for 2 hours, gradually enuresis. Limiting fluid intake after 6 p.m. helps the client
increasing the time between voidings until a 3- to 4-hour remain continent during the night. The total fluid intake for
schedule is achieved. 24 hours, however, should remain the same. The bladder
should be emptied immediately before going to bed.

Urge Incontinence Nursing Management

Urge incontinence occurs when a person is unable to sup- Identify impaired urinary elimination based on subjective and
press the sudden urge or need to urinate. Sometimes urine objective data. Assess vital signs. Encourage adequate fluid
may leak without any warning. An irritated bladder is often intake. Teach Kegel exercises. Initiate bladder retraining.
the cause. Infection or very concentrated urine may irritate
the bladder.
Treatment includes clearing up an infection, if present,
and encouraging the client to have a fluid intake of 3,000 mL
per day. This prevents the urine from becoming concentrated. INFECTIOUS DISORDERS
Less fluid does not prevent incontinence but may promote
infection. I nfectious disorders of the urinary system are called urinary
tract infections (UTIs). There are two types: lower UTIs
affect the bladder (cystitis) and urethra, and upper UTIs affect
Overflow Incontinence the kidneys (pyelonephritis, and acute and chronic glomeru-
lonephritis) and ureters.
When the bladder becomes so full and distended that urine
leaks out, it is called overflow incontinence. This occurs
when a blocked urethra or bladder weakness prevents nor-
mal emptying. The blockage may be an enlarged prostate.
■ CYSTITIS
The distended bladder cannot contract with enough force to
expel a stream of urine. Bladder weakness occurs most often
in persons who have diabetes, drink a large quantity of alco-
C ystitis is an inflammation of the urinary bladder. It
is more common in females because their short ure-
thra allows bacteria to ascend through the urethra from the
hol, and have decreased nerve function. Bladder retraining vagina or rectum to the urinary bladder. Also, bacteria from
may alleviate the situation. an infected kidney can descend through the ureter into the
urinary bladder. Most urinary tract infections are caused by
Total Incontinence Escherichia coli, but some are caused by Candida albicans.
Other common causes of cystitis are coitus, prostatitis, and
When no urine can be retained in the bladder, it is termed diabetes mellitus.
total incontinence. The client may be able to manage with As women age, pelvic floor muscles relax, leading to a
an indwelling catheter. A neurologic problem is usually the decreased ability to empty the bladder completely. This con-
cause. Surgery to make a temporary or permanent urinary tributes to stasis of urine and promotion of bacterial growth,
diversion may be required. Kobayashi, Nomura, Yamada, as in pregnancy or benign prostatic hypertrophy. In men,
Fujimoto, and Matsumoto (2005) surgically performed cystitis usually occurs secondary to another infection such as
the Mitrofanoff procedure, which creates a catheterizable epididymitis or prostatitis.

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 CHAPTER 8 Urinary System 245

Once bacteria enter the bladder, they multiply, caus- bedpan. Encourage orders for bathroom privileges or using a
ing redness and swelling of the wall of the bladder. These commode chair. Help allay the client’s fears of being inconti-
changes result in urinary frequency, dysuria, pyuria, hema- nent with properly timed bladder management.
turia, and sometimes burning and urgency with urination.
These symptoms increase as the bladder distends with even
a small volume of urine. Nursing Management
A clean-catch midstream urinalysis showing a bacte- Monitor vital signs. Accurately record intake and output.
ria count greater than 100,000 organisms/mL confirms the Encourage fluid intake, especially water and cranberry juice.
diagnosis. Microscopic examination of the urine also shows Encourage the client to void more frequently and women
hematuria (blood in the urine) and pus. to void after intercourse. Teach clients that when taking
Pyridium the urine will be red-orange and will stain cloth-
ing. Encourage cotton-crotch undergarments. Teach those
Medical–Surgical who wear an incontinence control product to change it
Management frequently.

Medical
Treatment of cystitis includes medication and fluids. NURSING PROCESS
Recurrence of a UTI usually occurs when it is not effec-
tively treated. Obtaining and sending a urine specimen for Assessment
C & S before the administration of any urinary antimicro-
bial is necessary to determine the most effective medica- Subjective Data
tion. A repeat urinalysis after 2 or 3 days on medication The client will usually describe having frequency or urgency
confirms its effectiveness. Chronic lower urinary tract of urination or nocturia. This is annoying and embarrass-
infections are often a factor in the development of pyelo- ing, regardless of age or sex. Burning and pain when voiding
nephritis. are common reasons clients seek medical care. Even clients
with an indwelling catheter may complain of dysuria, burn-
Diet ing, and frequency. Clients often feel body discomfort and
malaise.
Encourage fluid intake. Clients are usually asked to drink
between 3 and 4 liters of noncaffeinated fluid per day. The Objective Data
intake of meats and whole grains makes the urine more acidic
and may discourage the growth of bacteria in the urinary blad- Perineal irritation may be noticed when the client with a
der. Drinking cranberry juice has been advised for years, but catheter pulls on it in hopes of alleviating the bladder pain.
how it worked was not understood. Research suggests that The urine will smell foul and appear cloudy. Hematuria
condensed tannins in the juice prevent E. coli from sticking to may be present (Figure 8-5). The elderly population in
the urinary tract (Lynch, 2004). particular may become anorexic and develop a low-grade
fever. The urinalysis will indicate the presence of bacteria,
and the C & S will identify the specific microorganism caus-
Pharmacological ing the UTI and the medication to which the pathogen is
Cystitis treatment entails the use of antimicrobial medica- most sensitive.
tion in conjunction with urinary tract analgesics. Cysti-
tis is generally treated with trimethoprim-sulfamethoxazole
(TMP-SMZ, Bactrim), ciprofloxacin (Cipro), cephalexin
(Keflex), nitrofurantoin (Macrobid, Macrodantin), Amox-
icillin (Amoxil), doxycycline calcium (Vibramycin), and
Augmentin. Determine whether the client is allergic to
sulfonamides or penicillins before administering the medica-
tion. The antimicrobial ordered is determined by the results
of the urine culture and sensitivity. The length of treatment is
related to the type of cystitis, acute or chronic. Some physi-
cians may order a single dose or short course (3 or 4 days) of
antimicrobial therapy rather than the traditional 7- to 10-day
course. Dysuria (difficult or painful urination) related to a
burning sensation when voiding can be alleviated with the
COURTESY OF DELMAR CENGAGE LEARNING

use of the urinary tract analgesic phenazopyridine hydrochlo-

ride (Pyridium), which causes red-orange urine and stains
clothing and toilets.

Activity
Because cystitis causes frequency of urination, call lights must
be answered promptly for clients on bed rest or those in need
of assistance to the bathroom. Clients on bed rest are gener- Figure 8-5 Nurse Examining and Measuring Hematuria
ally not able to empty their bladder completely when using a Sample from Client with a UTI

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246 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with cystitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Urinary Elimina- The client will return to Encourage a large amount of fluid intake, at least 3,000 mL
tion related to UTI usual pattern of urinary each day, especially water and cranberry juice twice a day.
elimination. Administer urinary tract analgesics and antimicrobial
medications as ordered.
Alert the client, if Pyridium is being taken, that the urine
will be red-orange and will stain clothing.

Deficient Knowledge The client will comply with Discuss the importance of taking all medication ordered
related to treatment treatment regimen and even after the symptoms are relieved.
regimen and prevention practice preventive habits. Teach or reinforce the following preventive measures.
of recurrence
Clean the perineum from front to back.
If nylon undergarments are worn, they should have a cot-
ton crotch.
Wearing tight-fitting jeans and thongs, and taking long
bike rides may be irritating to the perineum.
Perfumed perineal products such as menstrual products,
douches, powder, or bubble bath may also be contribut-
ing factors to bladder infections.
Spermicidal contraceptive products can be irritating, thus
contributing to a lower UTI.
Advise the client to void more frequently and not retain
urine in the bladder. Advise women to void after sexual
intercourse.
Teach the elderly client who uses incontinence control
products, to change the product frequently to prevent cystitis.
When this client is hospitalized, plan time for frequent
ambulation to the bathroom or commode chair.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CRITICAL THINKING kidney in the renal pelvis. Bacteria can also enter from the
blood and lymph. Pyelonephritis can be secondary to ure-
terovesicular reflux (backflow of urine from the bladder into
Assessment Scenario the ureters) or when urine cannot drain from the pelvis of the
kidney because of an obstruction blocking the kidney or ureter.
Pyelonephritis may occur during pregnancy, with prostatitis,
A 24-year-old female client comes into the emer- when bacteria are introduced during a cystoscopy or catheter-
gency department complaining of frequency and ization, or from trauma to the urinary tract. Pyelonephritis can
dysuria on urination. be an acute illness or a chronic condition leading to the devel-
1. What assessment should the nurse perform? opment of high blood pressure and/or chronic renal failure.
2. What tests might be ordered? Escherichia coli is the microorganism most often cultured. The
3. What instructions should the nurse teach the inflamed kidney becomes edematous and the renal blood vessels
client? become congested. Sometimes abscesses form in the kidney. The
urine is usually cloudy, containing mucus, blood, and pus.

Medical–Surgical
■ PYELONEPHRITIS Management
P yelonephritis, also known as pyelitis or nephropyelitis, is
a bacterial infection of the renal pelvis, tubules, and inter-
stitial tissue of one or both kidneys. Bacteria generally ascend
Medical
Diagnostic tests that may be ordered include a CT scan, an ultra-
sound (when CT scan is contraindicated), a urinalysis with a
from the urinary bladder through the ureter and enter the C&S, complete blood count [CBC], BUN, and serum creatinine.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 8 Urinary System 247

Collect urine specimens before the administration of any antimi- juice twice a day. Cleanse perineum from front to back.
crobial medication. Medical treatment and care are focused on Encourage client to empty bladder frequently. Promote
preventing pyelonephritis from becoming chronic. Follow-up rest periods during the day. Weigh client daily. Monitor
care and treatment may be necessary for up to 6 months. adequate pain management. Monitor and record diagnostic
test results.
Pharmacological
Pyelonephritis is generally treated with sulfonamides, such as
trimethoprim-sulfamethoxazole (TMP-SMZ, Bactrim) or the
antimicrobial ciprofloxacin hydrochloride (Cipro). Cipro may
NURSING PROCESS
not be indicated if the client has renal damage. Antipyretics are
used to reduce fever and analgesics to manage pain.
Assessment
Subjective Data
Diet In acute pyelonephritis the client is acutely ill with malaise,
urgency in urination, and pain during voiding and in the flank
As with infections in general, the individual’s diet should be area. Renal colic, severe pain in the kidney that radiates to the
light during the febrile stage. Fluids must be increased to 3,000 groin, may occur, impairing urination. The client may describe
mL per day by mouth and supplemented intravenously when being hot, with or without chills. In chronic pyelonephritis,
indicated. only a general symptom of nausea may be present. The client
may be very anxious that this kidney infection will cause per-
Activity manent kidney damage.
Because the disease process causes fatigue, bed rest is main-
tained during the acute phase of pyelonephritis. Diversionary
activities are important while on bed rest. When the client is Objective Data
allowed to ambulate, dizziness related to the analgesic medica- Assessment may find the client tender on one or both sides of
tion taken for pain may be a problem. the lower back. Temperature, pulse, and respiratory rate may
all be elevated. The urine is foul smelling, cloudy, and often
Nursing Management hematuria is noted. The urinalysis results show bacteria and
pyuria (pus in the urine), and the CBC indicates leukocy-
Encourage client to verbalize concerns and fears. Answer tosis. The client with chronic disease will have the systemic
questions honestly. Monitor I&O and observe output. signs of vomiting, diarrhea, and elevated blood pressure.
Encourage fluid intake to 3,000 mL per day and cranberry Some clients with pyelonephritis may be asymptomatic.

Nursing diagnoses for a client with pyelonephritis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to The client will verbalize Encourage the client to verbalize fears and concerns. Use
unknown prognosis fears and concerns to family active listening and observe for behavioral signs of anxi-
and health care team. ety. Answer questions honestly.

Impaired Urinary The client will regain nor- Encourage drinking cranberry juice in the morning and
Elimination related to mal urinary pattern. evening.
UTI Encourage fluid intake to 3,000 mL per day, especially water.
Monitor intake and output. Evaluate kidney function by
measuring and observing urine output and monitoring
the results of blood and urine tests.

Deficient Knowledge The client will verbalize un- Teach or reinforce the hygiene measure of cleansing the
related to disease process, derstanding of disease pro- perineum from front to back and practice this when do-
treatment regimen, and cess, treatment regimen, ing perineal care on any client.
prevention and preventive measures. Instruct the client on the importance of taking all the an-
timicrobial medication as prescribed in order to eliminate
the bacteria.
Teach the client to refrain from using perfumed perineal
products such as menstrual pads, tampons, or douches,
and avoid bubble baths and hot tubs because they can be
irritating to the tissues of the genital area.

(Continues)

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248 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with pyelonephritis include the following:

(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Encourage the client to empty the bladder frequently to
avoid distention.
Promote rest periods, which aid the healing process.
Inform the client to call the physician immediately if
there is a decrease in urine output or signs of infection
(elevated temperature, chills, flank pain, urgency, fatigue,
nausea, and vomiting).
Teach client to weigh daily and report sudden weight
gain (2 pounds/week) to the physician.
Emphasize the importance of keeping all appointments
with the physician for follow-up care and when signs of
infection appear.
Teach the client the importance of long-term treatment
and monitoring for chronic pyelonephritis.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

must start as soon as the client is diagnosed to restore kidney

■ ACUTE GLOMERULONEPHRITIS function. Management includes drug therapy, diet, and rest.

G
Treatment is correlated with the blood pressure and the results
lomerulonephritis is a condition that can affect one or of urine testing for red blood cells and protein. The client is
both kidneys. In both acute and chronic disease, the not considered to be free from the disease until the urine tests
glomerulus within the nephron unit becomes inflamed. It negative for protein and red blood cells for 6 months.
is predominantly a disease of children and young adults when Plasmapheresis may be indicated if there is no response
the cause is bacterial. The viral form can affect all ages. The from other treatments and if the client also has Goodpasture’s
prognosis for most clients is a full recovery; however, some syndrome. Between 150 and 400 mL of blood is removed
may develop chronic glomerulonephritis. Acute glomerulo- from the client and put in a cell separator. Here the blood is
nephritis during childhood is known as Bright’s disease. divided into plasma and formed elements which are mixed
Clients may develop symptoms 1 to 3 weeks after an with a plasma replacement and returned to the client through
upper respiratory infection (tonsillitis or pharyngitis with a vein. Another technique filters the client’s own plasma
fever) or skin infection caused most commonly by group A to remove a specific disease mediator (antibody) and then
β-hemolytic streptococcus. The infection triggers an autoim- returns the plasma to the client.
mune response and the glomeruli are attacked by antibodies
at the site of the glomerular basement membrane, resulting
in inflammation. Some clients are asymptomatic. A nephro- Pharmacological
toxic drug or systemic disease such as diabetes or lupus may Prophylactic antimicrobial therapy may be administered. The
also be a cause (NIDDK, 2006). drug of choice is penicillin. If the client is allergic to penicil-
Immunologic effects on the body are not completely lin, erythromycin is ordered. Diuretic and antihypertensive
understood. Direct effects on the glomeruli result in the medication furosemide (Lasix) may be ordered. Corticos-
reduced ability of the glomeruli to function. The glomeruli teroids, chemotherapeutic drugs such as cyclophosphamide
become more permeable, resulting in the loss of red blood cells (Cytoxan), and/or immunosuppressive agents such as azathi-
and protein from the blood. These substances escape from the oprine (Imuran) may be ordered to control the inflammatory
body in the urine. The inflammatory process causes thickening response. Corticosteroids and immunosuppressive drugs
of the membrane of the glomeruli and potential scarring. may be prescribed to treat the underlying causes of glomeru-
Diagnostic tests on blood and urine as well as KUB x-rays lonephritis, such as lupus or vasculitis (Mayo Clinic, 2009).
will be performed. BUN, serum creatinine, potassium, eryth-
rocyte sedimentation rate (ESR), and antistreptolysin O titer Diet
(ASO titer) will be elevated. Urinalysis will show proteinuria and Fluid retention often requires fluid restriction. The restric-
red blood cells. A CBC and electrolytes are ordered. Cultures of tion is adjusted according to the client’s I&O record and
the throat and skin may be ordered to rule out Streptococcus. daily weight. Protein in the client’s diet will be regulated
according to the BUN and the creatinine blood levels. The
Medical–Surgical Management kidneys need to rest; however, particularly in children, it
may not be necessary to restrict protein. Potassium will
Medical need to be replaced if the diuretic promotes its excretion.
Prevention of renal complications and complications to cardiac Sodium may be restricted to prevent fluid retention. Strict
and cerebral functioning is the focus of care. Medical treatment intake and output are necessary to monitor kidney function.
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 CHAPTER 8 Urinary System 249

NURSING PROCESS
Sodium Restriction
Assessment
When water at home is naturally high in sodium or
Subjective Data
if water is chemically softened, teach the client to The health history will likely reveal a recent sore throat,
use low-sodium bottled water in cooking and for
skin infection, flulike symptoms, and a headache. The client
describes flank pain as the kidneys become congested. Other
the drinking allowance.
symptoms the client may describe are headache, malaise,
anorexia, cola-colored “smokey” urine, and a marked decrease
in the amount of urine (oliguria). Facial edema may be the
Activity first sign noticed, may impair vision, and may cause the client
Physical and emotional rest are essential. Compliance with to have negative feelings about body image.
bed rest may be difficult, especially for a child or the client
who feels well. Bed rest is indicated until the inflammation Objective Data
subsides, urinary flow increases, and as long as the client has
hematuria or proteinuria. During this time a strict turning Vital signs will generally show an increase in body temperature
schedule needs to be followed because skin breakdown is and blood pressure. Facial (periorbital) edema is present. The
more likely in the presence of edema. When ambulation is edema will progress to dependent areas such as the sacral area
allowed, the client may feel weak from the effects of anemia and the legs. Monitor daily the location and degree of edema.
and inactivity. Ascites may also develop. Assess the general condition of the
skin and skin integrity. Weigh the client to establish a baseline
Nursing Management weight. Assess heart and lung sounds for signs of heart failure
and pulmonary edema (unusual heart sounds and crackles in
Monitor vital signs and I&O. Blood pressure should be moni- the lungs). Neck veins may be distended. Dyspnea on exer-
tored closely. Assess for headache, flank pain, and edema. tion or when recumbent, and shortness of breath, may both
Weigh client daily. Assess heart and lung sounds. Monitor be noted. Urine output is decreased and cola colored to red
results of diagnostic tests. If fluids are restricted, work with colored urine is present.
client on fluid intake schedule. Encourage client to follow Monitor results of diagnostic tests: urine for red blood
schedule. Assist with or provide oral hygiene several times cells and protein (albumin) and blood for BUN, serum crea-
a day. Refer for dietary consultation if protein and sodium tinine, potassium, ESR, ASO titer, and specific gravity, all of
are restricted. which will be elevated.

Nursing diagnoses for a client with acute glomerulonephritis include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fear related to potential The client will communicate Provide client and family with support and understanding.
permanent damage to fears of kidney damage to Encourage client to discuss fears.
the kidneys the family and the health Explain the importance of protecting the client from other
care personnel. infections. Allow no one with an upper respiratory infec-
tion to visit the client.
Discuss the importance of compliance with medications,
bed rest, and diet to prevent permanent damage to kid-
neys.
Emphasize the importance of keeping the follow-up visits
to the laboratory for tests and to the physician’s office.
Arrange consultation with social services to assist the cli-
ent in arranging time off from work and to help the client
and family with their financial needs.

Excess Fluid Volume The client will have Fluids will be restricted with specific amounts designated
related to compromised decreased edema and throughout the day. For example, 900 mL of fluids for a
regulatory mechanism adequate urinary output. day might be divided in the following manner: 7 a.m. to
secondary to renal dys- 3 p.m. 600 mL; 3 p.m. to 11 p.m. 200 mL; 11 p.m. to 7 a.m.
function 100 mL.
Encourage compliance to the fluid amounts. Maintain
accurate intake and output records hourly.

(Continues)

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250 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with acute glomerulonephritis include

the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Provide oral hygiene several times a day. Advise that thirst
may be relieved by sucking on hard candy or, if allowed, a
few ice chips.
Provide eye care with normal saline to promote comfort
from the periorbital edema.

Impaired Social Interac- The client will resume social Encourage client to keep in contact with friends and rela-
tion related to changes in interaction. tives by telephone.
body image Encourage keeping appointments with the physician and
laboratory.

Imbalanced Nutrition: The client will comply with Once the client’s condition warrants solid foods, arrange a
More than Body Require- nutritional restrictions. dietary consultation to incorporate food preferences and
ments related to the religious and/or cultural needs. Finances may be an issue
disease process if the family has to incorporate foods that are not usually
part of its budget.
Teach client to plan menus and to read food labels in
order to comply with the dietary restrictions.
Before discharge, teach client and family about diet, fluids,
and activity restrictions and measuring fluid intake and
urine output.
Provide client with guidelines listing reasons to call the
physician.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ CHRONIC Medical–Surgical
GLOMERULONEPHRITIS Management
T he prognosis for acute glomerulonephritis is often good
when treatment is begun early; however, chronic glom-
erulonephritis generally leads to permanent kidney dam-
Medical
Prevention of further renal damage as well as heart or cere-
bral complications is the focus of care. Management includes
age. Those who develop chronic glomerulonephritis may drug therapy, diet, and bed rest. Exposure of the client to
have neither symptoms nor a recent history of an infection. infection of any kind must be avoided. Blood transfusion
Chronic diseases, such as diabetes mellitus or systemic lupus may be required for severe anemia. The client may be trans-
erythematosus, often mask renal symptoms and the client ferred to a facility where dialysis and/or kidney transplanta-
does not seek medical care until kidney function is impaired. tion can be performed.
It may take up to 30 years for the signs of renal insufficiency
to develop. Pharmacological
Chronic glomerulonephritis is a slowly progressive, des-
tructive process affecting the glomeruli, causing loss of kid- Diuretic and antihypertensive medications are ordered.
ney function. The kidney decreases in size as glomeruli are Antimicrobial therapy is generally given prophylactically.
destroyed. If end-stage renal disease (ESRD) develops, the Monitor for side effects from all medications and report to
client may die quickly. the physician immediately.
Nephrons lose their ability to filter nitrogenous wastes
from the blood. Protein (albumin) and red blood cells Diet
escape into the urine and are present on a urinalysis. Fluid intake is adjusted according to urinary output. Protein
Nitrogenous waste remains in the blood, and the BUN allowed in the diet will be regulated according to the BUN and
level increases. As glomeruli are destroyed, the serum level the creatinine blood levels. As these levels increase, protein
of creatinine also increases. BUN and serum creatinine are will be restricted to decrease the nitrogenous wastes. Sodium
checked on a regular basis to monitor renal function. Serum and potassium restrictions will be determined by the serum
electrolyte levels are also monitored. Anemia is evaluated electrolyte levels. Carbohydrates are usually increased in the
with a CBC. diet to provide adequate energy.

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 CHAPTER 8 Urinary System 251

Activity to perform ADLs. Facial edema and/or blurring of vision

caused by retinal edema may also be reported by clients.
Bed rest is indicated when the client has hematuria or
albuminuria.
Objective Data
Nursing Management As chronic glomerulonephritis develops, fluid retention
Assist client with ADLs and encourage bed rest with diversional becomes evident, leading to shortness of breath, especially
activities. Monitor vital signs and I&O. Measure urine hourly at night. Monitor vital signs; hypertension is usually pres-
or as ordered. Assess color and consistency of urine. Assess ent. Assess lung sounds every shift for crackles, a sign of
lung sounds, edema, speech, and mental functioning. Assist fluid retention. Monitor weight daily, and note the degree
client to reposition frequently and assess skin. Weigh client of edema, its location, and if it is pitting or nonpitting.
daily. Monitor laboratory reports. Anasarca is generalized edema that appears as the client’s
condition deteriorates. Assess skin for color, presence of
ecchymosis or rash, dryness, and evidence of scratching.
NURSING PROCESS Note mental functioning, irritability, tremors, ataxia, or
slurred speech.
Assessment As nephrons lose their ability to concentrate urine, the
urine becomes pale and dilute. Closely monitor I&O because
Subjective Data initially, polyuria develops, giving the client a false sense that
Clients may describe a morning headache, pruritis, a decreased recovery will be soon. Monitor results of blood and urine
ability to concentrate, fatigue, and dyspnea making it difficult tests.

Nursing diagnoses for a client with chronic glomerulonephritis include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Urinary Elimina- The client will have ad- Measure urine output hourly, or every 4 or 8 hours as
tion related to the failing equate urine output. ordered. Parameters will be set by the physician for im-
kidney function mediate notification. Assess and document the color and
consistency of the urine.
Measure intake to determine compliance with the amount
of fluids permitted.
Weigh client daily at the same time each day, on the same
scale and with the same clothes.

Excess Fluid Volume The client will have de- Assess and describe the location of the edema.
related to compromised creased edema. Administer medications as ordered for treatment of the
regulatory mechanism edema.
Monitor electrolyte values.
Maintain fluid intake at restricted amount. Document
I&O.

Anxiety related to threat The client will communi- Assist client to express concerns about possible treatment
to or change in health cate less anxiety about with dialysis.
status (potential dialysis possible treatment with Arrange for a dialysis nurse to visit client.
treatment) dialysis.
Provide written information about dialysis.

Risk for Impaired Skin The client will maintain Assess skin every time the client is repositioned.
Integrity related to im- skin integrity. Cleanse the skin frequently, especially when crystals of
mobility and edema urea form on the skin, causing itching and dryness.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

OBSTRUCTIVE DISORDERS ■ URINARY CALCULI

D isorders of this type include urolithiasis, urinary bladder

tumors, renal tumors, and polycystic kidney. A pproximately 1 million Americans each year have kid-
neystones (NKF, 2009c). Urolithiasis is a calculus, or

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252 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nephrolithiasis

Ureterolithiasis
Normal kidney
Hydronephrosis
Ureter
Hydroureter Normal ureter

COURTESY OF DELMAR CENGAGE LEARNING

COURTESY OF DELMAR CENGAGE LEARNING

Cystolithiasis Stone

Bladder

Urethrolithiasis
Urethra

Figure 8-6 Common Locations of Urinary Calculi Formation Figure 8-7 Hydronephrosis and Hydroureter Resulting
from a Stone in the Ureter
stone, formed in the urinary tract. A calculus (plural—cal- drained and strained every 2 to 4 hours. All strained particles
culi) is a solid mass of mineral salts occurring within a hollow are saved for the physician or sent to the laboratory.
organ such as the renal pelvis, ureters, bladder, or urethra (Fig- A very small calculus may be flushed out by peristalsis
ure 8-6). A urinary calculus can range in size from microscopic and fluids. The client is encouraged to drink at least 4,000 mL
to 10 to 20 mm in diameter. of fluid per day, unless contraindicated by other health prob-
Calculi are formed when minerals precipitate out of lems. The urologist may insert a small, pliable catheter stent
solution and collect within hollow areas. The reason stones into the ureter or urethra to allow temporary drainage of urine
form has not yet been identified, but individuals who are around the calculus.
immobile, hyperparathyroid, or have recurrent UTIs are
predisposed. When a person is immobile for long peri-
ods, calcium is pulled from the bones into the blood. The PROFESSIONALTIP
nephrons filter the excess calcium out of the blood into the
urine. Calculi can also lodge in and obstruct an indwell-
ing catheter. The size and location of the stone within the Risk Factors for Kidney Stone
urinary system greatly affects the degree of pain and other Development
symptoms present. When the stone is in the kidney, the pain The following factors may increase a client’s risk of
is dull and constant mainly in the back just below the ribs developing kidney stones:
near the spine. Stones in the ureter often cause ureteral colic,
• Diet: high protein, high sodium, foods contain-
an excruciating, intermittent pain that begins in the flank and
ing oxalate
radiates into the groin, inner thigh, or genitalia. It is caused
by spasm of the ureter as the calculus moves down the ureter. • Lack of fluids: causes a higher concentration of
The client often has nausea and vomiting. substances that can form stones
If a calculus becomes lodged anyplace along the ureter • Family/personal history
and urine cannot pass, a condition called hydronephrosis • Age/sex: common between 20 to 70 years of
and/or hydroureter occurs. The kidney and/or ureter become
age, men more likely to develop
enlarged with the accumulated urine (Figure 8-7).
Tests to confirm the diagnosis and determine the size • Limited activity: on bed rest or sedentary for
and location of the stone include spiral CT scan, KUB, IVP, long periods of time
cystoscopy, and ultrasound. A BUN and serum creatinine • Hypertension: doubles the risk of forming
indicate whether the calculus has damaged kidney function. A stones
urinalysis with a culture and a CBC may be ordered to deter-
• Obesity: higher body mass index (particularly in
mine whether an infection is present. A 24-hour urine may be
sent to the laboratory to determine whether there is abnormal women)
excretion of calcium oxalate, phosphorus, and uric acid. • Gastric bypass surgery, inflammatory bowel
disease, or chronic diarrhea: changes in diges-
tive process that affect absorption of calcium
Medical–Surgical increase the level of substances in urine that
Management form stones
Adapted from Mayo Clinic, 2009, Kidney Stones Risk Factors,
Medical from http://www.mayoclinic.com/health/kidney-stones/DS00282/
DSECTION=risk-factors
All urine is strained whether voided or from an indwelling
catheter drainage bag. Urine from a catheter drainage bag is

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 CHAPTER 8 Urinary System 253

Extracorporeal shock wave lithotripsy (ESWL) is a

noninvasive method of crushing a calculus in the urinary sys- Pharmacological
tem with ultrasonic waves to shatter or pulverize the stones Narcotic analgesics are generally prescribed for the severe pain
into tiny pieces that are small enough to be passed in the urine. often called renal colic. Antispasmodics such as propantheline
Sedation or light anesthesia is used to maintain comfort dur- bromide (Pro-Banthine) or belladonna preparations may be
ing the procedure due to the pain caused by the shock waves. ordered to relieve ureteral spasms. Antibiotics may be ordered
The procedure requires 30 minutes to 2 hours to complete. prophylactically.
The client is placed in a warm-water bath, and ultrasonic Drug therapy is specific to stone composition. Allopurinol
waves aimed at the stone break the stone into small pieces. (Zyloprim) reduces the serum urate level, preventing calcium
An alternate method is to appropriately place a fluid-filled oxalate stones. Diuretics, such as hydrochlorothiazide (Esi-
bag on the client’s body and aim the ultrasonic waves at the drex, Ezide, Hydro-Par), are prescribed to decrease the amount
stone through the bag, or the client is placed on a soft cushion. of calcium released by the kidneys in the urine. Tiopronin
There is some discomfort and the client may be bruised where (Thiola) and penicillamine (Cuprimine) are given to prevent
the ultrasonic waves hit the body. The urine will be slightly the formation of cystine stones by reducing the amount of
bloody for 24 to 48 hours and must be strained. The client cystine in the urine. Aluminum hydroxide gel (Amphojel)
should drink large amounts of fluids (3,000 mL to 4,000 mL binds with excess phosphates in the gastrointestinal tract. The
per day) unless contraindicated. Clients should avoid taking phosphates are then excreted. Rarely, clients with hypercal-
aspirin and other drugs that affect blood clotting for several ciuria are given sodium cellulose phosphate (Calcibind) to
weeks before the procedure (NIDDK, 2007a). bind with calcium in the intestines and facilitate excretion of
Ureteroscopy is used for mid- and lower-ureter stones. calcium and prevent it from leaking into the urine.
The small fiber-optic ureteroscope is passed through the ure-
thra and bladder into the ureter. The stone is either removed
in a cage-like device or shattered with a shock wave and the Diet
pieces removed (NIDDK, 2007b). In the past, clients who formed calcium stones were told
to avoid foods high in calcium. It was believed that foods
Surgical high in calcium, including dairy products, may contribute
to the formation of calcium stones. Recent studies have
The surgeon may choose from several surgical procedures,
shown that eating foods high in calcium may help prevent
depending on the location and size of the calculus. These
calcium stones, but taking calcium in pill form may increase
include nephroscopic removal, pyelolithotomy, or nephro-
the risk of developing stones (NIDDK, 2007a). When the
lithotomy (Figure 8-8).
stones contain uric acid, purine-rich foods (meat, fish, and
Percutaneous nephrolithotomy is an endoscopic proce-
poultry) are restricted, and organ meats, anchovies, and sar-
dure in which a small incision is made in the fleshy area on the
dines avoided. Foods rich in oxalic acid (broccoli, asparagus,
client’s side between the ribs and the hip. A catheter is inserted
chocolate, tea, rhubarb, and spinach) are restricted when
and an ultrasonic probe is inserted through the catheter. Ultra-
oxalate stones form. A deficiency of pyridoxine, thiamin,
sound waves directed at the stone break it into small pieces that
and magnesium may also contribute to the formation of
can be withdrawn through the catheter. The catheter is left in
oxalate stones.
place until the edema subsides, usually 1 or 2 days.
Sometimes an effort is made to change the pH of the
A bladder calculus may be crushed with special surgical
urine and thus prevent the formation of calculi. Acid-ash or
instruments and the fragments washed out through a catheter.
alkaline-ash diets are used. Acid-ash foods are meats, fish,
This is called a litholapaxy.
poultry, eggs, cereals, cranberries, and plums. Alkaline-ash
Alligator forceps foods are vegetables and all other fruits. These diets are often
A difficult for the client to maintain.
Kidney Drinking large amounts of fluid, at least half of it water,
stone dilutes the urine and helps move any microscopic calculi
fragments through the system. Up to 4,000 mL per day of fluid is indi-
Nephroscopic removal
cated for a client with renal calculi, unless contraindicated by
another health problem such as heart failure.

Activity
B C
Exercising regularly helps reduce the formation of calculi
COURTESY OF DELMAR CENGAGE LEARNING

and keeps calculi moving through the urinary tract. Cli-

ents on bed rest should perform active range-of-motion
(ROM) exercises daily in addition to frequent turning and
positioning.

Nursing Management
Strain all urine. Monitor I&O. Encourage 4,000 mL per day
Figure 8-8 Methods of Removing Urinary Stones; of fluid intake unless contraindicated. Refer to dietitian for
A, Nephroscopic Removal (percutaneous nephrolithotomy); special acid-ash or alkaline-ash diet. Encourage active ROM
B, Pyelolithotomy, Removal Through the Renal Pelvis; exercises for clients on bed rest. Assess for pain and administer
C, Nephrolithotomy, Removal Through Incision into the Kidney analgesic as ordered.
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254 UNIT 3 Nursing Care of the Client: Digestion and Elimination

bed. If the calculus is not moving, the client may describe

NURSING PROCESS symptoms of infection such as lethargy, frequency of urina-
Assessment tion, persistent urge to urinate, dysuria, burning on urination,
or feeling very warm. Nausea and vomiting are often reported.
Subjective Data The client may express feelings of frustration related to the
inability to complete daily tasks.
Many individuals are asymptomatic until the calculus begins
to move or becomes too large. When the stone moves, the Objective Data
client usually describes intractable pain (pain not relieved by
ordinary measures). The pain is often described as beginning Assess hematuria, vomiting, intake and output, and vital signs.
in the flank and radiating down to the groin and inner thigh. Elevated pulse and blood pressure may indicate pain. Check
Nonverbal client behaviors may indicate pain by tossing and urine for stones when it is strained. Assess for cloudy, foul
turning when in bed or the inability to sit still when out of smelling urine and fever and chills if infection is present.

Nursing diagnoses for a client with urolithiasis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS

Acute Pain related to irrita- The client will verbalize a Develop a pain management plan.
tion of the urinary tract and reduction in pain. Inquire about intensity, location, duration, and alleviating
the mobility of calculi factors of pain. Observe for nonverbal signs of pain.
Provide comfort measures and diversionary activities and
administer analgesics and antispasmodics as ordered.

Impaired Urinary Elimina- The client will return to nor- Encourage fluids to dilute the urine and flush out the calculi.
tion related to blockage of mal urine elimination. Monitor urine for color and amount.
urine flow by the calculi Assist client to ambulate, if able.
Accurately monitor intake and output. If a ureteral catheter is
in place, measure and record the urine output from it sepa-
rately from the urine output from the bladder.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

progresses, the client may present with a UTI, painful urina-

■ URINARY BLADDER TUMORS tion, back pain, and abdominal pain. The main risk factor is

T
cigarette smoking. Those individuals who smoke nicotine
he American Cancer Society estimates approximately products have twice the risk of developing bladder cancer
70,980 new cases of urinary bladder cancer in 2009 as do nonsmokers. Other risk factors are working with dyes,
(ACS, 2009b). Men are affected four times more often than rubber, leather, or paint products; arsenic in drinking water;
women. Bladder cancer occurs most frequently after the age genetics; bladder birth defects; low fluid consumption; che-
of 50. The only early warning signs are increased urinary fre- motherapy and radiation therapy; and chronic bladder inflam-
quency and painless, intermittent hematuria. As the disease mation (ACS, 2009d).
Benign papillomas are the most common urinary bladder
tumor. Although papillomas are quite small, they should be
CLIENTTEACHING treated aggressively because they are considered to be pre-
malignant. Cancer cells develop mainly in the area where the
Urinary System Calculi ureters enter the urinary bladder. The primary sites for metas-
tasis are the liver, lungs, or bones. Symptoms resulting from
A person with a family history of stones or who
has had more than one stone is at risk to develop
another stone. Instruct these clients to:
• Drink plenty of fluids—water is best—to prevent
stone formation.
CULTURAL CONSIDERATIONS
• Avoid immobility.
• Take medications and modify diet as prescribed. Bladder Cancer
• Keep a record of intake and output.
Caucasians are almost 2 times as likely to have
• Learn how to strain urine. bladder cancer as African Americans (ACS, 2009).

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 CHAPTER 8 Urinary System 255

COURTESY OF DELMAR CENGAGE LEARNING

A B

Figure 8-9 Ileal Conduit; A, Ureters Implanted into Ileal Segment; B, Closure of
Proximal End of Ileal Conduit

obstruction of the ureters are often the reason the client seeks used. A newer method is to create a neobladder, a urinary
medical care. Diagnostic studies usually include a urinalysis, reservoir composed of a piece of ileum, to route the urine
a cystoscopic visualization and biopsy of the lesions, an IVP, back into the urethra, restoring close-to-normal urination
CT scan, urine cytology and culture, tumor marker studies, (ACS, 2009a).
retrograde pyelography, chest x-ray, MRI, ultrasound, bone
scan, and PET scan.
Pharmacological
One chemotherapy treatment is the instillation of an
Medical–Surgical antineoplastic drug within the urinary bladder (intravesi-
Management cal). The most common and most effective intravesical
therapy used for treating low-stage bladder cancer is Bacillus
Surgical Calmette-Guerin (BCG). BCG causes the client’s immune
For superficial or early stage bladder cancer, a transure- system to attack the bladder cancer. Systemic chemotherapy
thral resection (TUR) is most commonly performed. The may also be used. Medications to relieve symptoms such as
urologist places a resectoscope into the bladder through the pain and nausea are important for the client’s well-being.
urethra to remove the tumor. The tumor tissue is sent to
pathology for examination. Surgical removal of small tumors Diet
is generally done by fulguration (a procedure to destroy
tissue with long, high-frequency electric sparks) to burn the If proctitis (inflammation of the rectum and anus) or diarrhea
lesions off the internal bladder wall. Other surgical procedures occurs, a low-residue diet is ordered to facilitate normal bowel
used are laser surgery or snaring of the lesion. These proce- elimination.
dures are usually performed with cystoscopic visualization.
Several times a year, the client who has had bladder lesions Activity
should be monitored for recurrence of the lesions. A cytologic When the client is on bed rest, turning and positioning are
examination is done on any lesion(s) noted during a cysto- important to maintain skin integrity because the client may
scopic examination. be emaciated as a result of significant weight loss. Activity
A cystoscopic examination is performed with either local should be encouraged as the client’s condition warrants.
anesthesia and sedation or general anesthesia. After the proce- During the intravesical instillation of an antineoplastic drug,
dure, the client’s legs may be sore from the lithotomy position the client will have to change positions every 15 minutes, for
used. Analgesics will be prescribed for use as needed. After a cys- a period of several hours, to evenly distribute the chemo-
toscopic procedure, the client may experience urinary frequency, therapeutic drug around the urinary bladder.
burning on urination, and the presence of pink-tinged urine.
When the pathology of tissue specimens indicates a need
for more extensive surgery, either a partial or total cystectomy
may be performed. The surgery may be done in conjunction Ureters
with radiation therapy or chemotherapy.
Ileal conduit
When the urinary bladder is completely removed, a with implanted
urinary diversion is necessary. Consideration is made for ureters
age, extent of the disease, and the prognosis. One option is
a bilateral cutaneous ureterostomy, in which the ureters are
implanted directly into the abdominal wall. Another option Stoma
COURTESY OF DELMAR CENGAGE LEARNING

Nipple valves Bladder

is for the ureters to be implanted into a piece of the ileum,
which is then attached to the abdominal wall as a stoma. This Ileal pouch
is known as an ileal (“wet”) conduit (Figure 8-9).
Other methods of urinary diversion are the implanta- Skin
tion of the ureters into the sigmoid colon (ureterosigmoi- (abdomen)
dostomy) and the creation of a continent stoma with a
pouch of bowel. This urinary diversion is known either as
a Kock (Figure 8-10) or Mainz pouch or a Gilchrist ileoce-
cal reservoir, depending on which surgical procedure was Figure 8-10 Urinary Diversion—Koch Pouch

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256 UNIT 3 Nursing Care of the Client: Digestion and Elimination

diversion is performed. Refer client to local ostomy support

group.
COLLABORATIVECARE
Urinary Diversions NURSING PROCESS
Nurses work together with the enterostomal
therapist to provide the specialized care and
Assessment
teaching required for a urinary diversion. Subjective Data
The client will describe having painless, intermittent hematu-
ria and changes in voiding patterns. Fatigue may also be men-
tioned. As the cancer progresses, the client may experience
Nursing Management abdominal and back pain.
Encourage clients to reduce or eliminate the use of nicotine
products and report urinary frequency and painless hema- Objective Data
turia to their physician. After a cystoscopic examination, Weakness will be noted if the client has become anemic from
administer analgesic as needed for sore legs from lithotomy the hematuria. Check urine specimen with a reagent strip for
position. Encourage client to have adequate fluid intake blood, review results of diagnostic tests, and assess the client’s
and to express fears and concerns, especially if a urinary understanding of current health situation.

Nursing diagnoses for a client with urinary bladder tumors include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS

Deficient Knowledge The client will describe If surgical removal of bladder lesions is done as an outpatient
related to surgery and surgical changes and procedure, teach the client to observe for pink-tinged urine and to
treatment regimen treatment regimen. notify the physician if bright red urine is seen.
Discuss the use of analgesics as ordered for pain of bladder spasms.
Encourage adequate fluid intake.
For urinary diversions: Refer the client with a stoma to the enteros-
tomal therapist for specialized care and teaching. The therapist will
assist the client with the appliance and skin care protocol.
Monitor the color and integrity of the stoma daily to ensure that the
tissue is receiving adequate circulation. The stoma is normally red
and edematous for a time postoperatively. The stoma will remain
red in color but will shrink in size during the healing process.
If the stoma color changes, notify the physician.
Refer to a local ostomy group for ongoing support and assistance
or to the United Ostomy Association, which provides support and
literature.
Teach the signs and symptoms related to potential problems that
should be reported to the physician.
Encourage the intake of fluids, up to 3,000 mL per day, unless
contraindicated.
Teach about the medications to be taken at home.
Encourage the client to attend all scheduled follow-up visits.
Assist the client to plan the gradual return to the routines of driv-
ing, lifting, sexual activities, and work.

Impaired Urinary The client will maintain Accurately monitor urine output because this is the major postop-
Elimination related to adequate urinary erative concern.
surgical procedure elimination. Assist client to discuss feelings about the altered urinary elimina-
tion method.

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 CHAPTER 8 Urinary System 257

Nursing diagnoses for a client with urinary bladder tumors include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Assist the client with a bilateral cutaneous ureterostomy to use
leg bags for easier ambulation.
Change the leg bag tubing back to straight bag drainage to pro-
mote uninterrupted sleep.
Teach the client how to use both a leg bag and a straight bag
drainage system.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Other diagnostic studies used to evaluate the kidney or the

■ RENAL TUMORS status of other body systems possibly involved are MRI, IVP,

T
angiography, ultrasound, urinalysis, CBC, biopsy, PET, and
he American Cancer Society estimates that there will bone scan.
be approximately 57,760 new cases of kidney cancer in
2009 (ACS, 2009c). A unilateral renal cell adenocarcinoma
is the most common tumor and is seen more often in men Medical–Surgical
between the ages of 50 and 70. Risk factors include smok-
ing, obesity, familial incidence, preexisting renal disorders,
Management
hypertension, and workplace exposure to asbestos, cadmium, Medical
some herbicides, benzene, and organic solvents, particularly The physician may insert a nephrostomy tube into the renal
trichloroethylene. pelvis of each kidney to evaluate their function. Treatment
Intermittent, painless hematuria is often ignored by the options may include immunotherapy, targeted therapy, che-
client, and medical attention is not sought until the malig- motherapy, radiation therapy, or a combination of these
nancy is quite advanced. By this time, the client usually has depending on the stage of the cancer and the client’s overall
experienced weight loss, dull flank pain, gross hematuria, health. Chemotherapy and/or radiation therapy have proved
and a mass that may be palpable in the flank area. Lymph to be of minimal benefit.
nodes in the area of the kidney, the renal vessels, and/or the
inferior vena cava may become involved. The primary sites
for metastases are the lungs, liver, brain, and bone. A patho-
logical fracture may be the reason for admission of the client, Surgical
resulting in the diagnosis of kidney cancer. Usually a laparoscopic nephrectomy, the preferred method, or
A helical (spiral) CT scan or standard CT scan are an open radical nephrectomy is performed if the other kidney
commonly used to provide detailed images of the kidney. is healthy and the disease is localized. The surgeon may enter
the thoracic as well as the abdominal cavity during this proce-
dure. If the chest is opened, the client will have a closed-chest
drainage system postoperatively. A nasogastric drainage tube
may be in place and attached to suction. Hemorrhage and
compromised respiratory effort are the postoperative prob-
lems for which to observe.
CULTURAL CONSIDERATIONS
Renal-Cell Carcinoma Pharmacological
Those most at risk are: If the client is receiving radiation therapy treatments, anti-
• African-American clients, who have a slightly
emetics or antispasmodics may be ordered. Analgesics are
ordered to control pain and facilitate respirations and client
greater rate
activity. An antiemetic will usually be ordered to promote
• People with a strong family history of renal cell comfort and to encourage eating.
cancer
• Siblings (brothers or sisters) of those affected
• Those exposed to asbestos, cadmium, some her- Diet
bicides, benzene, and organic solvents, particu- The client having a nephrectomy will have intravenous flu-
larly trichloroethylene, at their job (ACS, 2009e) ids until food can be tolerated. A well-balanced diet is then
ordered. Fluid intake of at least 2,000 mL per day is needed

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258 UNIT 3 Nursing Care of the Client: Digestion and Elimination

to maintain adequate hydration. The use of alcohol should be

avoided. If the client is cachectic (in a state of malnutrition NURSING PROCESS
and wasting) because of the cancer’s pathology, parenteral
nutrition may be indicated. Assessment
Activity Subjective Data
Encourage ambulation during the client’s recovery. Frequent The client will describe having a dull pain in the flank area and
rest periods are necessary even after discharge. noticing blood in the urine intermittently; however, the client
often comments that there is no difficulty in urinating. Fatigue
and weight loss are also described.
Nursing Management
Encourage client to express feelings and concerns about diag- Objective Data
nosis. Observe for signs of grieving. Answer questions hon- Observe client for weight changes. Monitor vital signs and diag-
estly. Assess neurologic status, lung sounds, peripheral pulses, nostic test results. Assess the client’s lung sounds for possible
and vital signs. Accurately record I&O. Provide preoperative respiratory distress resulting from metastases. Hematuria may
teaching. be present. A mass may be palpated in the client’s flank area.

Nursing diagnoses for a client with renal tumors include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fatigue related The client will understand Discuss with client that fatigue is a result of blood loss in the urine
to disease process and reason for fatigue and not and growth of the tumor.
treatment feel guilty for taking rest Because there is increased fatigue following any surgery, plan
periods. nursing care so the client will have several periods of uninterrupted
rest each day.

Anticipatory Grieving The client will maintain Actively listen to what the client says. Encourage the client to
related to diagnosis, open communications express feelings about the diagnosis and treatment.
treatment, and prog- with family and health Observe for signs of grieving such as crying, denial, anger, or
nosis care members. withdrawal. Answer questions honestly.
Assist client in identifying strengths and coping skills.
Make referrals to other professionals as needed.

Deficient Knowledge The client will verbalize Inform client of the assessments to be done: neurological status,
related to limited understanding of informa- lung sounds, the incision, Homans’ sign, peripheral pulses, vital
information of disease tion taught. signs, and serum electrolyte values.
process and treatment Teach the importance of accurate intake and output records.
regimen
Provide routine preoperative teaching.
Encourage client to eat a well-balanced diet to
enhance healing.
Instruct client not to wash off the skin markings if radiation
therapy is being used.
Teach the name, purpose, dosage, schedule, and side effects
of all medications and the importance of drinking plenty of fluids
and ambulating as tolerated.
Inform client and family of community resources and support
groups.
Point out the importance of following the instructions for care
when discharged and keeping physician appointments.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 8 Urinary System 259

used to diagnose an obstruction. An obstruction may be

■ POLYCYSTIC KIDNEY caused by renal calculi, blood clots, edema, tumors, urethral

A
strictures, benign prostatic hypertrophy (BPH), pregnancy,
pproximately 600,000 Americans have polycystic kid- or a nerve disorder. Postrenal failure can be ruled out if there
ney disease (PKD), which is the fourth leading cause is no obstruction. If an obstruction is confirmed, relief of
of kidney failure (NIDDK, 2007c). Two major inherited the obstruction is imperative to minimize renal damage and
forms of PKD include autosomal-dominant PKD, about resolve azotemia. When postrenal failure is prolonged, both
90 % of all cases, and autosomal recessive PKD, a rare form. blood creatinine and BUN will rise.
Acquired cystic kidney disease (ACKD) is associated with
Prerenal ARF
kidney failure and dialysis. Approximately 90% of clients on
dialysis for 5 years develop ACKD (NKF, 2009d). In PKD,
multiple grape-like clusters of fluid-filled cysts develop in and Any abnormal decline in kidney perfusion that reduces glomeru-
greatly enlarge both kidneys. They compress and eventually lar perfusion can cause prerenal failure. Common causes include
replace functioning kidney tissue. PKD has an insidious onset extremely low blood pressure from severe bleeding, infection,
that becomes obvious between 30 and 50 years of age. shock, congestive heart failure, myocardial infarction, or severe
Early symptoms include hypertension, polyuria, and dehydration. Fluid volume status does not indicate perfusion.
urinary tract infections. Flank pain and headache are com- Effective arterial blood volume (EABV) is the amount of fluid in
mon. Recurrent hematuria and proteinuria develop. Diagno- the vascular space that effectively perfuses the kidneys. Even in
sis is made by x-ray or sonogram showing the cysts. BUN and fluid volume excess situations, such as low cardiac output caused
creatinine are used to monitor kidney function. by heart failure, the EABV falls, causing prerenal failure. The
The goal of medical management is to preserve kidney kidney interprets a fall in EABV as fluid volume deficit.
function, prevent infections, and relieve pain. Hypertension The glomeruli are then unable to filter waste from the
is carefully managed with antihypertensive medications, blood. The renal tubules are structurally intact, and the kid-
diuretics, and fluid and dietary modifications. Eventually, neys can resume normal functioning if perfusion is restored
dialysis or renal transplantation may be needed. fairly quickly. Ischemia results from prolonged inadequate per-
fusion, which can cause acute tubular necrosis (ATN).
The client generally has pale, cool skin; orthostatic
RENAL FAILURE hypotension; and oliguria. The BUN-to-creatinine ratio

A
increases from 10:1 to more than 20:1. This increase occurs
ccording to the NIDDK (2006), any acute or chronic because of greater reabsorption of urea when fluids flow
loss of kidney function is called renal failure and is the slowly through the tubules. A urinalysis shows a low sodium
term used when some kidney function remains. Total, or level (<20 mEq/L), high osmolality (>500 mOsm/L), and
nearly total, and permanent kidney failure is called ESRD. It high specific gravity (>1.020). This results because the kid-
may take only a few days or weeks to lose renal function or it neys are retaining sodium and water in an attempt to correct
may deteriorate slowly over decades. Disorders of renal failure the perceived fluid volume deficit.
are either acute or chronic. When the client truly has a fluid volume deficit, treatment
consists of intravenous fluids and albumin, plasma, or blood
to restore the EABV. When the cause is inadequate cardiac
■ ACUTE RENAL FAILURE output, inotropic agents such as dobutamine hydrochloride

T
(Dobutrex) or amrinone lactate (Inocor) are used.
he rapid deterioration of renal function with rising blood
levels of urea and other nitrogenous wastes (azotemia)
is termed acute renal failure (ARF). The nephrons are unable Intrarenal ARF
to regulate the fluid and electrolyte or the acid–base balance of Tissue damage of the glomeruli and/or tubules causes a loss of
the blood. Predisposing factors include acute glomerular dis- renal function known as intrarenal ARF. Glomerulonephritis
ease; severe, acute kidney infection; decreased cardiac output; and ATN are the main reasons for renal tissue damage. The
trauma; or hemorrhage. antigen/antibody complexes formed in glomerulonephritis
There are three major forms depending on the location become trapped in the basement membrane, where they cause
of the cause: postrenal ARF (disrupted urine flow), prerenal inflammation. The glomeruli then become more permeable,
ARF (disrupted blood flow to the kidney), and intrarenal so red blood cells and protein are allowed to enter the filtrate
ARF (renal tissue damage). Both postrenal ARF and prer- and ultimately the urine.
enal ARF are reversible situations if they are identified early Most intrarenal failure cases are caused by ATN and
and treatment is begun. Undiagnosed postrenal ARF and are the most common cause of nosocomial acute renal
prerenal ARF lead to intrarenal ARF. Diagnostic testing to failure. ATN is the result of ischemia or toxic insult to the
identify the cause of ARF includes an ultrasound, CT scan, renal tubules. Ischemia may result from untreated prerenal
MRI, and, on occasion, a kidney tissue biopsy. failure or severe hypoxemia. Radiographic contrast dye, pig-
ments (myoglobin and hemoglobin), aminoglycoside and
Postrenal ARF cephalosporin antibiotics, and NSAIDs are all nephrotoxic
(substances that causes kidney tissue damage) and can cause
Postrenal ARF is caused by an obstruction. It should be acute tubular necrosis.
checked out first when a client has an unexplained decrease The BUN-to-creatinine ratio in acute tubular necrosis
in urine output or has anuria. Kidney function can be easily is usually normal between 10:1 and 15:1; however, both the
restored by removing the obstruction. Urine volume will BUN and creatinine are greatly elevated. For example, the
vary depending on the location and degree of obstruction. BUN may be 70 mg/dL and the creatinine 7 mg/dL. Urine
Catheterization, ultrasound, and retrograde pyelogram are sodium is more than 40 mEq/L, urine osmolality less than
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260 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Dialysis is now an early treatment in ATN. Homeostasis is

maintained while the cause of ATN is determined and treated.
CLIENTTEACHING Permanent kidney damage may thus be averted. See the sec-
Acute Renal Failure tion on dialysis later in this chapter.
Teach clients at risk for ARF (older clients; diabetic Surgical
clients; and clients with renal, heart, or liver dis-
The obstructions causing postrenal failure are often removed
ease) to:
surgically. The exact procedure will depend on what type of
• Immediately report to health care provider obstruction is present and its location.
signs of fluid retention, pain on urination, and
changes in urine output (amount or appear- Pharmacological
ance).
Drugs used to treat acute renal failure include antihyper-
• Avoid chronic use of and high doses of NSAIDs. tensives, diuretics, cardiotonics (inotropics), phosphate-
• Follow sodium and fluid restrictions as pre- binding antacids, potassium-lowering agents, and electrolyte
scribed. replacement. It is important to ensure that drugs used are
• Advise all health care providers of condition. not nephrotoxic. See Table 8-3 for drugs used in acute renal
failure.

Table 8-3 Drugs Used in Acute Renal

300 mOsm/L, and specific gravity less than 1.010. There are Failure
three phases to the clinical course of ATN: oliguric/nonolig-
uric, diuretic, and recovery. The first phase is either oliguric DRUGS NURSING
or nonoliguric depending on the causative factor. RESPONSIBILITIES
Antihypertensives Monitor BP and pulse, weigh
Oliguric/Nonoliguric Phase methyldopa (Aldomet) daily, monitor for postural
A nonoliguric phase is usually seen when nephrotoxic agents hypotension and K, Na, Cl,
are the causative factor. When adequate urine output is main- minoxidil (Loniten) and CO2 levels, I&O.
tained, dialysis is needed less often, and the morbidity and clonidine HCl (Catapres)
mortality rates are lower.
An oliguric phase, which may last 1 to 2 weeks, is seen hydralazine HCl
more often when ischemia is the causative factor. Oliguria, (Apresoline)
voiding less than 400 mL/24 hours, can cause fluid volume Diuretics Monitor output, maintain
overload; electrolyte imbalance, specifically high potassium fluid restrictions, weigh client
and phosphorus, and low sodium and calcium; metabolic furosemide (Lasix)
daily.
acidosis; and uremia. hydrochlorothiazide
(HydroDiuril)
Diuretic Phase
The diuretic phase is seldom seen because early dialysis keeps Cardiotonics/inotropics Assess apical pulse before
extracellular fluid volume at a fairly normal level. If it were digoxin (Lanoxin) giving, report blood level of
seen, there would be a tremendous increase in urine output. digoxin, monitor BP and P,
amrinone lactate (Inocor) monitor blood level of potas-
Recovery Phase sium.
As renal function begins to improve, the client’s urine output Phosphate-binding Monitor serum potassium,
returns to normal and serum and urine laboratory test values antacids assess BP and P, and for
move closer to normal. There is usually a short period of rapid constipation.
improvement and then a period (may be several months) of aluminum hydroxide
slower improvement. Some clients will have residual renal gel (Amphojel)
insufficiency and a few will require long-term dialysis.
Potassium Monitor serum potassium,
exchange assess BP and P, and for
Medical–Surgical sodium polystyrene constipation.

Management sulfonate
COURTESY OF DELMAR CENGAGE LEARNING

(Kayexalate)
Medical
Acute renal failure is often reversible, and complications can Electrolyte Monitor blood calcium and
be prevented with early diagnosis and treatment. The goal is replacement phosphate levels, report
to have kidney function stabilized and returned to normal. calcitrol (Rocaltrol) metallic taste.
Problems to be alert for are fluid volume overload, electrolyte
imbalances, metabolic acidosis, high rate of catabolism, ure- calcifediol (Calderol)
mia, hemotologic abnormalities, and infection.

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 CHAPTER 8 Urinary System 261

Diet CRITICAL THINKING

Restrictions generally include sodium, potassium, phos- Assessment Scenario
phorus, protein, and fluids. The amounts allowed are based
on the laboratory tests results. Carbohydrates and fats are A 52-year-old male client has been admitted to
increased to be sure energy needs are met and protein will the hospital for chest pain. After a couple of days
be spared as a source of energy. Clients with a high rate of
in the hospital, the nurse notices the client has a
catabolism often require total parenteral nutrition (TPN) to
total urinary output of 325 mL in 24 hours and has
provide adequate nutrition.
edema in both ankles. The lab results for this client
are: sodium 130 mEq/L, BUN 28, and serum creati-
Activity nine 2.5.
Because the client is often weak and may also be con-
1. What might be going on with the client at this
fused, activity is restricted during the initial phase of acute
time?
renal failure. As recovery becomes evident, ambulation is
begun. 2. What is significant about the client’s lab
results?

Nursing Management 3. What type of diet may this client need to be

on? Why?
Accurately record I&O (often hourly). Monitor vital signs,
BUN, creatinine, and serum electrolytes and protein. Weigh
client daily. Assess skin turgor, lung sounds, and jugular vein
distention. Provide fluids within prescribed limits. Ask dieti-
tian to discuss dietary restrictions with client. Provide or assist
Objective Data
with oral hygiene before meals. Listen to client’s concerns. Physical findings will depend on how far the disease process
has progressed. Assess for hypertension, GI bleeding and/or
bruising, reduction in urine output, anasarca, poor skin turgor,
NURSING PROCESS and dry mucous membranes because vomiting or diarrhea can
Assessment
cause dehydration. In a severe stage, the client may be drowsy
and have muscle twitching and convulsions.
Subjective Data The BUN and serum creatinine will be elevated, as are
The client may describe diarrhea; nausea, possibly with vom- the serum electrolytes potassium and phosphorus. The serum
iting; swelling; loss of appetite; headache; increasing fatigue; electrolyte calcium will be low. Blood level of red blood cells
and/or a change in mental alertness. Anxiety and fear related will decrease as the production of erythropoietin decreases.
to not knowing what is happening is often expressed. Leukocyte level will increase in the presence of an infection.

Nursing diagnoses for a client with acute renal failure include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Excess Fluid Volume The client will maintain a Monitor BUN, creatinine, and serum electrolyte and protein levels.
related to sodium and stable fluid volume. Accurately measure urine output, often on an hourly basis.
water retention Parameters are often set for notification of the physician.
Weigh daily to identify weight gain related to fluid retention. One
pound of weight gain is equivalent to 500 mL of retained fluid.
Assess skin turgor, edema, BP, lung sounds, jugular vein disten-
tion, pulse and respiratory rate and quality.
Provide fluids within the prescribed limits. Teach client about
importance of fluid restrictions.

Impaired Nutrition: The client will have Arrange for a dietary consultation to provide food in keeping with
Less than Body stabilized weight within the prescribed restrictions and client preferences, including
Requirements related normal limits. cultural and religious factors.
to anorexia, dietary Suggest 6 small meals throughout the day.
restrictions, and
increased catabolism Offer antinausea medications before meals.
Provide or assist with oral hygiene prior to meals.
Monitor weight and serum albumin level weekly
(Continues)

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262 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with acute renal failure include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to the The client will verbalize Establish rapport with the client. Listen to the client’s concerns.
disease process anxieties with the family Maintain open communications to foster expression of anxieties.
and health care workers.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Acute Renal Failure

R.H., age 65, has had a history of heart trouble for several years. He is admitted because he has urinated
very little for 2 days, he gets dizzy when he gets up from lying down, and he cannot get his shoes on be-
cause his feet are “fat.” He states that he does not know what is happening to him. Results of laboratory
tests are BUN 90 mg/dL, creatinine 4 mg/dL, urine sodium 15 mEq/L, and urine specific gravity 1.030.
NURSING DIAGNOSIS 1 Excess Fluid Volume related to sodium and water retention as evidenced
by “fat feet,” urine sodium 15 mEq/L, and urine specific gravity 1.030
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Fluid Balance Electrolyte Management
Electrolyte & Acid–Base Balance Fluid Management

PLANNING/OUTCOMES INTERVENTION RATIONALE

R.H. will have reduced fluid vol- Accurately measure and record Provides information about re-
ume excess. intake and output. tention of intake.
Weigh R.H. daily—same time, Allows weight comparisons.
scale, clothes.
Assess skin turgor, edema, BP, Provides information about
lung sounds for crackles. fluid in tissue, lungs, or vascular
system.
Monitor BUN, creatinine, and Gives insight to kidney
serum electrolyte and protein functioning.
levels.
Administer inotropics or cardio- Strengthens heartbeat, which will
tonic medications as ordered. give better perfusion to kidneys.
Provide fluids within prescribed Prevents fluid excess.
limits.

EVALUATION
R.H.’s feet are no longer “fat.” His urine sodium is 18 mEq/L and urine specific gravity is 1.027

NURSING DIAGNOSIS 2 Impaired urinary Elimination related to decreased perfusion as evidenced

by his urinating very little for 2 days and BUN–creatinine ratio of 22.5:1
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Urinary Elimination Urinary Elimination Management
Knowledge: Disease Process Teaching: Disease Process

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 CHAPTER 8 Urinary System 263

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
R.H. will increase amount of uri- Administer diuretics as ordered. Increases water elimination by
nation to 1,200 mL/day. enhancing sodium excretion by
the kidneys.
Accurately measure and record Provides information about fluid
intake and output. movement through the body.

EVALUATION
R.H. is urinating 1,000 mL/day. His BUN is 50 mg/dL and creatinine is 3 mg/dL.

NURSING DIAGNOSIS

Anxiety related to the disease process as evidenced by his statement that he does not
know what is happening to him

Nursing Outcomes Classification (NOC): Acceptance: Health Status

Nursing Interventions Classification (NIC): Teaching: Individual

CLIENT GOAL EVALUATION

R.H. will have less anxiety by understanding R.H. says that he feels better knowing what is
what is happening to him happening.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Establish rapport with R.H. 1. Begins a therapeutic nurse-client

relationship.
2. Encourage him to express his fears and 2. Some people need encouragement to
anxieties. express feelings and concerns.

3. Provide R.H. with information, at his 3. Understanding reduces anxieties.

level of understanding, about what is
happening to his body, why I&O and
weighing daily are important.

Concept Care Map 8-1

Renal erythropoietin decreases, causing anemia. Hyper-

■ CHRONIC RENAL FAILURE/ tension, acidosis, and glucose intolerance usually are also
END-STAGE RENAL DISEASE present. Urea in the blood is extremely elevated. As the disease

C
progresses, uremia develops.
hronic renal failure is a slow, progressive condition in There are three stages of chronic renal failure: reduced
which the kidney’s ability to function ultimately dete- renal reserve, renal insufficiency, and end-stage renal disease
riorates. This condition is not reversible. The kidneys have an (ESRD). Symptoms of reduced renal reserve are not appar-
amazing capability to perform effectively, even though most of ent until more than 40% of the nephrons fail. A prolonged
the nephrons are destroyed. urine concentration test or a decline in GFR may be the only

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264 UNIT 3 Nursing Care of the Client: Digestion and Elimination

evidence of reduced renal reserve. When 75% of the nephrons

stop functioning, renal insufficiency occurs. BUN and crea- Table 8-4 Effects of Chronic Renal
tinine are above normal, and the client may have nocturia Failure by Body System
and polyuria. The onset of ESRD occurs when at least 90%
of the nephrons fail: BUN and creatinine levels rise, polyuria SYSTEM EFFECT
changes to oliguria, and severe fluid and electrolyte imbal- Urinary Oliguria from renal insufficiency
ances are evident.
When the kidneys become unable to filter blood, an Azotemia
alternate method for filtration is necessary. Lifetime dialysis
becomes inevitable unless kidney transplantation is per- Blood Anemia from decreased red blood cell
formed and is successful. Life expectancy varies with the production
initial cause of chronic renal failure and the person’s overall Decreased platelet activity, causing
health at the time of diagnosis. bleeding tendency
According to the National Kidney Foundation (2008),
485,000 Americans have ESRD. There are numerous causes Cardiovas- Hypervolemia and tachycardia
of chronic renal failure. The four leading causes are diabetes cular Hypertension and dysrhythmias from
mellitus 45%, hypertension 27%, glomerulonephritis 8.2%,
and polycystic kidney 2.2% (NKF, 2008). Nephrotoxic hyperkalemia
drugs, including some over-the-counter drugs, aggravate the
Respiratory Dyspnea, pulmonary edema
situation.
The diagnosis is confirmed when the BUN is at least 50 Hyperventilation from metabolic acidosis
mg/dL and the serum creatinine level is greater than 5 mg/dL. Eventually Kussmaul respirations

Medical–Surgical Gastrointes- Urea in the blood is converted to

Management tinal ammonia by the mouth, causing uremic

halitosis
Medical Hiccups, anorexia, and nausea from
Chronic renal failure is a multisystem disease process. See edema within the gastrointestinal tract
Table 8-4 for the effects of chronic renal failure on various
body systems. Medical management focuses on preserving Skin Dry skin with pruritis from uremic frost
the remaining kidney function as long as possible and pre- (excretion of urea through the skin with
venting complications. This helps preserve the integrity of an odor of urine); pallor with anemia,
yellowish-brown skin color

Nervous Lethargy, headaches, confusion, impaired

concentration with disorientation, depres-
CLIENTTEACHING sion, decreased level of consciousness,
Herbal Facts for Renal Clients sleep disturbances, and uremic encephal-
opathy resulting in seizures and coma
Use of herbal supplements may be unsafe for renal
clients because their bodies are unable to clear Sensory Peripheral neuropathy with numbness
waste products effectively. Listed below are facts and tingling of extremities with com-
about herbs that every renal client should know plaints of a prickly, crawling feeling in the
(NKF, 2009e): feet and legs, especially at night, sleep
• The government does not regulate herbal sup- problems
plements, so the exact contents and affects are
unknown. Reproduc- Decrease in libido
tive Decreased sperm count
• Many herbs can interact with prescription drugs.
• Check with the physician, dietitian, or pharma- Amenorrhea
cist regarding safety, dosage, duration of use, Impotence
interaction with prescription drugs, etc. for all
herbal products. Delayed puberty
• Any interaction between herbs and medications Musculosk- Joint pain and muscle cramping/twitching
could potentially put a transplant client at risk eletal Bone demineralization from
for rejection or losing the kidney.
COURTESY OF DELMAR CENGAGE LEARNING

• Herbs that may be toxic to the kidneys are Hypocalcemia

artemisia absinthium (wormwood plant), peri-
Immune Greater chance of infections from
winkle, autumn crocus, tung shueh, chuifong
tuokuwan (Black Pearl), vandelia cordifolia, and immunosuppression
horse chestnut. Decrease in antibody production

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 CHAPTER 8 Urinary System 265

the person’s life. Fluid retention increases the risk of complica- bananas, sweet potatoes, spinach, products with tomatoes,
tions such as edema (ascites), hypertension, and heart failure. oranges, chocolate, artichokes, avocados, pumpkins, and
Electrolytes are monitored and regulated. mushrooms.

Pharmacological Activity
The client is encouraged to participate in activities of daily liv-
Antihypertensives such as methyldopa (Aldomet) and pro- ing. Safety becomes a significant factor during periods when the
pranolol hydrochloride (Inderal) are used to control hyper- client has weakness, fatigue, or mental confusion. Confusion is
tension. Diuretics such as furosemide (Lasix) are used to seen in clients who have uremic encephalopathy. When bed rest
treat fluid retention; anticonvulsants, phenytoin (Dilantin) is required, turning, ROM exercises, and skin care are impor-
to control seizures; antiemetics, prochlorperazine (Com- tant. As symptoms continue to become more severe, the client
pazine) to control vomiting; and antipruritics, cyprohepta- will need total assistance for all ADLs.
dine hydrochloride (Periactin) to control itching. Calcium
acetate (Phos-Lo) is used to lower the phosphate level in the
blood; however, it can be constipating. A low renal erythropoi- Nursing Management
etin level causing anemia is often treated with epoetin alpha Monitor daily weight, skin turgor, vital signs, and lung sounds.
(Epogen). An iron supplement is used to decrease the anemia- Provide prescribed amount of fluids and accurately record
related symptoms. Multivitamins with folic acid are used intake and output (sometimes hourly). Assist with or pro-
because dialysis promotes the loss of water-soluble vitamins. vide oral hygiene before meals and as needed. Administer an
antiemetic 30 minutes before meals. Arrange for a dietitian
Diet to plan meals with the client. Assist with or provide bathing
Diet restrictions are similar to those in acute renal failure. frequently, followed by applying lotion on the skin. Encourage
Sodium, potassium, phosphorus, and protein are restricted. repositioning at least every 2 hours, ROM exercises, and use
Fluids are also limited. Modifications are made as kidney of an egg-crate mattress or Clinitron bed. Monitor for mental
function deteriorates. With consistent compliance, symp- confusion. Refer client and family to the National Kidney
toms decrease, resulting in fewer complications. Resources Foundation website at www.kidney.org for more information.
are available for clients to obtain assistance with dietary
restrictions. Meal ideas are published in newsletters such as
NephroNotes. Long-term dietary compliance is a challenge,
and daily activities as well as special events during the year NURSING PROCESS
are a continual reminder of the client’s dietary restrictions.
As with other chronic diseases, those with renal failure need Assessment
to have all family members and friends encouraging them to Subjective Data
adapt to their restrictions. Dietitians can assist the family to Inquire about the client’s past medical history including treat-
incorporate religious and cultural dietary practices. The per- ments for maintenance of renal disease. Take a complete medi-
son with chronic renal failure may also have to incorporate cation history, including the use of over-the-counter drugs.
dietary guidelines for additional diagnoses such as diabetes Description of fatigue, joint pain, severe headaches, nausea,
mellitus and/or coronary artery disease. anorexia, some chest pain, intractable singultus (hiccups),
With the progression of chronic renal disease, dialysis decreased libido, menstrual irregularities, and impaired concen-
becomes necessary. Fluid restrictions must be followed, tration is given by the client. The client may feel uncomfortable
and the amount allowed divided throughout the day. The talking directly to the nurse if uremic halitosis is a problem.
greatest amount of fluid should be allowed during the day,
incorporating enough fluids with oral medications. Some
fluids should be planned for the evening meal, with a small Objective Data
amount to be allowed during the night; for example, days— Note changes in the client’s neurological status such as reduced
500 mL, evenings—200 mL, and nights—100 mL. Protein alertness and awareness. Kussmaul respirations appear as
restriction is closely monitored and regulated with the coma develops. Halitosis with a urine odor and “uremic frost,”
blood albumin level. The development of hyperkalemia will a white powder on the skin, result from the accumulation of
lead to a diet restricted in potassium. Foods high in potas- urates. Observe for dark-colored urine and bloody or tarry
sium include dried fruits or dried beans and peas, peanuts, stools, which could indicate bleeding in the intestinal tract.

Nursing diagnoses for a client with ESRD include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Excess Fluid Volume The client will understand Monitor daily weight, intake and output (maybe hourly), skin
related to compromised the importance of prescribed turgor, edema, blood pressure, respirations, and lung sounds.
renal mechanism (restricted) fluid amounts. Provide prescribed amounts of fluids. Teach client to plan
nutritional and fluid intake within the prescribed amounts.
Monitor laboratory reports for serum albumin level and serum
electrolyte levels.

(Continues)
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266 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Nursing diagnoses for a client with ESRD include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: The client will stabilize Provide or assist with complete mouth care before meals
Less than Body Require- weight within normal limits because uremic halitosis leaves a metallic taste in the client’s
ments related to dietary and participate in dietary mouth.
restrictions, GI distress, plan. Provide a clean, quiet, odor-free environment for meals.
anorexia
Suggest 6 small meals throughout the day. Encourage self-
feeding.
Arrange a consultation with the dietitian to plan alternate
ways to prepare foods allowed on the diet.
Ask the family to bring favorite foods, within the dietary
restrictions, from home.
Administer antiemetics 30 minutes before meals to control
nausea.

Risk for Impaired Skin The client will maintain skin Bathe skin frequently to remove “uremic frost.” Encourage
Integrity related to altered integrity. the use of emollients and lotions on the skin.
metabolic state leading to Administer antihistamines, as ordered, for the temporary
pruritis from “uremic frost” relief of itching.
Assist the client to change position every 2 hours. Provide an
egg-crate mattress or Clinitron bed.

Ineffective Coping related The client will verbalize feel- Encourage the client to discuss feelings about long-term
to uncertainty of long-term ings and intention to comply lifestyle changes.
compliance of the treat- with treatment. Refer client to the National Kidney Foundation website at
ment regimen www.kidney.org for information about client services and
treatments for diseases of the kidney.
Include the client and family in rehabilitation and discharge
planning to ensure compliance. Topics for these sessions
include diet, rest, medications, fluid restrictions, intake and
output, activities, dialysis, required lab tests, and frequent
visits to the physician.
Incorporate into the discharge planning and teaching the
client’s socioeconomic needs, cultural background, role in
the family unit, accessibility to medical care, and anticipated
follow-up care.
Complete referrals before discharge to lessen client anxiety.

Consider future needs of a newly diagnosed client with end-

stage renal disease and include the availability of dialysis, vo-
cational rehabilitation, home health care, financial assistance
with medical needs, and psychological therapy for the client
and family.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

sion of wastes, drugs, and excess electrolytes and/or osmosis of

DIALYSIS water across a semipermeable membrane into a dialysate solu-
As the kidneys continue to deteriorate, nitrogenous waste prod- tion. The dialysate is a solution designed to approximate the
ucts accumulate in the circulatory system. These waste products normal electrolyte structure of plasma and extracellular fluid.
need to be removed artificially with dialysis, a mechanical There are two types of dialysis: hemodialysis and perito-
means of removing nitrogenous waste from the blood by imitat- neal dialysis. These treatments can be obtained throughout
ing the function of the nephrons. It involves filtration and diffu- the country at dialysis centers or at hospital dialysis units.

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 CHAPTER 8 Urinary System 267

Hemodialysis Nearest adjacent vein

Hemodialysis is performed by a machine with an artificial semi-

permeable membrane used to filter the blood. This machine
is often referred to as an artificial kidney. A graft or fistula is
surgically prepared to access the client’s circulatory system.
Figure 8-11 illustrates several ways this can be done. With each
hemodialysis treatment, a catheter is inserted into the graft or
Arteriovenous fistula
fistula. The client’s blood is circulated through the semiper- Artery
meable membrane (Figures 8-12 and 8-13). Excess fluids are
removed by osmosis, and by-products of protein metabolism, Edges of incision in artery and vein are
sutured together to form a common opening.
especially urea and uric acid, as well as creatinine, drugs, and
excess electrolytes, are removed from the blood by diffusion or
Venous cannula
filtration. In return, the client receives fluids, electrolytes, and installed in vein
blood products, as necessary. The solution (dialysate) is espe-
cially prescribed to meet the client’s metabolic needs.
For the entire process, Standard Precautions must be
followed and strict asepsis maintained. The client is weighed
before and after each dialysis session to determine if fluid is
being retained. It is important to keep the client comfortable
and provide diversionary activities during the treatment. Arteriovenous shunt Arterial cannula
Hemodialysis is usually performed 3 times a week and takes 3 installed in artery
to 4 hours each time.
The graft or fistula site requires strict aseptic care and
must be assessed daily for signs of infection: redness, swelling,

COURTESY OF DELMAR CENGAGE LEARNING

or drainage. Assess circulation through the site by palpation or
feeling the area and/or listening with a (Doppler) stethoscope.
A thrill should be felt and/or a bruit should be heard. Lack of
these signs may indicate a blood clot, which requires immediate
surgical attention. Patency must be documented. Assess pulses
Arteriovenous vein graft
peripheral to the graft site.
Blood pressure and blood draws are never done on the Ends of natural or synthetic graft sutured
extremity where the graft or fistula is placed. Also, restraints or into an artery and a vein.
intravenous solutions are never applied to or inserted into that
extremity. All health care personnel should know the location
Figure 8-11 Types of Hemodialysis Access Sites
of the hemodialysis access site. These sites should not be used
for any other purpose than dialysis.

COURTESY OF DELMAR CENGAGE LEARNING

Figure 8-12 Client Receiving Hemodialysis

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268 UNIT 3 Nursing Care of the Client: Digestion and Elimination

Dialyzer inflow
pressure monitor Various PROFESSIONALTIP
Heparin pump pressure monitor
(to prevent
dotting) Nutrition for Dialysis Clients
Dialyzer Air trap and Dialysis clients need to follow strict dietary and
air detector
fluid guidelines. Listed below is information and
Air detector
damp discussion of several of these guidelines.
• Refer the client to a dietitian. A dietitian with
Clean blood
Artertal returned to special training in care for kidney health is
pressure body called a renal dietitian.
monitor Blood removed
Blood pump • Monitor and record how much fluid the client
for cleansing
drinks and ensure that fluid restrictions are
Figure 8-13 Hemodialysis (Adapted from National Institute followed as ordered by the physician.
of Diabetes and Digestive and Kidney Diseases 2006, Treatment • Teach client to limit or avoid sodium and to eat
Methods for Kidney Failure: Hemodialysis.) fresh foods that are naturally low in sodium.
• Potassium levels can rise between dialysis
sessions and affect the client’s heartbeat.
Because most medications are removed during dialysis, they
are generally not administered until after the dialysis session. Evaluate serum potassium levels and assess client
Vancomycin hydrochloride (Vancocin) is not removed during for cardiac arrhythmias.
dialysis and so is often used. If the client is hypertensive before • Educate client that foods high in potassium
dialysis, nifedipine (Procardia) is given because of its fast action. must be avoided or limited as ordered (refer
Possible complications include hemorrhage, infection, to Chapter 24 for a listing of foods high in
and emboli formation. Some factors for the client and family potassium). Potassium can be reduced from
to consider about hemodialysis are the distance they must potatoes and other vegetables by peeling and
travel to the dialysis center, the expense, the time involved, soaking them in a large container of water for
and the presence of a permanent arteriovenous (AV) line.
several hours, then dicing or shredding, and
Clients can be taught to do their own hemodialysis at a cen-
ter. Portable units are being developed to make hemodialysis cooking in fresh water (Figure 8-14).
more usable in the client’s home. This is a growing trend with • Teach client that foods high in phosphorus
home health care. should be avoided. The client will probably need
Continuous renal replacement therapy (CRRT), a slow, to take a phosphate binder such as Renagel,
gentle form of dialysis, is available. PhosLo, Tums, or calcium carbonate with food
to control the serum phosphorus level between

Peritoneal Dialysis
dialysis sessions.
• Clients on dialysis are encouraged to eat high-
Peritoneal dialysis uses the peritoneal lining of the abdominal quality protein.
cavity as the membrane through which diffusion and osmosis
• Instruct client to not take over-the-counter
occur instead of the artificial kidney machine. It is usually
performed 4 times a day or overnight 7 days a week. A Tenc vitamin supplements as they may contain
khoff or a flanged-collar catheter is placed by the physician, vitamins and minerals that are harmful to
under aseptic conditions, into the client’s peritoneal space. dialysis clients. The physician may prescribe
The client must void just before catheter insertion to prevent a vitamin and mineral supplement such as
accidental puncture of the bladder. As with hemodialysis, Nephrocaps for the client.
weigh the client before and after each dialysis session. Also Adapted from National Institute of Diabetes and Digestive and
auscultate bowel sounds. Kidney Diseases (NIDDK), 2008, Eat right to feel right on hemo-
dialysis, retrieved July 26, 2009 from http://kidney.niddk.nih.
gov/kudiseases/pubs/eatright/index.htm

CLIENTTEACHING
Dialysis
Clients who are receiving dialysis need a significant CRITICAL THINKING
amount of teaching. All clients should have the
process thoroughly explained. Other teaching topics Peritoneal Dialysis, Hemodialysis,
are the importance of physician and laboratory vis- and Kidney Transplantation
its, and observations for which the physician needs
What are the pros and cons for peritoneal dialysis,
to be notified. Clients undergoing dialysis should
hemodialysis, and kidney transplantation?
wear Medic Alert tags stating their condition.

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 CHAPTER 8 Urinary System 269

Fresh
dialysate
solution

Peritoneal
Tenchkoff cavity
peritoneal
catheter

Adapter

COURTESY OF DELMAR CENGAGE LEARNING

Figure 8-14 Hemodialysis clients need to follow strict Used
dietary guidelines. (Courtesy of Centers for Disease Control and dialysate
Prevention/photo by Cade Martin.) solution

The dialysate, held within a sterile soft container similar

to an IV bag, is instilled aseptically through the catheter into Figure 8-15 Peritoneal Dialysis Setup
the abdominal cavity. To decrease client discomfort, the dialysate
should be at body temperature and not instilled too rapidly. Severe
pain should not be experienced. The container, still connected The main complication of peritoneal dialysis is infection.
to the catheter, is then rolled up and the dialysate remains in Strict aseptic care of the catheter site is necessary. Standard
the abdominal cavity for a specified length of time. The client is Precautions are essential in caring for the dialysis client. Figure
free to ambulate during this time. The container is then unrolled 8-15 shows a peritoneal dialysis setup.
and lowered below the abdominal cavity to allow the dialysate
to drain, by gravity, back into the container. The dialysate now
contains excess fluids, nitrogenous waste, and other impurities.
The outflow of dialysate is inspected for color, sediments, and
KIDNEY TRANSPLANTATION
amount. The fluid should be light yellow and clear enough to According to the Open Procurement and Transplantation
read the printing on the bag when placed on a white towel. Usu- Network (OPTN, 2006), 16,000 kidney transplants will be
ally 2 liters of dialysate are exchanged each time. If the outflow performed in 2006. Transplants are either from a live donor
does not at least equal the inflow, the client is asked to turn from (usually a relative) or a cadaver. There are approximately 76,000
side to side to increase the outflow. persons on the waiting list for a kidney transplant (United Net-
Peritoneal dialysis may be performed manually by the work for Organ Sharing, 2008).
nurse, client, or family member as just described; by a cycler Before being placed on the nationwide donor waiting
machine; or by continuous ambulatory peritoneal dialysis list, the client with ESRD must be tissue- and blood-typed to
(CAPD). The cycler machine automatically completes dialysis determine a compatible donor. Insurance coverage varies for this
after sterile setup and connection; CAPD is performed by the procedure. Lack of funds does not exclude anyone from needed
client. After the dialysate is aseptically installed, the empty bag care. Since 1973, an amendment to the Social Security Act
is rolled up under the clothing, and the client can go about nor- allows Medicare to pay 80% of the cost for treating ESRD clients,
mal activities. Every 6 to 8 hours, the solution is drained into regardless of age, including dialysis and kidney transplantation.
the bag, which is then discarded following standard precaution When a donor kidney becomes available, the client is
guidelines. A new bag of dialysate is attached and instilled. This transported to the transplant medical center. The donor kidney
provides continuous dialysis 24 hours per day, 7 days per week. can be preserved for 36 hours in solution or up to 72 hours if
The client’s lifestyle is only minimally disrupted. Peritoneal it is attached to an irrigating pump with perfusion maintained
dialysis is less expensive, easier to perform, less stressful for the while en route to the recipient. Through a lower abdominal
client, and almost as effective as hemodialysis. incision, the surgeon attaches the donor kidney to the client’s

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270 UNIT 3 Nursing Care of the Client: Digestion and Elimination

blood supply. The donor kidney is usually placed in the iliac

fossa anterior to the iliac crest. The donor ureter is anastomosed
(surgical connection of tubular structure) to the client’s ureter
or surgically implanted into the client’s urinary bladder (Figure
8-16). Generally, the client’s nonfunctioning kidney is left in
place to reduce the postoperative risk of hemorrhage.
After a couple days of bed rest, the client is allowed increas-
ing activities and, if no complications occur, is discharged in
1 to 3 weeks. Routine nursing care includes monitoring urine Diseased
kidneys
output, blood tests, vital signs, and level of consciousness. Vein
Encourage turning, coughing, and deep breathing. Assess the
incision to ensure that wound closure is intact. In addition, Artery
Transplanted
assess for rejection. kidney

Organ Rejection Transplanted

Signs of rejection include generalized edema, tenderness ureter
over the graft site, fever, decreased urine output, hematuria, Bladder
edema (extremities or eyes), weight gain, oliguria or anuria,
and/or an increase in feeling tired. The BUN and creatinine
Figure 8-16 Kidney Transplantation (Adapted from
will be elevated. National Institute of Diabetes and Digestive and Kidney Diseases,
Immunosuppressive drug therapy is begun to decrease 2006, Treatment Methods for Kidney Failure: Transplantation.)
the chance of organ rejection. These drugs include azathio-
prine (Imuran), cyclophosphamide (Cytoxan), cyclosporine
(Sandimmune), and corticosteroids such as prednisone (Met-
icorten). The scheduling and dosage of these drugs vary with Complications
acceptance of the donor kidney and the side effects exhibited The greatest complication in renal transplantation is infec-
by the client. People continue to survive many years with a tion. The immunosuppressive therapy to prevent rejection
kidney transplant and maintain a quality life. of the kidney increases the risk and masks the usual signs of
Researchers at the University of Cincinnati have discovered infection. The client and family must learn how to recognize
a new therapy for transplant clients. The cancer drug, borte- these signs of infection. There will be only a slight increase in
zomib, used for cancer of plasma cells, is effective in treating and/ temperature, development of a cough, low back pain, cloudy
or reversing rejection episodes that do not respond to standard urine, or wound drainage. The client must always monitor
therapies (American Association of Kidney Patients, 2009). urine output.

CASE STUDY
A.R., 56, is a client in the extended care facility. She has amyotrophic lateral sclerosis (ALS) with muscle weakness
that has progressed and involves her legs and arms. A hydraulic lift is used to transfer her out of bed. A student
nurse and a classmate enter with the lift to assist A.R. OOB, when she asks to use the bedpan. As they help her
onto the bedpan, they recall that the staff nurse gave A.R. the bedpan about a half hour ago. Returning in a
few minutes, they help A.R. off the bedpan and notice the urine is cloudy with a foul odor. A.R. is not on I&O;
however, they notice that there is a very small amount of urine. She tells them that she does not know why she is
going to the bathroom so often and why her urine smells bad.
The following questions will guide your development of a nursing care plan for the case study.
1. What subjective data should be gathered? What objective data should be gathered?
2. List diagnostic tests that may be ordered.
3. Write two nursing diagnoses for A.R., related to her cystitis/UTI.
4. Write a goal related to each of A.R.’s nursing diagnoses.
5. List pertinent nursing actions for the care of A.R. for each of the following areas as they relate to the cystitis/UTI:
elimination—bladder
diet and fluids
safety, comfort, and rest
teaching (client and nursing staff)
6. List two classifications of medications used for the treatment of an UTI.
7. List two successful client outcomes for A.R.

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 CHAPTER 8 Urinary System 271

SUMMARY
• The functions of the urinary system are reflected in their • Encourage an adequate intake of fluids for clients unless
relationship with nearly all of the systems in the body. fluids are restricted.
• Accurate intake and output is imperative for every client • Monitor laboratory test results for BUN, creatinine, and
with a urinary system disorder. electrolytes.
• Teach proper perineal care, especially to female clients of • Level of consciousness, vital signs, lung sounds, edema,
all ages, about cleansing from front to back. and urine characteristics are important to monitor.
• Diet management is important for clients with renal • Strict aseptic care is mandatory for dialysis clients.
calculi, glomerulonephritis, renal failure, and dialysis.

REVIEW QUESTIONS
1. A client has been admitted for chronic 1. “Yes, only if you have not done so today.”
pyelonephritis. She is jittery and states she is 2. “Yes, as you want to keep the procedure as clean
concerned. Which of the following signs would as possible.”
indicate potential kidney damage? 3. “No, since you just went to the bathroom.”
1. Urine output is 100 mL on your shift. 4. “No, because all the equipment is sterile.”
2. Blood pressure is decreased with a rapid pulse. 6. A client has been diagnosed with renal carcinoma.
3. Blood pressure is elevated with a decreased pulse. The client states, “My husband will leave me if I lose
4. BUN and creatinine clearance are within normal my hair from chemotherapy.” What would be the
limits. most appropriate answer for this client?
2. A male client, age 64, has had hematuria for several 1. “You seem to be concerned that your relationship
years. He is admitted to your same-day surgical unit with your husband might change.”
scheduled for cystoscopic fulguration. Postoperatively, 2. “You should focus on your disease and not your
which of the following would you anticipate? hair.”
1. Blood in the urine. 3. “Why don’t you wait and see if your husband
2. An elevated temperature. leaves you before you get too upset.”
3. Hypotension. 4. “Everything is going to be fine. Don’t worry
4. Smoky urine. about your hair loss.”
3. A male client, age 29, had impetigo 2 weeks before 7. A client has an order for a throat and skin culture;
his noting a decrease in urine output and urine what might the physician be testing for?
that “did not look right.” His admission diagnosis 1. Nephrolithiasis.
is acute glomerulonephritis. He is on intake and 2. Glomerulonephritis.
output with fluid restriction. Which of the following 3. Nephrotic syndrome.
comments indicates knowledge of his nursing care? 4. Chronic renal failure.
1. “I had my wife empty my urinal.” 8. The nurse is teaching a new hemodialysis client
2. “My urine still looks pretty bad.” about dietary restrictions. Which of the following
3. “I put my call light on so you can empty my urinal.” client statements indicates that further teaching is
4. “My wife helped me out of bed, so I urinated in needed?
the bathroom.” 1. “Peeling, dicing up, and boiling potatoes in fresh
4. A client with chronic glomerulonephritis is water when cooking helps to lower the amount of
discharged home with home health care. As the LP/ potassium.”
VN assigned to her case, you are planning her a.m. 2. “I need to eat high quality protein in my diet.”
care. While preparing the bath supplies, she says, 3. “Drinking several glasses of orange juice each day
“Please do not use any soap. My skin is so dry and will keep me healthy.”
flaky.” The rationale for this would be: 4. “I should only take vitamin supplements
1. kidney failure leads to uremia. prescribed by my physician.”
2. the bladder does not concentrate urine. 9. A client is scheduled for hemodialysis today and has
3. her blood sugar is elevated. called to see if she should take her blood pressure
4. confusion leads to comments of this nature. pills prior to coming in for the procedure. The nurse
5. A client is attending classes to be able to do his should inform the client:
own peritoneal dialysis. He states he feels well and 1. “Take your pills after your procedure is
is eager to continue to learn. He asks if washing his completed.”
hands before the procedure is important. The best 2. “It is ok to take your pills prior to coming in for
response is: your procedure.”

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272 UNIT 3 Nursing Care of the Client: Digestion and Elimination

3. “No, do not take your blood pressure pills at all, 1. Frequency and urgency of urination, flank pain,
today.” nausea, and vomiting.
4. “You can take your blood pressure pills after we 2. Chills and flank pain.
get your treatment started. I want to check your 3. Fever, nausea, vomiting and flank pain.
blood pressure first.” 4. Frequency and urgency of urination, suprapubic
10. A women presents to the urgent care center with pain, and foul smelling urine.
dysuria and hematuria, and states that she has a
history of cystitis. The nurse assesses for which of the
following symptoms that are indicative of cystitis?

REFERENCES/SUGGESTED READINGS
American Association of Kidney Patients. (2009). Cancer drug may using the appendix (Mitrofanoff procedure) for urethral cancer.
treat rejection. Retrieved April 18, 2009 from http://www.aakp. International Journal of Urology, 12(6), 581–584.
org/newsletters/Kidney-Transplant/January-2009/Drug-May- Lynch, D. (2004). Cranberry for preventions of urinary tract infections.
Treat-Rejection/ American Family Physician, 70, 2175–2177.
American Cancer Society. (2008). Cancer facts and figures 2008. Martchev, D. (2008). Improving quality of life for patients with kidney
Retrieved April 18, 2009 from http://www.cancer.org/downloads/ failure. RN 71(4), 31–36.
STT/2008CAFFfinalsecured.pdf Martin, C. (2009). Unpublished manuscript. Denver, PA.
American Cancer Society. (2009a). Detailed guide: Bladder cancer Mason, D., Newman, D., & Palmer, M. (2003). Changing UI practice:
surgery. Retrieved July 25, 2009 from http://www.cancer.org/ People have the right to be continent. AJN, 103(3), 129.
docroot/CRI/content/CRI_2_4_4X_Surgery_44.asp?rnav=cri Mayo Clinic. (2009). Glomerulonephritis treatments and drugs.
American Cancer Society. (2009b). What are the key statistics for Retrieved July 24, 2009 from http://www.mayoclinic.com/
bladder cancer? Retrieved July 25, 2009 from http://www.cancer. health/glomerulonephritis/DS00503/DSECTION=treatments-
org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_ and-drugs
statistics_for_bladder_cancer_44.asp?sitearea= McConnell, E. (2002). Protecting a hemodialysis fistula. Nursing2002,
American Cancer Society. (2009c) What are the key statistics for 32(11), 18.
kidney cancer? Retrieved July 25, 2009 from http://www.cancer. Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_ Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby.
statistics_for_kidney_cancer_22.asp?sitearea= National Association for Continence (NAFC). (2008). Prevalence.
American Cancer Society. (2009d). What are the risk factors for Retrieved from http://www.nafc.org/media/statistics/
bladder cancer? Retrieved July 25, 2009 from http://www.cancer. prevalence-2/
org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_ National Institute of Diabetes and Digestive and Kidney Diseases
factors_for_bladder_cancer_44.asp?rnav=cri (NIDDK). (2006a). Glomerular Diseases. Retrieved
American Cancer Society. (2009e). What are the risk factors for April 18, 2009 from http://kidney.niddk.nih.gov/kudiseases/pubs/
kidney cancer? Retrieved July 25, 2009 from http://www.cancer glomerular/index.htm
.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_ National Institute of Diabetes and Digestive and Kidney Diseases
factors_for_kidney_cancer_22.asp?rnav=cri (NIDDK). (2006b). Treatment methods for kidney failure:
Arbique, J. (2003). Stop UTIs in their tracts. Nursing2003, 33(6), hemodialysis. Retrieved July 26, 2009 from http://kidney.niddk.nih
32hn1–32hn4. .gov/kudiseases/pubs/hemodialysis/index.htm
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. (2008). National Institute of Diabetes and Digestive and Kidney Diseases
Nursing Interventions Classification (NIC) (5th ed.). St. Louis, MO: (NIDDK). (2006c). Treatment methods for kidney failure:
Mosby/Elsevier. transplantation. Retrieved July 26, 2009 from http://kidney.niddk
Campbell, D. (2003). How acute renal failure puts the brakes on kidney .nih.gov/kudiseases/pubs/transplant/index.htm
function. Nursing2003, 33(1), 59–63. National Institute of Diabetes and Digestive and Kidney Diseases
Castner, D., & Douglas, C. (2005). Now onstage: Chronic kidney (NIDDK). (2007a). Kidney stones in adults. Retrieved April
disease. Nursing2005, 35(12), 58–63. 18, 2009, from http://kidney.niddk.nih.gov/kudiseases/pubs/
Castina, S., Boyington, A., & Dougherty, M. (2002). Urinary stonesadults/index.htm
incontinence. AJN, 102(8), 85–87. National Institute of Diabetes and Digestive and Kidney Diseases
Dowling-Castronovo, A., & Specht, J. (2009). Assessment of transient (NIDDK). (2007b). Kidney stones: what you need to know.
urinary incontinence in older adults. American Journal of Nursing, Retrieved April 18, 2009 from http://kidney.niddk.nih.gov/
109(2), 62–71. kudiseases/pubs/stones_ES/index.htm
Gray, M., Ratliff, C., & Donovan, A. (2002). Tender mercies: Providing National Institute of Diabetes and Digestive and Kidney Diseases
skin care for an incontinent patient. Nursing2002, 32(7), 51–54. (NIDDK). (2007c). Polycystic kidney disease. Retrieved
Growe, S. (2009). Manuscript submitted for publication. Henderson, NV. April 18, 2009 from http://kidney.niddk.nih.gov/kudiseases/pubs/
Hayes, D. (2003). Performing peritoneal dialysis. Nursing2003, 33(3), 17. polycystic/index.htm
Kaplow, R., & Barry, R. (2002). Continuous renal replacement National Institute of Diabetes and Digestive and Kidney Diseases
therapies. AJN, 102(11), 26–33. (NIDDK). (2008). Eat right to feel right on hemodialysis.
Kobayashi, M., Nomura, M., Yamada, Y., Fujimoto, N., & Matsumoto, Retrieved July 26, 2009 from http://kidney.niddk.nih.gov/
T. (2005). Bladder-sparing surgery and continent urinary diversion kudiseases/pubs/eatright/index.htm

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 CHAPTER 8 Urinary System 273

National Institutes of Health (NIH). (2006). Kidney infection Paton, M. (2003). Continuous renal replacement therapy. Nursing2003,
(pyelonephritis). Retrieved April 18, 2009 from http://www.nlm 33(6), 48–50.
.nih.gov/medlineplus/ency/article/000522.htm Patraca, K. (2005). Measure bladder volume without catheterization.
National Kidney Foundation (NKF). (2003). About kidney disease. Nursing 2005, 35(4), 46–47.
Retrieved from www.kidney.org/general/aboutdisease/index Polt, C. (2006). Taking the pressure off for women with stress
.cfm incontinence. Nursing2006, 36(2), 49–51.
National Kidney Foundation (NKF). (2008). The problem of kidney Rice, J. (2002). Medications and mathematics for the nurse (9th ed.).
and urologic disease. Retrieved April 18, 2009 from www.kidney Clifton Park, NY: Delmar Cengage Learning.
.org/news/newsroom/fs_new/prblmkd&urologd.cfm Roth, R., & Townsend, C. (2002). Nutrition and diet therapy (8th ed.).
National Kidney Foundation (NKF). (2009a). Diet and kidney stones. Clifton Park, NY: Delmar Cengage Learning.
Retrieved April 18, 2009 from http://www.kidney.org/atoz/ Scherer, J., & Timby, B. (2002). Introductory medical–surgical nursing
atozItem.cfm?id=41 (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
National Kidney Foundation (NKF). (2009b). How your kidneys Schofield, C. (2002). Patient may have a UTI—What next?
work. Retrieved April 18, 2009 from http://www.kidney.org/ Nursing2002, 32(10), 17.
kidneydisease/howkidneyswrk.cfm#whatare Schultz, J. (2002). Urinary incontinence: Solving a secret problem.
National Kidney Foundation (NKF). (2009c). Kidney stones. Nursing2002, 32(11), 53–55.
Retrieved April 18, 2009 from http://www.kidney.org/atoz/ Smith, D. (1999). Gauging bladder volume without a catheter.
atozItem.cfm?id=84 Nursing99, 29(12), 52–53.
National Kidney Foundation (NKF). (2009d). Polycystic kidney Stockert, P. (1999). Getting UTI patients back on track. RN, 62(3),
disease. Retrieved April 18, 2009 from http://www.kidney.org/ 49–52.
atoz/atozItem.cfm?id=102 Stothers, L. (2002). A randomized trial to evaluate effectiveness and
National Kidney Foundation (NKF). (2009e). Use of herbal supplements cost effectiveness of naturopathic cranberry products as prophylaxis
in chronic kidney disease. Retrieved April 18, 2009 from http://www against urinary tract infection in women. Canadian Journal of
.kidney.org/news/newsroom/fs_new/herbalsuppckd.cfm Urology, (9), 1558–1562.
Newman, D. (2003). Stress urinary incontinence in women. AJN, United Network for Organ Sharing (UNOS). (2008). U.S. transplant
103(8), 46–55. waiting list passes 100,000. Retrieved April 18, 2009 from http://
Newman, D., & Giovannini, D. (2002). The overactive bladder: A www.unos.org/news/newsDetail.asp?id=1165
nursing perspective. AJN, 102(6), 36–45. Van Snell, S., & Miller-Anderson, M. (2007). Stress incontinence: It’s
North American Nursing Diagnosis Association International. (2010). no laughing matter. RN, 70(4), 25–29.
NANDA-I nursing diagnoses: Definitions and classification 2009– Wetherbee, S. (2006). New weapons to snuff out kidney cancer.
2011. Ames, IA: Wiley-Blackwell. Nursing2006 36(12), 58–63.
Organ Procurement and Transplantation Network (OPTN). (2006). Williams, L., & Hopper, P. (2003). Understanding medical surgical
Scientific registry of transplant recipients annual report. Retrieved nursing. (2nd ed.). Philadelphia: F. A. Davis.
April 19, 2009 from www.ustransplant.org/annual_reports/ Zabat, E. (2003). When your patient needs peritoneal dialysis.
current/107_dh.htm Nursing2003, 33(8), 52–54.

RESOURCES
American Association of Kidney Patients, National Association for Continence (NAFC),
http://www.aakp.org http://www.nafc.org
American Foundation for Urologic Disease, National Kidney and Urologic Diseases Information
http://www.afud.org Clearinghouse, http://www.kidney.niddk.nih.gov
American Society of Nephrology, National Kidney Foundation, http://www.kidney.org
http://www.asn-online.org Polycystic Kidney Disease Foundation,
Bard, C.R. Bard, Inc., http://www.crbard.com http://www.pkdcure.org
Interstitial Cystitis Association, http://www.ichelp.org The Simon Foundation for Continence,
Medic Alert® Foundation, http://www.medicalert.org http://www.simonfoundation.org

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 4 Mobility, Coordination,
and Regulation
Chapter 9 Musculoskeletal System / 276

Chapter 10 Neurological System / 305

Chapter 11 Sensory System / 359

Chapter 12 Endocrine System / 388

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 9
Musculoskeletal System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the musculoskeletal system:
Adult Health Nursing • Immune System
• Oncology • The Older Adult
• Cardiovascular System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• List the diagnostic tests used in the evaluation of orthopedic disorders and
diseases.
• Describe preventive nursing care of the orthopedic client (e.g., positioning,
mobility).
• Identify the various types of casts used in the treatment of orthopedic
disorders.
• Describe nursing care of clients with orthopedic devices.
• List four types of fractures and their related treatment.
• Discuss the nursing care of the client undergoing a total hip replacement.
• Utilize the nursing process to plan nursing care including physical and
emotional needs of the orthopedic client.

KEY TERMS
amphiarthrosis fracture paresthesia
amputation Heberden’s nodes phantom limb pain
arthroplasty internal fixation scoliosis
bruxism kyphosis sprain
closed reduction locomotor strain
contracture lordosis subluxation
crepitus open reduction synarthrosis
diarthrosis orthopedics tophi
dislocation osteoporosis windowing

276

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 CHAPTER 9 Musculoskeletal System 277

stand erect and ambulate. Figure 9-1 identifies the bones of the
INTRODUCTION skeleton.
Orthopedics, also spelled orthopaedics, is the branch of The skeletal system consists of bones attached to each
medicine that deals with the prevention or correction of other by cartilage and strong ligaments. The functions of the
the disorders and diseases of the musculoskeletal system. It skeleton are to:
involves the muscles, skeleton, joints, and supporting struc- • Provide the body with structural framework
tures such as ligaments and tendons. • Act as a protective casing for internal organs such as the
The prime concern of the nurse caring for a client with brain, heart, and lungs
locomotor (pertaining to movement or the ability to move) • Allow movement by muscles attached to the skeleton
disorders is the prevention of contractures (permanent
shortening of a muscle) or deformities. The objective of • Store calcium, phosphorus and magnesium and release
all caregivers is to maintain good body alignment, preserve these minerals when the body requires them
muscle tone, prevent disuse, and continue joint motion for • Manufacture blood cells in the red bone marrow
the client with acute or long-term therapeutic or rehabilitative Bones in the skeletal system are classified as long, short,
needs. Caring for orthopedic clients also requires an under- flat, or irregular. Examples include the humerus, a long bone;
standing of basic principles that apply to all clients whether the phalanges of the finger, short bone; occiput, flat bone;
they are in traction, casts, or recovering from surgery. and the vertebrae, irregular bone. Figure 9-2 illustrates these
bones.
There are two types of bone. One type of bone is cancel-
ANATOMY AND PHYSIOLOGY lous, which resembles a sponge with spaces and is found in the
REVIEW epiphysis or end of the long bones as well as in all other bones.
The other type is cortical bone, which is compact bone and is
The musculoskeletal system consists of bones, muscles, ten- found in the diaphysis or shaft of the long bones. Short bones
dons, ligaments, cartilage, and joints. When it is functioning consist of cancellous bone covered by a layer of compact
properly, the musculoskeletal system allows an individual to bone. Flat bones are made of cancellous bone layered between

Anterior Posterior

Cranium
Skull
Zygoma Maxilla Clavicle
Mandible Cervical vertebrae
Clavicle
Scapula Scapula
Sternum

Xiphoid process Humerus Humerus

Rib Rib
Costal cartilage Vertebral column

Ulna Ulna
Pelvis Radius Radius
Ilium
Sacrum
Carpals Coccyx
Carpals

Phalanges
Phalanges

Femur Metacarpals Metacarpals

Femur
Femoral condyles Patella

Tibia Tibia
COURTESY OF DELMAR CENGAGE LEARNING

Fibula Fibula
Medial maleolus
Tarsals
Lateral maleolus Metatarsals
Phalanges
Calcaneus

Figure 9-1 Anterior and Posterior Views of the Adult Human Skeleton

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
278 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

compact bone. Generally, the makeup of irregular bones is

similar to that of flat bones.

er
ng
The muscular system is composed of muscle fibers and

Fi
Phalanges
tendons innervated by nerves (Figure 9-3). The muscle fibers
vary in size and shape and are arranged according to a muscle’s
Short
function. The muscles act as motors controlled by nerve
impulses from the cerebral cortex. The muscles and the skel-
eton work together to permit body movement. Muscles are
attached to bones by tendons.
The action of muscles is to contract or shorten. Muscles
are arranged within the body as opposing pairs to act as antag-
onists to each other. For example, the biceps flex the forearm Occipital
and the triceps extend it.
Muscles are surrounded and divided by fibrous envelopes
called fascia. In the extremities, the muscles surround and give Flat

COURTESY OF DELMAR CENGAGE LEARNING

support to main blood vessels and nerves. Muscles also give Humerus
support to and keep the body erect as well as give shape to
the body. Vertebrae
Movement of the muscles may be either voluntary or
involuntary. Muscles attached to bone can function at the will
Irregular
of the person (voluntary). Involuntary muscles, found within
body organs, regulate the physical activity of the organs so Long
the organs can perform their functions. These actions are not
under the person’s control. Involuntary muscles are located in Figure 9-2 Bone Shape Classification
the intestinal tract, the pupil of the eye, and in the heart and
blood vessels.
A joint is a junction of two or more bones. There are hinge (elbow, knee), ball and socket (hip and shoulder),
three types of joints: diarthrosis, synarthrosis, and amphiar- pivot (skull and first vertebrae), gliding (wrist), and saddle
throsis. Diarthrosis joints are freely movable, such as the (thumb). Synarthrosis joints are immovable, such as the

Anterior Posterior

Orbicularis oris
Sternocleidomastoid Splenis capitis
Trapezius Rhomboideus major
Pectoralis major Trapezius
Biceps Deltoid Teres major
Serratus anterior Triceps Infraspinatus
lateral head Triceps
Brachioradialis Linea alba Flexor carpi Latissimus dorsi
Pronator teres ulnaris Extensor carpi
Rectus
External oblique abdominis radialis longus
Extensor
Flexor carpi radialis carpi External oblique
Aponeurosis
Palmaris longus ulnaris
Extensor
digitorum

Extensor
Adductor longus Rectus femoris retinaculum
Gluteus maximus Biceps
Adductor magnus
femoris
Vastus medialis Adductor magnus
Sartorius
Vastus lateralis Peroneus longus
COURTESY OF DELMAR CENGAGE LEARNING

Tibialis anterior Semitendinosus

Patellar ligament Gastrocnemius
Gastrocnemius
Extensor Peroneus longus
digitorum longus Soleus
Extensor retinacula Achilles
Soleus tendon

Figure 9-3 Muscular System: Anterior and Posterior Views

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 9 Musculoskeletal System 279

Diarthrosis glide over ligaments or bones. Fascia is connective tissue

that covers a muscle. Tendons are strong fibrous tissue
attaching muscle to bones, providing mobility. Ligaments
grow out of the periosteum and lash bones together more
firmly.
Hip joint
Elbow joint
Knee joint ASSESSMENT
Assessment of the musculoskeletal system ranges from a basic
assessment of functional abilities done by the nurse to a com-
Hinge Hinge
Ball and Socket
plete physical exam by the physician for diagnosis of specific
muscle and joint disorders. The extent of the physical exam
depends on the client’s symptoms, health history, and any
other physical signs.
Inspect and palpate to evaluate bone integrity, posture,
joint function, muscle strength, and gait. Also assess the cli-
ent’s ability to perform basic activities of daily living.
The medical history includes information on any past
medical or surgical disorders and any symptoms relative to
Saddle
onset, duration, or location of discomfort or pain. Ask if activ-
Gliding
ity makes symptoms better or worse. A family medical history
Pivot should also be obtained.
Assessment of the bony skeleton includes notation of
Synarthrosis Amphiarthrosis deformities, body alignment, abnormal growths, shortened
COURTESY OF DELMAR CENGAGE LEARNING

extremities, amputations, abnormal angulation other than at

the joints, and crepitus, a grating or crackling sensation or
sound.
Assessment of the spine necessitates exposure of the
client’s back, buttocks, and legs for adequate visualization.
Note differences in the height of the shoulders or iliac crests.
Suture Gluteal folds should appear symmetrical. The vertebral col-
Symphysis umn should be straight and perpendicular to the floor, with
the spine convex through the thoracic portion and concave
Figure 9-4 Joints Classified by the Degree of Movement through the cervical/lumbar portion.
Permitted Three common spinal curvatures are scoliosis, kyphosis,
and lordosis. A lateral curving deviation is known as sco-
liosis. Scoliosis is seen most frequently in school-age chil-
suture line between the temporal and occipital bones of the dren and adolescents. Kyphosis (hump back) is seen as an
skull. Amphiarthrosis joints are slightly movable, such as increased roundness of the thoracic spinal curve. This condi-
the vertebrae and pelvic bones separated by fibrous cartilage. tion is frequently seen in older persons with osteoporosis.
Figure 9-4 illustrates types of joints. Lordosis (sway back) is an exaggeration of the lumbar spine
The ends of articulating joints are covered with a curvature as seen in pregnancy as a woman’s body adjusts
smooth articular cartilage. The joint capsule is composed its center of gravity. These three curvatures are illustrated in
of an outer fibrous layer and an inner synovial layer that Figure 9-5.
secretes synovial fluid. This clear fluid acts as a lubricating Assessment of the articular system includes range of
fluid for the joints. motion (limited, active, and passive), stability of joints,
Other structures related to the musculoskeletal sys- deformities and any nodular formation, and pulses in the
tem include bursa, fascia, tendons, and ligaments. Bursae extremities. Normal ranges of motion (ROM) are shown in
are sacs filled with fluid that facilitate joint movement by Figure 9-6. Assess for the angle of the joint movement; pres-
making it possible for muscles and tendons to move or ence of pain, tenderness, and crepitus; and client’s ability
to move joint by self through full range of motion (active),
with limited movement (limited), or with assistance only
(passive) (Estes, 2006). When assessing passive ROM,
remember to keep the motion steady and avoid causing any
MEMORYTRICK pain.
ROM includes assessment of the client’s ability to change
position, muscle strength and coordination, and the size of
Tendons tend to bind muscles to bones, and individual muscles. Assess muscle groups for strength and
equality with the client using the movements of ROM. Com-
ligaments bind bone to bone. pare the right and left muscles in strength and size. Normal
muscle strength is equal bilaterally. Assess if the client has

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280 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

voluntary movement against gravity and resistance. Table 9-1

describes two grading scales used in assessing muscle strength;
grading scale of 0-5 and the Lovett scale. Figure 9-7 shows
assessment of muscle strength and resistance. Assess for invol-
untary movements (Estes, 2006).
Joints are examined for excessive fluid. The knee is the
most common site for fluid accumulation. Edema and an
elevated temperature may be signs of active inflammation
in the joint. Normal joint movement is stable and smooth.
If there is a snap or crack sound when a joint is passively
moved, it may indicate a ligament slipping over a bony
prominence.
A Scoliosis B Kyphosis
Deformities are caused by several factors, including con-
tractures, dislocations, and subluxation (a partial separation
of an articular [joint] surface). Nodular formations are pro-
duced by musculoskeletal diseases such as gout, rheumatoid
arthritis, and osteoarthritis.
Pulse points in the extremities are palpated to assess for
COURTESY OF DELMAR CENGAGE LEARNING
weak or absent pulses. The strength of the pulse in affected
extremities is compared with that of nonaffected extremities.
Note skin color and temperature and check capillary refill by
pressing down on the client’s fingernail or toenail for a few sec-
onds, then release and note the time it takes for the client’s nail
to return to normal color. The color should return immediately
C Lordosis (less than 2 seconds); if a client has an arterial disorder, the
color will take longer than 2 seconds to return to normal. Refer
Figure 9-5 Curvatures of the Spine

A B 180°
0°
Left Right

70° 70°

Hyperextension Forward flexion

C 180° 50°

Abduction
D
E

160°
PHOTOS COURTESY OF DELMAR CENGAGE LEARNING

90°

Flexion
External
rotation

0°
Adduction 50° Extension

Figure 9-6 Range of Joint Motion; A, Cervical Spine Rotation; B, Shoulder Flexion and Hyperextension; C, Shoulder Abduction
and Adduction; D, Shoulder Rotation; E, Elbow Flexion and Extension (Continues)

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 9 Musculoskeletal System 281

F G

0°
70°
90°
Flexion Hyperextension

45°
0° 30°
90° Supination 90° Pronation Abduction Adduction

I 130° J
Flexion

PHOTOS COURTESY OF DELMAR CENGAGE LEARNING

Dorsiflexion
20°

0°

0°
Extension 15° 45° Plantar flexion
Hyperextension

Figure 9-6 (Continued) F, Elbow Supination and Pronation; G, Wrist Flexion and Hyperextension; H, Hip Abduction
and Adduction; I, Knee Flexion, Extension, and Hyperextension; J, Dorsiflexion and Plantar Flexion

Table 9-1 Assessing Muscle Strength

GRADING DESCRIPTION LOVETT SCALE
0 No contraction Zero (0)
1 Slight contraction Trace (T)
2 Full ROM with gravity Poor (P)
eliminated (passive
motion)
3 Full ROM with gravity Fair (F)
4 Full ROM against Good (G)
COURTESY OF DELMAR CENGAGE LEARNING

gravity, some
resistance
5 Full ROM against Normal (N)
gravity, full resistance
Adapted from Assessing the Musculoskeletal System, by S. Wise, in
press, and Caring and Clinical Decision Making (2nd ed.). Clifton Park,
NY: Delmar Cengage Learning.
Figure 9-7 Assessment of Muscle Strength

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
282 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

to Box 9-1 for guidance in completing client musculoskeletal

assessments.
Table 9-2 Common Diagnostic Tests for
Clients with Musculoskeletal Disorders
Laboratory Tests
BOX 9-1 QUESTIONS TO ASK AND Alkaline phosphatase (ALP)
OBSERVATIONS TO MAKE WHEN Aspartate aminotransferase (AST)
COLLECTING DATA Aldolase (ALD)
Antinuclear antibodies (ANA)
Subjective Data
Complete blood count (CBC)
What is your current occupation?
• WBC
Describe your current activity level, sport
• Hg
participation, and lifestyle.
C-reactive protein (CRP)
What leisure or recreation activities or exercise
regimen do you enjoy? Creatine kinase (CK-MM)
Have you gained or lost any weight over the last few Erythrocyte sedimentation rate (ESR)
months? Lactate dehydrogenase (LDH)
Describe a typical 3-day diet. Rheumatoid factor (RF)
Do you need assistance to care for yourself? Assistance Serum calcium
to the bathroom? Assistance cleaning house? If the
Serum phosphorus
answer is yes, ask: Who is available to assist you with
mobility or self-care activities? Uric acid
Do you have any pain? • serum
Do you take any medication for pain? • urine
Have you ever broken any bones?
Radiologic Studies
Have you gone to a chiropractor or masseuse for
treatment? Arthrogram/graphy
Does muscle or joint pain or discomfort have an Bone scan
adverse impact on your ability to sleep and rest? Computed tomography (CT scan)
Tell me how you feel about yourself. Dual energy x-ray absorptiometry scan (DEXA)
Do you feel in control of your life? Electromyography (EMG)
Tell me about your relationship with your spouse and Indium (white blood cell) scan
family Magnetic resonance imaging (MRI)
Myelogram
Objective Data
Radiography (x-ray)
Obtain vital signs, including height and weight.

COURTESY OF DELMAR CENGAGE LEARNING

Compare to ideal body weight chart. Other Tests
Assess the volume (1⫹, 2⫹, 3⫹, 4⫹) of peripheral Arthrocentesis
pulses. Arthroscopy
Observe the gait, use of assistive devices, and range Joint aspiration
of motion. Is the ability to transfer or ambulate
Somatosensory evoked potentials (Evoked potentials)
limited?
Observe body build and posture. Visually scan the
body for deformities.
Assess muscle strength according to grading scale.
Visually scan the body for symmetry, contour, and
COMMON DIAGNOSTIC TESTS
size of muscles, and muscle atrophy. Clients must Commonly used diagnostic tests for clients with symp-
be assessed bilaterally to compare one extremity or toms of musculoskeletal system disorders are listed in
muscle group with the other side. Table 9-2.
Assess for crepitus.
Assess for swelling and tenderness.
Assess for pain on a scale of 1–10, with 0 being no MUSCULOSKELETAL TRAUMA
pain and 10 being the worst pain ever felt.
Assess ROM of joints.
Adapted from Wise (2008).
T rauma to the musculoskeletal system causes a variety
of injuries to clients of all ages. Such injuries include
strains, sprains, dislocations, fractures, and compartment
syndrome.
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 CHAPTER 9 Musculoskeletal System 283

CRITICAL THINKING area. The part may then be immobilized with an elastic com-
pression bandage or a brace and elevated. After the edema has
Client Assessment decreased significantly, a cast may be applied.

After reading the anatomy and physiology and ■ DISLOCATION

assessment sections of the text, examine the
accompanying photo of a client.
1. Identify the anatomical abnormality.
2. List the variations from the norm that you identify.
D islocation occurs when articular surfaces of a joint are no
longer in contact. The bones are literally “out of joint.” The
displaced bone may hinder the blood supply, damage nerves,
tear ligaments, or rupture muscle attachments. Traumatic
dislocations are considered orthopedic emergencies. Congeni-
tal dislocations are present at birth, whereas spontaneous or
pathologic dislocations are caused by diseases affecting joints.
Symptoms of a dislocation include localized joint pain,
loss of function of the joint, and a change in the length of the
extremity and contour of the joint. Diagnosis is based on the
symptoms, physical exam, and x-rays. X-rays reveal either a
complete or partial separation of the articulating surfaces.

■ FRACTURE
Image not available due to copyright restrictions

A fracture is a break in the continuity of a bone. Fractures

occur when the forces from outside the body are greater
than the strength of the bone, causing the bone to break.
Fractures usually involve soft tissue (edema and bleeding),
damaged nerves, and tendons. Most fractures are caused by
accidents. These may be the result of direct force, torsion or
twisting, or violent contractions of highly developed muscles.
Other fractures may be the result of a disease process that
weakens the bone. This type of fracture is known as pathologic
or spontaneous. Individuals considered at high risk for fractures
include those who have predisposing bone conditions such as
metastatic or primary bone tumors or osteoporosis, poor coor-
dination, diminished vision, dizzy spells, or general weakness.
There are more than 90 different classifications of fractures.
Some of the more common types include greenstick or incom-
plete, simple or closed, compound or open, impacted or tele-
■ STRAIN scoped, spiral, comminuted, compression, and stress or fatigue.
In a greenstick fracture, the continuity of the bone is not
completely disrupted but has splintering on one side and
A strain is an injury to a muscle or tendon caused by overuse
or overstretching. A strain may be either acute or chronic.
An acute strain may be caused when an individual performs
bending on the other. This fracture is seen most frequently in
children. An uncomplicated (clean) fracture in which the skin
unaccustomed exercises vigorously. A chronic strain may develop remains intact is called a closed or simple fracture; the fractured
after repeated overuse of certain muscles. Individuals with acute surfaces are not contaminated by outside air. In a compound or
strains experience sudden severe pain, whereas the onset is gradual open fracture, the bone is broken and the skin is also broken,
in chronic strains, with the affected part feeling only stiff and sore. allowing the bone to protrude and be susceptible to a greater
Chronic strains require no specific treatment, but acute chance for infection. An impacted fracture is also called a tele-
strains require rest and possibly immobilization. Immediately scoped fracture; one portion of a bone fragment is forcibly
after injury, apply cold packs for 20- to 30-minute periods, and driven into another. A spiral fracture twists around the shaft of
then remove for 1 hour during a 24-hour period to reduce any the bone. This type of fracture may occur from a twisting force.
edema. Then apply heat for the client’s comfort. In the case of In a comminuted fracture, the bone is splintered into many
a severe strain when the muscle may be completely ruptured, unaligned fragments. A compression fracture usually occurs
surgical repair may be necessary. when a bone, such as a vertebra, becomes weakened from
osteoporosis. A fall or lifting excess weight causes a compres-
sion or crushing of the vertebral body (Zdeblick, 2009). Stress
■ SPRAIN or fatigue fractures occur from repetitive overuse of a bone and
are one of the five most common injuries of runners (Reeser,

A sprain is an injury to ligaments surrounding a joint

caused by a sudden twist, wrench, or fall. Symptoms
include pain, edema, loss of motion, and ecchymosis. X-ray
2007). Various types of fractures are shown in Figure 9-8.
Healing time for fractures is affected by the age of the cli-
ent and the type of injury or any underlying disease process,
will reveal soft tissue edema but no evidence of joint or bone and may take weeks, months, or even years before healing
injury. Immediate treatment is RICE (rest, ice, compression, is complete. The average healing time for an uncomplicated
and elevation). The client rests and ice is applied to the injured fracture is 6 to 8 weeks. The sequence of healing takes place
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284 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Transverse

Oblique

COURTESY OF DELMAR CENGAGE LEARNING

Greenstick Closed Open Spiral Comminuted
(incomplete) (simple, complete) (compound)

Figure 9-8 Classifications of Common Bone Fractures

beginning with the formation of a hematoma, then granula- Complications of a fracture include infection, fat embo-
tion tissue formation, callus formation, callus ossification, and lism syndrome, and compartment syndrome. Complications
ultimately remodeling. may delay healing or be life threatening.
Hematoma formation begins with the formation of a clot Infections may result from an open fracture in which the
that serves as a fibrin network. Bleeding comes from ruptured bone extends through the skin, allowing contamination from
vessels within the bone as well as from tears in the periosteum the outside. They may also occur following surgical repair of
and adjacent tissues. The hematoma is not absorbed but devel- a fracture using an internal fixation device. Any infection may
ops into granulation tissue. Granulation tissue forms a soft tissue lead to a delayed union of the bone.
callus that surrounds the fracture site and serves as a temporary Fat embolism syndrome is usually associated with frac-
splint. Callus ossification is the result of deposits of calcium tures of the long bones, multiple fractures, or crushing injuries.
salts in the callus forming rigid bone in excess as a protective An embolus usually occurs within 24 to 72 hours following a
measure. The formation of bone binds the bone ends together. fracture but may occur up to a week after injury. Much is still
Remodeling is completed by osteoclastic activity, whereby unclear about how a fat embolism occurs (Walls, 2002). When a
excess bone is gradually reduced and removed by absorption small area of the lungs is involved, the symptoms are pain, tachy-
until the original shape and outline of the fractured bone is cardia, and dyspnea. Larger areas of lung involvement produce
reestablished. Figure 9-9 outlines the healing sequence. more pronounced symptoms, including severe pain, dyspnea,

A Hematoma B New blood vessels

Medullary
cavity Compact bone Spongy bone
Fibrocartilage

A hematoma forms from blood from ruptured vessels. Spongy bone forms close to developing blood vessels;
fibrocartilage forms away from new blood vessels.

Bony callus

C D
COURTESY OF DELMAR CENGAGE LEARNING

Bony callus replaces fibrocartilage. Excess bony tissue is removed by osteoclasts.

Figure 9-9 Steps of Bone Repair

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 CHAPTER 9 Musculoskeletal System 285

cyanosis, restlessness, and shock. Petechiae may appear over

the neck, upper arms, chest, or abdomen. Treatment consists
of bed rest, respiratory support, oxygen, and IV fluids.
CLIENTTEACHING
Casts
Medical–Surgical Management Because plaster casts dry from the inside out, they
Medical should not be covered or dried with a hairdryer
The treatment of a fracture requires immediate attention. or heat lamp. Allow moisture and heat from the
The most important objectives are to (1) realign the fracture, drying cast to evaporate naturally. Inform clients
(2) maintain the alignment, (3) regain the function of the that the heat they feel during the application,
injured part, and (4) prevent complications. The method of drying, and setting process is normal and should
treatment depends on the first aid given; the site, severity, and subside in 10 to 15 minutes. To avoid indentation,
type of the fracture; and the age and condition of the client. a drying cast is placed on pillows and not on a hard
Closed Reduction Repair of a fracture accomplished with- surface. For the same reason, when handling the
out surgical intervention is called closed reduction. External cast, only the palms of the hands are used. Plaster
manipulation is used to correct bone position. This manipulation casts cause clients to feel cold when they are drying.
requires three maneuvers: traction and countertraction, angula- Apply blankets only to body areas that are not
tion, and rotation. Following the reduction, x-rays are taken to covered with the cast. Synthetic casts dry in minutes
visualize the fracture alignment. The part is then immobilized by to a couple of hours. Teach the client not to insert
using a cast, bandage, or traction. Local or general anesthesia may any objects such as rulers or hangers into the cast
be used to make the reduction easier and less painful to the client.
to relieve itching as the skin is soft and can be
Casts Casts are made either from plaster bandages or syn- damaged. After the cast has dried, use a hairdryer
thetic materials such as fiberglass. The cast should include the to blow cool air inside the cast to alleviate itching.
joint above and below the affected part. The major purposes of Keep the plaster cast dry because the cast
casts are immobilization, support and protection of the affected weakens if it gets wet. Sometimes a waterproof cast
part, prevention of deformities resulting from conditions such
is applied so the client can shower or possibly swim.
as arthritis, and the correction of deformities such as scoliosis.
A fiberglass cast weighs less, wears longer, breathes bet- Obtain physician approval for swimming with a cast.
ter, and is more penetrable to x-rays than plaster casts (AAOS,
2007a). A dry cast should be odorless, shiny in appearance, reso-
nant (produces vibrating sound on percussion) when percussed, unstable spinal injuries, or for degenerative disorders. Figure
and have a temperature similar to the room air. Moisture occur- 9-10 shows different types of casts.
ring from any underlying drainage gives the cast a musty smell, After the application and drying of a cast, the doctor
dullness on percussion, a lusterless color, and cool temperature. may order a cast cut to allow visualization of a body area or to
Numerous types of casts exist. Long and short arm casts relieve pressure. This procedure is known as windowing. A
allow the fingers to be visible; long and short leg casts allow cast is also split in half or bivalved to relieve pressure.
the toes to be visible. A spica cast is used for hip, shoulder, and When a cast is removed, the client becomes conscious
thumb dislocations or injuries. The hip spica has an abduction of aches and discomforts caused by the constricted joint
bar that keeps the cast in the correct position. A walking cast structures and immobilized muscles. Minimize the client’s
with a cast shoe facilitates client ambulation. Body casts are discomfort by supporting the joint and maintaining the part in
used to immobilize the spine following surgical spinal fusions, the same position as it was in the cast. The skin is cool and pale
with mottling and edema present. A yellow exudate, which is
part dead skin and part secretions from oil sacs, is on the skin.
Long
This exudate is not rubbed or forced off.
arm
cast Traction The principle of traction is to have two forces pulling
in opposite directions. Traction consists of weights and counter-
weights. Countertraction forces are provided by the weight of
Short the client’s body or other weight such as elevating the foot of the
arm
cast bed. Traction is used to reduce a fracture, immobilize an extrem-
ity, lessen muscle spasms, or correct or prevent a deformity.
Types of traction are skeletal, skin, and manual. Skeletal
traction requires the surgical insertion of pins (Steinmann) or
COURTESY OF DELMAR CENGAGE LEARNING

Body cast LIFE SPAN DEVELOPMENT

Long
leg Cast Removal
cast
Children often are afraid when a cast is removed.
Short leg Letting the child feel and see the cast cutter before
Hip spica cast
cast (with cast shoe) starting to remove the cast alleviates fear.
Figure 9-10 Casts Used to Correct Musculoskeletal Disorders
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286 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

wires (Kirschner) through the bones. Skeletal traction is con-

tinuous and is used most frequently for fractures of the femur, PROFESSIONALTIP
tibia, and cervical spine. Head tongs (e.g., Gardner-Wells
tongs) are fixed in the skull to apply traction that immobilizes
cervical fractures. An external fixation (fixator) is applied Pin Care
outside of the body to stabilize a break. Two or more pins are
placed on either side of the fracture and attached to the fixator. Pin care varies with health-care providers’ orders
The pins or screws remain in place with the fixator for 6 weeks and hospital protocol, therefore, basic guidelines
or until the fracture heals, which may take up to a year or lon- are provided.
ger if complicated (The Ohio State University Medical Center, • Keep the pin site clean and dry.
2008). Figure 9-11 shows examples of traction devices. • Cleanse the pin site with prescribed solution
Skin traction is a nonsurgical method of providing necessary and a gauze pad using sterile technique.
pull for shorter periods, such as Buck’s traction (Figure 9-11). • Use a new gauze pad for each pin.
• Remove any crust from the pin site.
• Remove all drainage from the pin site.
• Notify the health care provider if there is
redness, swelling, purulent drainage, or pain at
A the pin site or if the pin becomes loose.
• Notify the health care provider if the client
develops a fever of 101.5ºF.
(The Ohio State University Medical Center, 2008)

Materials used include tapes, traction strips, cervical halters,

pelvic belts, and lower extremity boots. Skin traction is fre-
quently used to temporarily immobilize a part or stabilize a
fracture. The disadvantage of skin traction for adult use is that it
does not adequately control rotation and cannot be maintained
Locking disk for the length of time necessary for adult healing. Tapes and
bandages are applied smoothly to prevent any pressure areas.
Adjusting knob A nurse caring for a client in traction knows the purpose of
the traction, how it accomplishes its purpose, and any complica-
tions associated with the use of the traction. It is also important to
Locking know the extent of the injury and the movements and positions
disk B allowed. Care of the client includes maintenance of the injured
part, general body alignment, the alignment of the traction appa-
ratus, and range of motion in as many joints as possible.
Guide bushing
Rehabilitation The physician determines when the bone
has healed sufficiently for rehabilitation. Healing is monitored
by periodic x-rays and physical examinations. The major
objective of rehabilitation is to assist the client to return to
the former level of functioning. Rehabilitation programs vary
depending on the injury and the client.
The nurse has a major role in client education reinforcing
the directions of both the physician and the physical thera-
pist. Patience and encouragement are extremely important
in assisting the client to feel comfortable in learning self-care
techniques. Teach the client to report any unusual signs or
symptoms to the physician.
C
The client learns proper use of equipment such as crutches,
canes, or walkers. Crutches allow ambulation with limited or no
weight bearing on the affected extremity. Walkers allow limited
COURTESY OF DELMAR CENGAGE LEARNING

weight bearing and provide stability when the client ambulates.

Canes allow the client to walk with balance and support.
The tripod position is the basic stance for crutch walking.
Tips of the crutches are placed approximately 8 to 10 inches
in front of and lateral to the client’s feet. The client must place
his weight on the handpiece of the crutches and not on the
axilla. Crutch gaits depend on the client’s disability and are
prescribed by the physician.
Figure 9-11 Types of Traction Devices; A, Skeletal Traction; Canes are held in the hand opposite the affected extremity.
B, Head Tongs; C, Buck’s Traction, a Type of Skin Traction In normal walking, the opposite arm and leg move together.
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 CHAPTER 9 Musculoskeletal System 287

(CMS). CMS is very important. Provide comfort measures and

administer analgesia as ordered. An important nursing responsi-
bility is the prevention of constipation, skin breakdown, urinary
COLLABORATIVECARE calculi, and respiratory complications from immobility.
Use of Crutches, Canes, and Walkers
Nurses collaborate with physical therapists to assist NURSING PROCESS
clients in the use of crutches, canes, and walkers.
Clients generally go to physical therapy to learn how Assessment
to use the walking aid, and nurses reinforce the Subjective Data
teaching when they see clients using their walking aid. The neurovascular assessment of a client with a fracture may
reveal subjective data of pain, especially on movement; muscle
spasms; and paresthesia.
This same action is done when walking with a cane. Walk-
ers provide more support than canes or crutches. They are Objective Data
especially useful for clients who have poor balance. The client Assess for edema, shortening and deformity of the affected
places the walker 12 to 18 inches in front and walks toward the limb, hematoma, and pallor. Check pulses in the affected and
walker holding onto the hand grips. unaffected extremity and compare with each other. Take the
client’s vital signs routinely, and note the client’s general physi-
Surgical cal and mental condition. Check the skin, especially over bony
Open reduction is a surgical procedure that enables the sur- prominences, for color and temperature.
geon to reduce (repair) the fracture under direct visualization. When the client has a cast applied, check all cast edges for
When an open reduction/internal fixation (ORIF) is done, smoothness. Also check the cast for spots indicating wound
orthopedic devices are used to maintain the reduction. Some drainage, including the color and amount. Mark the size of the
of the devices used include pins, screws, nails, plates, wires, drainage spot on the cast with a ballpoint pen and indicate the
and rods. These internal fixation devices are inserted through date and time. Then an increase in the size of the drainage spot
bone fragments or fixed to the sides of the bones. can easily be identified. Assess extremities including fingers, toes,
The major disadvantage of the open reduction is the pos- hands, and feet for changes in skin color, pulse, or temperature.
sibility of introducing infection into the bone. Possible com- Check all traction wires, pulleys, and weights. Weights should
plications include impaired circulation and accidental injury hang free and are not removed unless a health-care provider
to major nerves, blood vessels, and bone caused by the fixation writes specific orders for removal. When providing pin care,
devices. X-rays are taken during and after the open reduction nurses use sterile technique according to health-care facility
to evaluate the alignment of the fracture. guidelines. Observe for drainage and infection at the pin sites.

Pharmacological
Analgesics are given to relieve pain. Muscle relaxants, such as
cyclobenzaprine hydrochloride (Flexeril), also are prescribed PROFESSIONALTIP
for muscle spasms. Severe or continued pain indicates compli-
cations and is given immediate attention. Stool softeners, such Neurovascular Assessment
as docusate sodium (Colace), are given to prevent constipa-
tion in the immobilized client. • CMS assessments are performed on clients
following musculoskeletal trauma; after surgery,
Diet if nerve or blood vessel damage is possible; and
The client is encouraged to eat regular meals with foods that following casting, splinting, and bandaging.
provide fiber, protein, calcium, phosphorus, and fluids. For • The CMS assessment is performed every 15 to
the client whose dietary intake is inadequate, vitamin and 30 minutes for several hours, and then every
mineral supplements, especially calcium and phosphorus, are 3 to 4 hours.
included. Consultation with a dietitian regarding client food
• All findings are documented.
preferences may be necessary.
• Tingling and numbness are relieved by flexing
Activity fingers or toes or repositioning extremity.
Client activity and exercise are important in maintaining • Remember 6 Ps when performing a CMS
muscle strength and tone and minimizing cardiovascular assessment:
problems. Joints that are not immobilized are exercised either 1. Paresthesia (unrelieved tingling or numbness)
actively or passively to maintain function. Isometric (maintain- 2. Pain
ing constant resistive force) exercises help maintain muscle 3. Pallor (Assessment may reveal a slow capillary
strength of immobilized muscles. return. Normal capillary refill is 2 to 4 seconds.)
4. Paralysis
Nursing Management 5. Puffiness (edema)
Frequent and accurate assessment of the musculoskeletal trauma 6. Pulselessness
area includes circulation (color), movement, and sensation
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288 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for a client with musculoskeletal trauma include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will have relief of Assess for pain and swelling.
fracture pain with medication. Provide comfort measures. Administer medications for pain as
ordered.
Risk for Impaired Skin The client’s skin remains Change client position, if allowed, maintaining correct body
Integrity related to intact. alignment.
immobility Check bony prominences and keep the client’s skin clean and dry.
For the client in a cast, check the edges of the cast for
roughness, keep the exposed skin next to the cast clean and dry.
Inspect all body pressure points including the head, ears, and
heels; turn the client as orders direct; and check for friction rubs.
Instruct clients not to place anything inside the cast or use
objects to scratch, causing skin breakdown or infections.
Avoid getting the cast wet.
Impaired Physical The client will perform If the client in a cast is allowed to turn, use an overhead
Mobility related to loss range-of-motion exercises trapeze.
of integrity of bone in unaffected joints. Assist client in performing ROM exercises.
structures The client will demonstrate Assist client in use of adaptive devices.
use of adaptive devices to
improve mobility.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CRITICAL THINKING
■ RHABDOMYOLYSIS

C rushing injuries most commonly cause rhabdomyolysis,

the release of myoglobulin (muscle protein) from dam-
aged muscle cells (MedlinePlus®, 2007). Myoglobin, creatine
Immobility Complications

Prepare a teaching plan for an immobile client to

kinase (CK), and other inflammatory mediators escape from prevent constipation, skin breakdown, urinary
the injured muscle tissue into the circulation. The circulating calculi, and respiratory complications.
myoglobin, filtered by the kidneys, can precipitate, causing
renal tubular obstruction. About 15% of rhabdomyolysis cases
will have acute renal failure (Walls, 2002). Two other major
problems are respiratory distress from muscle weakness and than active, diminished capillary refill, weak or unequal pulses,
fluid and electrolyte imbalance. Standard treatment includes paresthesia (numbness or tingling), and paralysis indicates
IV fluids to maintain circulating blood volume and renal per- this orthopedic emergency. Treatment consists of relieving
fusion so the myoglobin is flushed from the kidneys. pressure by removing the cast or dressing or by performing a
fasciotomy. A surgical fasciotomy is an incision into the fascia
to relieve pressure on the nerves and blood vessels.
■ COMPARTMENT SYNDROME

C ompartment syndrome is a form of neurovascular impair-

ment that may lead to permanent injury of an affected
INFLAMMATORY DISORDERS
limb caused by progressive constriction of blood vessels and
nerves. It occurs with any orthopedic injury as a result of bleed-
ing into the tissue, tissue edema, or prolonged external pressure
I nflammatory disorders involve inflammation of the joints
and include conditions such as rheumatoid arthritis, bursi-
tis, and osteomyelitis.
(cast or tight dressing). If untreated, in 4 to 6 hours it leads to
irreversible damage to nerves and muscles, and within 24 to 48
hours permanent loss of normal limb function. Accurate, regu- ■ RHEUMATOID ARTHRITIS

R
lar assessments and early detection are the best ways to avoid
permanent disability. A neurovascular assessment that reveals heumatoid arthritis is an autoimmune disease of unknown
throbbing pain not relieved by narcotic analgesics or greater in etiology, with recurring inflammation involving the syn-
comparison with the injury, greater pain with passive motion ovium or lining of the joints. It can also affect the lungs, heart,

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 CHAPTER 9 Musculoskeletal System 289

blood vessels, muscles, eyes, and skin. Rheumatoid arthritis is

a potentially destructive and disabling disease. The course is
variable with either slow or rapid progress and/or periods of

COURTESY OF DELMAR CENGAGE LEARNING

remissions. Women are affected more often than men. Rheu- Infection Abscess
matoid arthritis occurs at any age; however, it most commonly develops
affects young adults. In children, it occurs in a form known as
juvenile rheumatoid arthritis (Still’s disease). See the immune Blood Sequestrum
system chapter for more information on rheumatoid arthritis. flow (dead bone) Pus
impaired results from
ischemia
■ BURSITIS A B C

B ursitis is inflammation of the bursa, a sac filled with syn-

ovial fluid that facilitates joint movement. Major bursae
are found in the shoulder, knee, hip, and elbow. The inflam-
Figure 9-12 A, Osteomyelitis; B, Without early treatment,
an abscess forms; C, Bone dies (sequestrum) and pus forms.

mation is usually the result of trauma or repetitive movements.

The client experiences painful joint movement. Diagnosis is painful, unnecessary movement is avoided and the affected
made from the client’s symptoms and x-ray, which shows a extremity handled very gently.
calcified bursa. Treatment includes rest of the joint and the
administration of anti-inflammatory drugs including salicy- Pharmacological
lates and nonsteroidal anti-inflammatory drugs (NSAIDs). For Osteomyelitis is treated with vigorous antibiotic therapy and
some clients, corticosteroids may be injected into the bursa. analgesics. Wound irrigations with antiseptics or antibiotics
are often prescribed by the physician. Specific drugs given are
■ OSTEOMYELITIS determined by the causative organism.

O steomyelitis is the inflammation of the bone and bone

marrow. The most common cause of osteomyelitis is
the introduction of pathogenic bacteria into a penetrating
Diet
A high-calorie, high-protein diet is generally ordered for the
client with osteomyelitis. Dietary supplements of vitamins
injury such as an open fracture. Bone infections may also and calcium are also given. Fluids are increased as tolerated,
result from the spread of infection from another site such as and a high-fiber diet is encouraged due to analgesic use and
infected teeth, tonsils, or an upper respiratory infection. The immobilization.
most common pathogen causing osteomyelitis is Staphylo-
coccus aureus. Other organisms found in osteomyelitis are Activity
Pseudomonas and Escherichia coli. Osteomyelitis may become
a chronic disabling problem affecting the quality of life. The Absolute rest of the affected extremity is needed. Avoid exces-
affected bone may have spontaneous fractures. sive handling of the extremity because it is very painful. The
Local symptoms of an acute infection are sudden pain extremity is handled in a smooth, unhurried manner, support-
and tenderness of the affected bone, warmth, redness, edema, ing the joints above and below the affected area.
and pain on movement. General symptoms with acute severe
bone infections include chills, elevated temperature, rapid Nursing Management
pulse, and marked leukocytosis. Maintain the client on bed rest and the infected bone at abso-
lute rest. Avoid excessive handling of the affected extremity.
Medical–Surgical Management Administer IV antibiotics, analgesics, and dietary supplements
(vitamins and calcium) as ordered. Maintain strict asepsis if
Medical wound irrigations are ordered. Encourage the client to drink
The client is placed on bed rest, and the infected bone is kept at more fluids and to eat the high-calorie, high-protein diet
rest with the use of sandbags or casts. Antibiotics are given IV as ordered. Provide for diversional activities.
soon as osteomyelitis is suspected. Unless the infective process
is controlled early, a bone abscess forms (Figure 9-12). Cultures
of the abscess may indicate a need for change in the antibiotic NURSING PROCESS
therapy. The abscess may drain naturally; however, it usually
requires an incision, allowing it to drain. The abscess cavity of Assessment
dead bone tissue does not liquefy easily, drain, and heal as in
soft tissue abscesses. A bone sheath forms around the seques- Subjective Data
trum (dead bone), giving the appearance of healing; however, Inquire about pain, muscle spasms, and tenderness in the
chronically infected sequestrum has the tendency to produce bone. Ask about any traumas, surgeries, and other diseases.
recurrent abscesses throughout the life of the individual.
Objective Data
Surgical Observe the client for signs of infection, including chills,
A sequestrectomy to remove the dead bone tissue may need elevated temperature, pain, redness, and edema of the affected
to be performed. Strict aseptic technique is maintained when extremity. The client may also experience headaches, restless-
changing any dressings. Because infected bone is extremely ness, and irritability.

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290 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for a client with osteomyelitis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize Protect client from jerky movements and falls.
inflammation reduction of pain. Assess wound appearance and new sites of pain.
Provide diet high in protein and vitamin C.
Administer pain medications as ordered.

Impaired Physical The client will maintain Encourage and assist client to maintain active ROM or perform
Mobility related to pain movement of unaffected passive ROM to unaffected extremities.
extremities.

Risk for Impaired Skin The client will maintain skin Handle the affected extremity gently, protect it from injury, keep
Integrity related to integrity. it in good body alignment and level with the body.
immobility Irrigate wound as ordered. Use aseptic technique when
irrigating the affected area and when changing the dressing.
Assess skin and bony prominences for reddened areas.
Encourage adequate fluid intake.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Osteoporosis has been called the “silent disease” because

DEGENERATIVE DISORDERS there are no symptoms of bone loss. As the bone tissue loses

D
density, fractures and kyphosis occur. Very slight trauma frac-
egenerative disorders include osteoporosis, degenera- tures the brittle bones. With multiple vertebral fractures, the
tive joint disease, and total joint arthroplasty. individual experiences a loss of height.
The only way to determine whether an individual has
osteoporosis is to measure bone mineral density (BMD). The
■ OSTEOPOROSIS recommended type of BMD test is the dual-energy x-ray absorp-
tiometry (DXA or DEXA) that identifies low bone density

O steoporosis is an increase in the porosity of bone. It is

a common disorder in bone metabolism in which both
mineral and protein matrix components are diminished and
prior to a fracture and predicts the chances of a person having
a fracture in the future (NOF, 2008a, 2008c, 2008d). The test
measures the bone density of the spine, hip, or total body and is
the bone becomes brittle and fragile. There is an increased painless, noninvasive, and safe.
susceptibility to fractures of the hip, spine, and wrist.
Medical–Surgical
Ten million individuals in the United States have osteopo-
rosis, and another 34 million have low bone mineral density,
which places them at risk for osteoporosis (NOF, 2008d). Of
those affected by osteoporosis, 80% are women (NOF, 2008d).
Management
In 2005, more than 2 million osteoporosis related fractures There is no cure for osteoporosis. Prevention through diet,
occured, including 297,000 hip fractures, 547,000 vertebral regular exercise, eliminating tobacco and alcohol use, hav-
fractures, 397,000 wrist fractures, 135,000 pelvic fractures, and ing BMD testing, and taking medication is possible for most
675,000 fractures of other types (NOF, 2008d). people (NOF, 2002e).

PROFESSIONALTIP PROFESSIONALTIP

Absolute Fracture Risk Osteoporosis

A DXA machine is in development that reports an Risk factors for osteoporosis include being female,
absolute fracture risk. The report uses a client’s having thin or small bones, history of fractures,
bone mineral density results, age, risk factors advanced age, family history of osteoporosis,
for osteoporosis, and fractures to determine the postmenopause without estrogen replacement
client’s risk of a fracture in the next 10 years. therapy, amenorrhea, eating disorders, low calcium
The information enables health care providers to intake, inactive lifestyle, smoking, excessive alcohol
determine appropriate osteoporosis treatment intake, use of corticosteroids or anticonvulsant
(NOF, 2008d). medications, and low testosterone level in men.

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 CHAPTER 9 Musculoskeletal System 291

Pharmacological
Several medications are approved for the prevention and treat-
ment of osteoporosis. Alendronate sodium (Fosamax) and
alendronate plus vitamin D3 (Fosamax plus D™), risedronate
CULTURAL CONSIDERATIONS
(Actonel®) and risedronate with calcium (Actonel® with
calcium), and zoledronic acid (Reclast®) are used for preven- Osteoporosis
tion and treatment of osteoporosis in postmenopausal men • Significant risk has been reported in persons of
and women. Ibandronate (Boniva®) is used for prevention all ethnic backgrounds.
and treatment of postmenopausal women only. Calcitonin
(Forical® and Miacalcin®) is used in treatment of osteoporo- • White women older than age 65 have twice
sis in women at least 5 years beyond menopause. Raloxifen as many fractures as African American women
(Evista®), an estrogen agonists/antagonists or selective estro- (NOF, 2002c).
gen receptor modulators (SERMs), is used for the prevention • White men are at greater risk for osteoporosis,
and treatment of osteroporosis in postmenopausal women. but osteoporosis is found in men from all ethnic
Estrogen is used both for prevention and treatment, but groups (NOF, 2002d).
according to the FDA, other medications should be used first
(NOF, 2008c). Estrogen is used both for prevention and treat-
ment, but according to the FDA, other medications should be
used first (NOF, 2008c). Teriparatide (Forteo®), a parathyroid
hormone, is used in the treatment of postmenopausal men and
women with very low BMD and at risk of a fracture. The FDA Osteoporosis
recommends the client take teriparatide for no more than
2 years (NOF, 2008c). • Maintain physical activity—walking, isometric
Testosterone-replacement therapy may be used for men exercises.
with low testosterone levels. • Remove potential hazards, such as throw rugs.
Nonnarcotic analgesics are prescribed for relief of pain.
The client also is advised to take supplemental vitamin D with • Eat a diet high in calcium and vitamin D.
calcium. • Be out in the sun 10 to 15 minutes a day.
• Move items down from top shelves of cupboards
because it is difficult to see or reach the items as
Diet a result of curvature changes in the spine.
Encourage the client to maintain an adequate balanced diet
• Wear sturdy shoes.
rich in calcium and vitamin D. A reduction in the consump-
tion of caffeine, alcohol, excess protein, and smoking cessation
is recommended.
NURSING PROCESS
Activity Assessment
Encourage the client to practice good body mechanics and
posture and to walk, preferably outdoors for the benefits of Subjective Data
sunshine (vitamin D). This is effective in preventing further This includes the client’s gender, age, and family health history.
bone loss and stimulating new bone formation. Note any symptoms the client expresses regarding altered body
image or back or neck pain that worsens when coughing, sneez-
ing, straining, or standing. Take a nutritional history. Note life-
Nursing Management style patterns such as smoking, inactivity, or immobilization. A
medical history regarding any medications is also important.
Encourage clients to prevent osteoporosis through a diet
adequate in calcium and vitamin D, regular exercise, and elimi-
nating tobacco and alcohol use. Teach correct body mechanics
Objective Data
and encourage good posture. Kyphosis, gait impairment, and poor posture are noted.

Nursing diagnoses for a client with osteoporosis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to The client will express Administer analgesics as ordered; teach client about the
disease process minimal discomfort. medications.
Handle client carefully; instruct client to avoid any twisting
movements.
The bed should have a firm mattress or bed board for support.

(Continues)

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292 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for a client with osteoporosis include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related to The client will practice Teach client correct body mechanics.
disease process correct body mechanics.

Impaired Physical The client will maintain Teach client about types of exercises and physical activities
Mobility related to physical activity. that help maintain bone mass and isometric exercises to
disease process strengthen muscles.
Encourage ambulation with the client using a walker or cane if
necessary.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

The onset of osteoarthritis begins during middle

■ OSTEOARTHRITIS (DEGENERA- age, and by age 65 most people have some degeneration.
TIVE JOINT DISEASE) Symptoms include early morning stiffness and pain after

O
physical activity. There is joint enlargement and charac-
steoarthritis (OA) is considered a “wear-and-tear” dis- teristic hypertrophic spurs, called Heberden’s nodes, in
ease and is characterized by slow and steady progressive the terminal interphalangeal finger joints. More women
breakdown of cartilage. It is a nonsystemic, noninflammatory are affected with OA, especially in the hands. The hips are
disorder causing bones and joints to degenerate. It is the most more affected in men.
common type of arthritis. The etiology is unknown, but pre- Diagnosis is made from the client’s symptoms and
disposing factors include increased age, obesity, an injury to examination of the joints that are enlarged and tender. X-ray
a joint, poor posture, or occupations that put strain on joints. shows a narrowing of joint spaces and gross irregularities
Genetics plays a role in OA, especially in the hands (Arthritis of joint structure. A CT scan or MRI shows vertebral joint
Foundation, 2002b). The weight-bearing joints of the lower involvement.
extremities as well as the hands and cervical and lumbar ver-
tebrae are the joints most frequently affected. The cartilage
covering the bone becomes thin and then wears off. The syn-
ovial membrane thickens and fibrous tissue around the joint
Medical–Surgical
ossifies. The effects of degenerative changes on the knee joint Management
are shown in Figure 9-13.
Medical
No treatment exists to stop the degenerative process; there-
fore, treatment focuses on relief of the client’s discomfort.
Medical management includes local heat and rest for the
affected joint, weight reduction for obese clients to relieve
Degeneration
of cartilage
strain on affected joints, and orthotic devices (braces, canes,
crutches) to support the joints. Physical therapy can provide
exercises to strengthen muscles and keep joints flexible and
Possible increased teach self-management skills.
synovial fluid

Surgical
Loose cartilage
particles
Surgical procedures such as total hip or knee replacement
may be recommended for clients with severe osteoarthritis.
Osteotomy may help correct malalignment situations. Refer to
Osteophyte the section on total joint arthroplasty in this chapter.
COURTESY OF DELMAR CENGAGE LEARNING

Loss of cartilage
Pharmacological
Pharmacological treatment includes the use of aspirin or
NSAIDs. Narcotics are avoided because of the chronic
nature of the disease. Steroids may be used and are some-
times injected into a joint to provide immediate relief of
pain and to stop the degenerative process temporarily. If
the client has vertebral involvement with muscle spasms,
Figure 9-13 Degenerative Changes in the Cartilage of the cyclobenzaprine hydrochloride (Flexeril) may be given to
Knee Due to Osteoarthritis relax the muscles.
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 CHAPTER 9 Musculoskeletal System 293

joint. Collaborate with physical therapy for muscle-strength-

ening exercises and self-management skills.
CLIENTTEACHING
Osteoarthritis
• Set priorities each day, and do the most
NURSING PROCESS
important activities first.
• Do not plan too many activities for one day.
Assessment
• Plan rest periods during the day between
Subjective Data
activities. The client describes nonspecific symptoms such as general
musculoskeletal pain, joint stiffness especially on rising, and
• Prevent rushing and stressful situations by
joint pain or tenderness. Note weight gain, occupation, and
planning ahead. any conditions or situations that exacerbate the client’s joint
• Lose weight, if necessary. pain. Some of these situations include cold weather, overex-
• When knees or hips are affected, avoid climbing ercising, or extreme fatigue. Assess the client’s understanding
stairs, bending, stooping, or squatting. of the disease and its effect on lifestyle and ability to perform
activities of daily and social living.

Objective Data
Nursing Management This includes edema and tenderness around the joints and
Encourage clients to maintain a proper weight for height and bony enlargements of distal interphalangeal joints (Heberden’s
to practice good posture. Provide rest and heat for the affected nodes).

Nursing diagnoses for a client with osteoarthritis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to The client will express Handle the affected extremity gently and apply heat as ordered.
joint tenderness and minimal discomfort. Administer prescribed analgesic and evaluate its effectiveness.
edema

Impaired Physical The client will maintain Coordinate with physical therapy and assist in a planned
Mobility related to joint mobility within the exercise program as ordered.
deterioration parameters of the disease Advise client to plan rest periods during the day.
process.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

and a faster rehabilitation. The incisions are 2 to 3 inches or less,

■ TOTAL JOINT ARTHROPLASTY whereas the traditional method has a 10- to 12-inch incision on

J
the side of the hip and possibly with a portable suction device in
oint replacement or arthroplasty is the replacement of place (AAOS, 2007c). The traditional method has more drain-
both articular surfaces within a joint capsule. The hip, knee, age and the drain is removed when the drainage is 30 mL or less.
shoulder, and fingers are the joints most frequently replaced. The hip prosthesis by either method can be cemented in place
Replacements consist of metal and polyethylene and may be or be coated with a special textured metal or bone-like sub-
cemented in the prepared bone with methyl methacrylate, stance that is not cemented into the joint. A cemented ball and
which has properties similar to bone. See Figure 9-14 for knee- a noncemented socket are sometimes used (AAOS, 2007d).
and hip-replacement components. Surgical complications are venous thrombosis, bleeding,
Newer techniques use porous-coated cementless artificial respiratory problems, and, after several years, the hip prosthe-
joint components. These allow bone to grow into the joint sis may loosen or need replacing. Potential problems with the
component and securely fix the prosthesis. This reduces the hip replacement include dislocation of the prosthesis, exces-
incidence of prosthesis failure. Joint replacement is usually an sive wound drainage, and infection. To prevent venous throm-
elective procedure, and clients may wish to have autologous bosis, antiembolism stockings are worn. They are removed
blood transfusions whereby they predonate their own blood twice daily to inspect the skin.
in case a blood transfusion is needed. After a total hip replacement, the client’s hip and leg are
kept in a position of abduction and extension. The knees
Total Hip Replacement are kept apart by using a foam V-wedge, several pillows, or
an abductor pillow. When the client turns from the back to
Total hip replacement is the replacement of a damaged hip with a side-lying position, the entire leg is supported with pil-
an artificial joint. The hip is replaced with a traditional proce- lows to keep the hip abducted. The client usually prefers to
dure or a minimally invasive procedure. The minimally invasive lie on the unaffected side. Instruct the client to avoid acute
method has less pain, less muscle injury, shorter hospitalization, hip flexion of greater than 90 degrees. The legs should not
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294 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Pelvis
Hip Knee

Metal Polyethylene Femur

Metal

A B
Metal

Femur

COURTESY OF DELMAR CENGAGE LEARNING

Polyethylene

Tibia

Figure 9-14 A, Total Hip and Knee Replacement; B, Radiograph of a Total Knee Replacement (Anterior-Posterior View). The
patella is plastic, and, therefore, it is not visible here.

be crossed nor the hips flexed to pull up a blanket or sheet. an adjustable soft knee immobilizer to stabilize the leg when
A fracture bedpan is used until the client can ambulate to walking. The client may transfer out of bed to a wheelchair
the bathroom. Use a raised toilet seat in the bathroom or a with the immobilizer in place. No weight bearing is allowed on
bedside commode. Any specific client turning, movement, the knee until it is prescribed by the surgeon.
and positioning are ordered by the physician. Vital signs and The most common complication after total knee replace-
CMS checks are performed routinely. Encourage the client ment is blood clots in the leg veins. The orthopedic surgeon
to cough and deep breathe or use an incentive spirometer may order periodic elevation of legs, leg exercises to improve
after surgery to prevent respiratory problems. Inspect the circulation, support hose, and an anticoagulant (AAOS,
dressings frequently. 2007e).
The goal for clients who have total hip or knee joint
replacement is to ambulate independently. Ambulatory
activity progresses rapidly for clients with joint replace- Nursing Management
ment. Clients who have total hip replacement are usually Perform neurovascular assessment of the affected extremity
out of bed the night of surgery or early the next day. Physi- as well as incision assessment, vital signs, lung sounds, pedal
cal therapy teaches exercises to strengthen the hip muscles. pulses, and I&O. Maintain the client’s hip in a position of
Gait training begins with the use of a walker and progresses abduction and extension for 6 to 10 days as ordered. Keep
to the use of crutches or a cane. The client avoids hip flex- client’s skin and bed dry and clean. Encourage the client to
ion of more than 90 degrees and stair climbing for at least cough and deep breathe and to use the trapeze to raise hips off
3 months. the bed for bedpan use.

Total Knee Replacement NURSING PROCESS

Total knee replacement, like hip replacement, is considered Assessment
for clients experiencing severe pain and functional disability
related to joint destruction. The prosthesis chosen for the Subjective Data
replacement provides the client with a painless, stable, and Assess for irritability, restlessness, orientation, and neurovas-
functional joint. cular assessment of the affected extremity for pain, numbness,
Immediately after surgery a firm compression dressing tingling, and paresthesia.
is applied to the operative site. The physician may order a
special ice machine applied to circulate ice water around the
knee. The cold water decreases pain and swelling. After the Objective Data
dressing is removed, a CPM machine helps increase circula- Assess the incision for approximation, redness, and drainage
tion to the operative area and promotes flexibility within the and the skin over all bony prominences. Assess for tachypnea,
knee joint. The surgeon orders the frequency of use and dyspnea, hypoxemia, and crackles and wheezes in the lungs
the amount of tension, flexion, and extension produced by the (signs of fat embolism). Vital signs, pedal pulses, and I&O are
machine. A sequential compression device (SCD) is used or also assessed.
antiembolism stockings worn to minimize the development The client with a total hip replacement is assessed for
of thrombophlebitis. After the arthroplasty, the client wears position of the affected hip. The hip should be maintained in

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 CHAPTER 9 Musculoskeletal System 295

a position of abduction and extension. The most prominent Assessment of the client with a total knee replacement
symptom of a dislocation is a clicking, popping sound. Other includes the neurovascular status of the leg and the dressing and
symptoms are a sudden sharp pain that is unrelieved by narcotic drainage device. Vital signs, intake and output, and the color and
analgesics, loss of leg motion, and edema of the affected hip. The temperature of the extremity are also assessed. The knee is elevated
client is not moved, and the physician is notified immediately. and the nurse monitors the ice machine and CPM machine.

Nursing diagnoses for a client undergoing arthroplasty surgery include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Skin Integrity The client’s skin will remain Maintain a clean and dry dressing. If a drainage device is used,
related to immobility and free from redness or any assess functioning.
surgical incision other signs of breakdown. Keep client’s skin and bed clean and dry. Assess bony
prominences for redness.
Provide high-protein diet with dairy products and vitamin C.

Impaired Physical The client will ambulate Keep hip in a position of abduction. Use an abductor pillow
Mobility related to following physician’s or wedge to maintain the position when turning the client.
surgery direction. Encourage client to use the trapeze to raise hips off the bed to
use the bedpan.
Assist client in accomplishing activities of daily living.

Ineffective Peripheral The client will have Encourage client to cough and deep breathe.
Tissue Perfusion related adequate circulation of Monitor vital signs until stable. Assess pedal pulses and
to surgery and immobility extremity. capillary refill in both extremities.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

MUSCULOSKELETAL Medical–Surgical Management

DISORDERS Medical

M
Rehabilitation for the client with an amputation requires the
usculoskeletal disorders discussed include amputations, effort of the entire rehabilitation team. The client’s physical
temporomandibular joint disease/disorder, and carpal and psychological responses to the amputation are monitored
tunnel syndrome. by all members of the team. If appropriate, counseling and job
training will enable many clients to return to their jobs.

■ AMPUTATIONS Surgical

A
Before surgery, the surgeon evaluates the client and makes
n amputation is the removal of all or part of an extrem- several decisions. These decisions include necessity of an
ity. Amputations are done in response to injuries result- amputation, type of amputation (open or closed), level of
ing in extensive laceration of arteries or nerves, or diseases amputation, potential for rehabilitation, and type of prosthesis
such as malignant tumors, infections, and peripheral vascular and rehabilitation program.
disorders. Other disease conditions that may require amputa- The surgeon attempts to save as much of the limb as
tion include extensive osteomyelitis or congenital disorders. possible. A closed amputation is done by using skin flaps to
In severe trauma situations, an amputation may be done to cover the bone end of the extremity. This type of amputation
save the client’s life. is done when there is no evidence of infection. Sometimes a
Recent advances in microsurgical techniques have allowed Guillotine (open) amputation is necessary. This amputation
replantation (limb reattachment) in some injuries. These pro- requires a straight cut and allows for free drainage of infectious
cedures involve the use of microscopes and highly specialized material. Tissue, bone, and vessels are severed at the same level
instruments to reconnect severed nerves and blood vessels. without skin flaps. The major indication for doing an open
Amputations involving the hand or wrist are more likely con- amputation is infection.
sidered for replantation rather than an injury involving a large The level of an amputation is determined by the vascular
muscle mass because of extensive tissue, bone, and muscle supply and is never higher than absolutely necessary. If the
damage. Any amputation creates a major physical and psycho- blood flow at the site of the incision is normal, the amputation
logical adjustment for the client. is performed at that level. If the bleeding is scant, a higher level

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296 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

stretch the flexor muscles and prevents contractions of the hip.

Physical therapy starts exercises to prevent contractures and
increase muscle strength and assists with ambulation as soon
after surgery as possible.

Above-knee
amputation Nursing Management
Perform routine postoperative care by encouraging deep
breathing, coughing, and turning; assessing pain on a 1 to
10 scale; and administering analgesics as ordered. The
residual limb is shaped for prosthesis by using a figure-8
wrapping of wide elastic bandages. Some physicians prefer a
two-way elastic compression shrinker that forms the residual
Below-knee
amputation limb to the prosthesis. Other more rigid dressings are also
used.
Encourage client to eat a balanced diet with extra
COURTESY OF DELMAR CENGAGE LEARNING
protein for wound healing. Collaborate with physical ther-
apy regarding bed exercises, transfer techniques, and later
ambulation.

Syme amputation
Mid-foot amputation
(e.g., Lisfranc and Toe amputation
NURSING PROCESS
Assessment
Chopart procedures)

Figure 9-15 Different Amputation Levels

Subjective Data
Subjective assessment data include pain, sensations felt on
the extremity to be amputated, and the emotional status of
of amputation is performed to ensure adequate postoperative the client. If a client has experienced chronic pain before
healing. See Figure 9-15 for different lower-extremity amputa- the amputation, pain may seem mild following the surgery.
tion levels. Severe pain may indicate a hematoma or excessive pres-
sure from a cast or elastic bandage on a bony prominence.
Sometimes the client confuses phantom limb pain with
Pharmacological the incisional pain. Phantom limb pain is the sensation that
Narcotic analgesics are required immediately after surgery. there is pain, soreness, tingling, burning, and stiffness in the
After several days, pain is controlled with nonnarcotic anal- amputated limb. The sensory sensations of the missing limb
gesics. If infection exists, appropriate antibiotic therapy is remain in the brain causing the feelings of phantom pain.
ordered. Phantom pain decreases as inflammation subsides at the
incisional site.
Diet
A balanced diet with adequate vitamins and protein is essential Objective Data
for adequate wound healing. Many elderly clients are poorly Objective assessment data include the color and tempera-
nourished or require special diets. Nutritional care plans are ture of the skin, pulse, and responses to limb movement.
discussed with the physician and a dietitian. The unaffected extremity also is assessed for function and
circulation.
Activity
The surgeon determines postoperative positioning of the
stump. The stump is alternately placed in an extended position
or elevated on pillows for short periods. Encourage the client PROFESSIONALTIP
to spend some time in the prone position. This position helps
Robotic Ankle

CRITICAL THINKING Hugh Herr developed a robotic ankle that

simulates the action of the human ankle-foot. The
prosthesis is made with springs and an electric
Phantom Limb Pain
motor so it propels the person with each step,
giving the person a natural appearing gait. The
How would you explain phantom limb pain to a
robotic ankle makes one less tired when walking
client?
and improves balance (MIT, 2007).

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 CHAPTER 9 Musculoskeletal System 297

Nursing diagnoses for a client who has an amputation include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Skin Integrity The client will remain free Inspect the incision for any inflammation, excessive
related to amputation from infection. drainage, edema, increased pain, and hypersensitivity to
touch.
Use aseptic technique for all dressing changes.
Monitor vital signs.

Disturbed Body Image The client will participate Handle the residual limb gently and treat it as though a
related to loss of limb in the care of the residual prosthesis will be worn.
limb. Encourage client to watch dressing change and eventually
assist with and do the dressing changes.
Encourage client to express feelings and concerns about the
amputation.

Impaired Physical The client will demonstrate Encourage client to participate in physical therapy and to
Mobility related to loss improved physical mobility. perform ROM exercises.
of limb Assist client when ambulating with assistive devices.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with a Below-the-Knee Amputation

R.S. is a 76-year-old resident in a retirement home. She has remained active since her retirement from
the secretarial job she held for 20 years. Her health history indicates she has had circulatory problems
with inadequate peripheral circulation resulting from atherosclerosis. Her physician hospitalized her
for a planned below-the-knee amputation on the left leg and has ordered an arteriogram to assist in
determining the site for the amputation. The arteriogram determines the point of adequate circulatory
status to promote wound healing after the limb is amputated.

The nurse’s assessment of R.S.’s vital signs are blood pressure 120/68 mm Hg, pulse 72 beats/minute,
and respirations 18 breaths/minute. Femoral pulses are present in both extremities; however, the
pedal pulse in her left foot is barely palpable, and the skin is cool and pale. She stated that lately
her left foot is always cold and is a bluish-black color. R.S. expresses concern about her ability to take
care of herself after she loses her foot.

NURSING DIAGNOSIS 1 Disturbed Body Image related to scheduled amputation as evidenced by

statement of concern over losing foot
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Psychosocial Adjustment: Life Change Body Image Enhancement
Grief Resolution Grief Work Facilitation

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.S. will communicate her Involve R.S. in participating in her Gives sense of independence.
concerns and feelings about daily care.
the changes in her body image.
Encourage R.S. to voice her Helps resolve concerns.
concerns.

(Continues)

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298 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Provide positive reinforcement Encourages client to continue
when R.S. attempts to adapt to adapting.
body changes.

EVALUATION
R.S. has demonstrated beginning acceptance of body changes by taking an active interest in her
appearance.

NURSING DIAGNOSIS 2 Situational Low Self-Esteem related to loss of body part as evidenced by
expression of concern about ability to care for self
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Psychosocial Adjustment: Life Change Coping Enhancement
Decision Making Support Group
Cognitive Restructuring

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.S. will identify at least two Encourage R.S. to express her Helps identify positive qualities.
positive qualities about herself. feelings about herself.
Involve R.S. in decision making Helps maintain a sense of control
regarding her care. over her life.
Provide R.S. with positive Gives a feeling of acceptance and
feedback. approval.

EVALUATION
R.S. has voiced two positive qualities about herself.

NURSING DIAGNOSIS 3 Deficient Knowledge related to postoperative care and activity as evi-
denced by concern about ability to care for self
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Treatment Regimen Teaching: Procedure/Treatment

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

R.S. swill perform stump wrapping Encourage R.S. to participate in Helps client adjust to body
correctly. the care of the residual limb. changes.
Demonstrate how to wrap her Helps client to know how to care
stump, then allow her to do it for self.
several times.

EVALUATION
R.S. demonstrated the ability to care for the residual limb by wrapping the stump correctly.

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 CHAPTER 9 Musculoskeletal System 299

NURSING DIAGNOSIS

Anticipatory Grieving related to loss associated with amputation as evidenced by her expression
of concern

NOC: Coping, Grief Resolution

NIC: Coping Enhancement, Grief Work Facilitation, Emotional Support, Anticipatory Guidance

NURSING GOAL
R.S. will express her feelings about the loss of her foot.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Encourage R.S. to express her feelings by 1. Gives several options for expression.
talking, crying, writing.

2. Spend quality time each shift with R.S. to 2. Allows.expression of feelings and shows
let her share her thoughts and feelings. concern and understanding.

3. Inform R.S. and her family about support 3. May help R.S. find new ways of adapting to
groups and organizations in the community. loss.

EVALUATION
Is R.S. expressing feelings about her potential loss?

Concept Care Map 9-1

a combined hinge and gliding joint. Normally, the mandible

■ TEMPOROMANDIBULAR moves smoothly, appears symmetrical, and is without defor-
JOINT DISEASE/DISORDER mity. Causes for TMD include trauma, stress, teeth clenching,

T
or grinding (bruxism), and joint diseases such as rheuma-
emporomandibular joint disease/disorder (TMD) is toid arthritis or osteoarthritis. Common symptoms of TMD
commonly referred to as TMJ. It is a collection of condi- include limited jaw movement, clicking or crepitus when the
tions affecting the temporomandibular joint and/or the mus- jaw moves, popping when chewing or talking, and radiating
cles of mastication. More than 10 million people in the United pain in the face, neck, or shoulders. The clicking is caused
States have TMD. It affects both males and females, but 90% by displaced cartilage. The jaw may lock as a result of muscle
of those seeking treatment are females between puberty and spasms.
menopause (The TMJ Association, 2002). Diagnosis of TMD may include an x-ray to evaluate the
The temporomandibular joint is the articular surface bony structure, a CT scan to evaluate any degenerative changes,
between the mandible and temporal bone of the skull. It is an MRI or arthrography, and an evaluation of the teeth and jaw

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300 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

in a bite position. Nursing assessment of the joint includes

movement and appearance. If the mandible protrudes, it may
indicate a mandibular dislocation. Transverse
carpal
ligament
Medical–Surgical Tenosynovium

Management
Medical
Medical management consists of moist heat to promote
muscle relaxation, cold therapy to reduce muscle spasms, and
analgesics or nonsteroidal anti-inflammatory drugs. Clients
may be fitted with a dental retainer or bite plate to prevent

COURTESY OF DELMAR CENGAGE LEARNING

teeth clenching or grinding, or splints to help realign maloc-
clusions. Carpal
bones
A B
Surgical Median
nerve
Procedures such as arthroscopy or surgery to reshape the joint Carpal
bones Flexor
may be done in some cases that do not respond to medical tendons
treatment.
Figure 9-16 Carpal Tunnel Syndrome; A, Cross-section
Diet of carpal tunnel shows nerves and tendons; B, Inflamed flexor
tendons and tenosynovium put pressure on the median nerve.
A soft diet allows the jaw and muscles to relax. Clients are
advised against chewing gum.
nerve. After surgery, the hand is elevated and may be in
Nursing Management a splint for up to 2 weeks. Lifting is restricted for several
weeks.
Encourage clients to practice relaxation techniques. Advise
client to see a dentist for an evaluation of the teeth and jaw
and to use the dental retainer or bite plate if given one. Pharmacological
Anti-inflammatory drugs may decrease inflammation and
edema and reduce symptoms. NSAIDs may provide pain
■ CARPAL TUNNEL SYNDROME relief. If symptoms are not controlled with these measures,

C
cortisone is injected into the carpal tunnel.
arpal tunnel syndrome occurs when the median nerve
in the wrist is compressed by inflamed, edematous
flexor tendons and tenosynovium (Figure 9-16). Symptoms
include pain, paresthesia, and weakness of the thumb, index,
Nursing Management
middle and part of ring fingers, but never the little finger. Per- Encourage clients performing repetitive hand movements to
sons performing assembly line work or extensive keyboarding take rest periods from the task.
are especially at risk. Assemblers are three times more likely
to have carpal tunnel than data-entry personnel (NINDS,
2002). Arthritis or fractures may also be a cause. Diagnosis
is based on a physical examination and the subjective symp-
NURSING PROCESS
toms of the client and may be confirmed by motor nerve
velocity studies.
Assessment
Subjective Data
Medical–Surgical Subjective assessment data consist of the client’s description
Management of tingling in the hands and numbness in the thumb, index,
middle and part of the ring fingers. The client may also state
Medical that there is a feeling of “puffiness” in the affected hand and
that the client is unable to grasp or hold small objects. Wak-
Treatment consists of rest for the hands. Splints to immobilize ing in the middle of the night with pain and a feeling that the
the hand and wrist also are used to help relieve some of the entire hand is asleep is very common.
discomfort.

Surgical Objective Data

If conservative treatment does not control the symptoms, Objective assessment data include atrophy of the padded area
surgery is necessary to relieve the pressure on the median at the base of the thumb.

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 CHAPTER 9 Musculoskeletal System 301

Nursing diagnoses for a client with carpal tunnel syndrome include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related The client will have less Administer analgesics as ordered and teach client
to inflammation and discomfort. about use, side effects, and dosage.
swelling causing pressure Encourage client to wear wrist brace.
on the median nerve
Encourage client to refrain from repetitive hand
movements.

Risk for Disuse The client will use fingers Teach client to do ROM exercises, and to prevent twisting and
Syndrome related to and hand. turning of wrist.
tingling and numbness of
hand and wrist

Evaluation: Evaluate each outcome to determine how it has been met by the client.

To reduce inflammation, NSAIDs are given, especially

SYSTEMIC DISORDERS WITH indomethacin (Indocin) and ibuprofen (Motrin). Colchicine
MUSCULOSKELETAL (Colsalide) is added in acute cases. When tophi develop,
medicine to reduce hyperuricemia is used, such as allopurinol
MANIFESTATIONS (Zyloprim) and probenecid (Benemid).

S ystemic disorders that result in musculoskeletal symptoms

include gout and Lyme disease.
■ LYME DISEASE
■ GOUT
L yme disease is caused by a spirochete, Borrelia burgdorferi,

G
carried by deer ticks. In the United States, it has been
out is a metabolic disease of ineffective purine metab- reported in nearly all states, but Lyme disease is endemic in
olism resulting in deposits of needlelike crystals Connecticut, Delaware, Maryland, Massachusetts, Minne-
of uric acid in connective tissue, joint spaces, or both. sota, New Jersey, New York, Pennsylvania, Rhode Island, and
Middle-aged men are most commonly affected, but it may Wisconsin. The onset of the disease is most prevalent in May
occur in women after menopause. Gout may be primary (7%), June (25%), July (29%), and August (13%) (MMWR,
(an inherited problem with purine metabolism), secondary 2005).
(complication from another disease or from use of certain These ticks should be removed by using a tweezers. Early
drugs), or idiopathic (unknown cause). Up to 18% of cli- manifestations occur from spring through late fall. People
ents with gout have a family history of the disease (NIAMS, living in states with a high incidence of Lyme disease should
2002b). The excessive use of alcohol interferes with uric wear protective clothing and check for ticks frequently. Insect
acid removal from the body and may contribute to or exac- repellent containing 20% to 30% DEET is applied to exposed
erbate symptoms. parts of the body and to clothing (CDC, 2008). For preven-
The acute gout attack begins abruptly with severe constant tive protection, household pets wear a flea and tick collar, are
pain. The joint becomes swollen, red, and tender. The great given monthly preventive medication, and also are checked
toe is the joint most frequently involved; however, any joint frequently for ticks.
may be affected. The course of gout is variable, with one to two For most individuals, the first symptom is a red rash
attacks being severe. If the disease is untreated, the attacks may called erythema migrans. It starts as a red spot at the site of
occur with increasing frequency. Clients with symptoms of the tick bite and expands, resembling a bull’s eye. Other symp-
gout develop tophi, which are subcutaneous nodular deposits toms are headache, neck stiffness, fever, swelling in the knees
of sodium urate crystals appearing in various parts of the body, and other large joints, and muscle pain. For those individuals
including the rim of the ears, the knuckles, and great toe. Diag- untreated with antibiotics, arthritis (joint swelling and pain),
nosis is made from the client’s health history and an examina- fatigue, and neurological abnormalities such as facial palsy,
tion of the affected joint. Aspiration of the joint synovial fluid meningitis, and encephalitis become evident. The antibody
may show urate crystals. The client should be instructed to test ELISA is used to identify antibodies to B. burgdorferi in
avoid foods high in purine, such as liver, sardines, sweetbreads, blood or spinal fluid specimens. Antibiotics such as doxycy-
anchovies, gravies, and asparagus. Avoid excessive use of alco- cline (Vibramycin), cefuroxime exetil (Ceftin), or amoxicillin
hol. Oral fluid intake is increased to 3,000 mL per day to reduce (Amoxil) speed healing of the rash and may prevent arthritis
the possibility of urate stone formation in the kidneys. and neurologic symptoms.

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302 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

CASE STUDY
G.E., a 40-year-old truck driver, was getting ready to help unload his cargo. He was climbing into the truck when
he lost his balance and fell to the ground, twisting his left leg. He stated he was in severe pain and was unable to
stand. His coworkers called the emergency ambulance service to transport him to the hospital. Upon arrival in the
emergency department, the nurse immediately took G.E.’s vital signs, which were temperature 98.6°F, pulse 92
beats/minute, respirations 24 breaths/minute, and blood pressure 158/90 mm Hg. The nurse also noted that G.E.’s
face was flushed and his left leg was shorter than his right.
The following questions will guide your development of a nursing care plan for the case study:
1. List five types of fractures.
2. Based on the action of the fall, what type of fracture do you think G.E. sustained?
3. What diagnostic measures will determine whether or not G.E. has a fracture of his left leg?
4. What would be the best immediate care for G.E.?
5. List four nursing interventions for clients in traction.
6. What possible treatment options are best for G.E.’s injury?
7. What objective and subjective data are important for the nurse to obtain regarding G.E.’s injury?

SUMMARY
• When assessing the client with a musculoskeletal disorder, pulleys, use the prescribed amount of weights, and keep
the nurse evaluates any changes in appearance, including the weights hanging freely.
alignment, loss of motion, and any signs of circulatory • Osteoarthritis is characterized by slow progressive
impairment. degeneration of joint articular cartilage.
• Treatment of a fracture includes any one or more of the • Hips, knees, and fingers are the joints most frequently
following methods: closed reduction, open reduction that considered for replacement.
may include internal fixation, casts, and traction. • After total hip replacement, the hip is kept in a position of
• Compartment syndrome is a serious form of neurovascular abduction and extension.
impairment. Symptoms include severe pain that is not • After total knee replacement surgery, some clients use a
relieved with narcotic analgesics, sluggish capillary refill, CPM machine that promotes knee joint flexibility and
weak pulses, numbness, and paralysis. increased circulation to the operative area.
• When a client is in traction, it is important to remember • Individuals at greatest risk for developing osteoporosis
to preserve body alignment, maintain continuous pull and are postmenopausal women and older adults who are
countertraction, keep the ropes moving freely through the generally inactive.

REVIEW QUESTIONS
1. A client is admitted to the hospital and expresses 1. scoliosis.
concerns for his job. This information will become 2. lordosis.
what part of his nursing care plan? 3. contracture.
1. Nursing diagnosis. 4. muscle atony.
2. Goal. 4. A client is admitted to the hospital with
3. Validating data. osteoarthritis (degenerative joint disease).
4. Evaluation. Upon assessing the client, the nurse expects to
2. A client returned from surgery with an internal find: (Select all that apply.)
fixation of the right femur. The nursing primary 1. nausea after each meal.
treatment goal of the repaired fracture is: 2. joint stiffness especially on arising.
1. aid in the formation of osteoclasts. 3. an increased appetite.
2. establish a callus between the broken ends of 4. muscle spasms after exercising.
bone. 5. Heberden’s nodes.
3. aid in the formation of granulation tissue. 6. pain after physical exercise.
4. prevent further injury to the fractured limb. 5. A 48-year-old man has suffered low-back pain and
3. A nurse enters the room and notices a client in sciatica for over 2 years. He is admitted to the
skeletal traction is lying with poor positioning hospital for evaluation and treatment of this
and alignment. The nurse repositions the client in problem. A thorough assessment of his level
good alignment to prevent the possible deformity of discomfort from low-back pain is important
of: primarily because:
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 9 Musculoskeletal System 303

1. this will provide a baseline for later comparison. 8. A client was admitted to the hospital following a
2. this is a method for identifying clients with “low motorcycle accident with multiple fractures to the
back neurosis.” left leg. A long leg cast was applied and 6 hours after
3. clients who have pain localized to the back and surgery the client is expressing extreme pain in his
radiating to one extremity are probably not left leg after receiving medication by a PCA. The
candidates for surgery. nurse suspects compartment syndrome. If the nurse
4. surgery is contraindicated for clients who have is correct, what other symptoms would the client
had pain for less than 2 years. have? (Select all that apply.)
6. In preparing a teaching plan for an adult who has 1. Sluggish capillary refill.
had an arthroscopy, what following information will 2. Pain from the lower spine down the back of
the nurse include? the leg.
1. Client should check extremity for color, mobility, 3. Numbness or tingling in the leg.
and sensation at least every 2 hours after the 4. Weak pulse in the left toes and strong pulse in the
procedure. right toes.
2. Client may return to regular activities 5. Increased length of the right leg.
immediately after procedure. 6. Foul odor from the cast.
3. Remove compression dressing 6 to 8 hours after 9. An appropriate nursing diagnosis for a client with a
procedure. recent amputation is:
4. Keep extremity in flexion for 24 hours after 1. Ineffective Peripheral Tissue Perfusion.
procedure. 2. Risk for Injury.
7. A client just returned from surgery for the repair of a 3. Nausea.
right fractured tibia and fibula and has a cast applied 4. Disturbed Body Image.
to the extremity. The nurse first: 10. A client was admitted to the hospital with a fracture
1. listens to the breath sounds for respiratory after a skiing accident. One of the most common
complications. fractures from this type of accident is:
2. listens to the abdomen for bowel sounds. 1. comminuted.
3. covers the client with a warm blanket. 2. greenstick.
4. checks the right toes for circulation, sensation, 3. spiral.
and movement. 4. impacted.

REFERENCES/SUGGESTED READINGS
American Academy of Orthopaedic Surgeons (AAOS). (2007a). Care Centers for Disease Control (CDC). (2008). Lyme disease.
of casts and splints. Retrieved April 8, 2009, from http://orthoinfo Retrieved April 9, 2009, from http://www.cdc.gov/ncidid.dvbid/
.aaos.org/topic.cfm?topic=a00204 lyme?prevention/ld_Prevention_Avoid.htm
American Academy of Orthopaedic Surgeons (AAOS). (2007b). Curry, L., & Hogstel, M. (2002). Osteoporosis. AJN, 102(1), 26–32.
Compartment syndrome. Retrieved April 8, 2009, from D’Arcy, Y. (2002). How to treat arthritis pain. Nursing2002, 32(7), 30–31.
http://orthoinfo.aaos.org/topic.cfm?topic=a00204 Daniels, R. (2009). Delmar’s guide to laboratory and diagnostic tests.
American Academy of Orthopaedic Surgeons (AAOS). (2007c). Clifton Park, NY: Delmar Cengage Learning.
Minimally invasive total hip replacement. Retrieved April 8, 2009, Daniels, R., Grendell, R., & Wilkins, F. (2010). Nursing fundamentals:
from http://orthoinfo.aaos.org/topic.cfm?topic=A00404 Caring & clinical decision making (2nd ed.). Clifton Park, NY:
American Academy of Orthopaedic Surgeons (AAOS). (2007d). Total Delmar Cengage Learning.
hip replacement. Retrieved April 8, 2009, from http://orthoinfo Estes, M. (2010). Health assessment & physical examination (4th ed.).
.aaos.org/topic.cfm?topic=A00377 Clifton Park, NY: Delmar Cengage Learning.
American Academy of Orthopaedic Surgeons (AAOS). (2007e). Total Fort, C. (2002). Getting a fix on long-bone fracture. Nursing2002,
knee replacement. Retrieved April 8, 2009, from http://orthoinfo. 32(6), 32hn1–32hn6.
aaos.org/topic.cfm?topic=A00389 Fort, C. (2003). How to combat 3 deadly trauma complications.
Arthritis Foundation. (2002a). Gout. Retrieved April 9, 2009, from Nursing2003, 33(5), 58–63.
http://ww2.arthritis.org/conditions/diseaseCenter/gout.asp Hayes, D. (2003a). How to wrap an above-the-knee amputation stump.
Arthritis Foundation. (2002b). Osteoarthritis. Retrieved April 9, Nursing2003, 33(1), 70.
2009, from http://ww2.arthritis.org/conditions/DiseaseCenter/ Hayes, D. (2003b). How to wrap a below-the-knee amputation stump.
oa.asp Nursing2003, 33(2), 28.
Bailey J. (2003). Getting a fix on orthopedic care. Nursing2003, 33(6), Ignatavicius, D. (2002). Catching compartment syndrome early.
58–63. Nursing2002, 32(11), 10.
Bryant, G. (2001). Stump care. AJN, 101(2), 67–71. Infectious Disease Society of America (IDSA). (2007). Updated
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. guidelines on diagnosis, treatment of Lyme disease. Retrieved April
(2008). Nursing Interventions Classification (NIC) (5th ed.). 9, 2009, from http://www.idsociety.org/Content.aspx?id=3744
St. Louis, MO: Mosby/Elsevier. Ingham Regional Orthopedic Hospital, A McLaren Health Service.
Burke, S. (2001). Boning up on osteoporosis. Nursing2001, 31(10), (2004). Regaining an active lifestyle: A helpful guide for patient
36–42. undergoing knee replacement surgery. Retrieved April 10, 2009, from
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http://www.irmc.org/documents/Health%20Articles/KNEE%20 National Osteoporosis Foundation (NOF). (2008c). Prevention: Five

REPLACEMENT%20BROCHURE.pdf steps to prevention. Retrieved April 9, 2009, from http://www.nof.
Lawrence, B., & Tasota, F. (2003). Detecting neuromuscular problems org/prevention/index.htm
with electromyography. Nursing2003, 33(4), 82. National Osteoporosis Foundation (NOF). (2008d). Fast facts on
Leslie, M. (2000). When the ache is not arthritis. RN, 63(3), 38–40. osteoporosis. Retrieved April 8, 2009, from http://www.nof.org/
Lewis, A. (1999). Orthopedic and vascular emergencies. Nursing99, osteoporosis/diseasefacts.htm
29(12), 54–56. North American Nursing Diagnosis Association International. (2010).
Lindgren, V. (2003). When to suspect this bone disorder. RN, 66(6), NANDA-I nursing diagnoses: Definitions and classification 2009-2011.
32–36. Ames, IA: Wiley-Blackwell.
Maher, A. (2002). Assessment of the musculoskeletal system. In A. B. O’Hanlon-Nichols, T. (1998). Basic assessment series: Musculoskeletal
Maher, S. W. Salmond, & T. A. Pellino (eds.), Orthopaedic nursing system. AJN, 98(6), 48–52.
(3rd ed., pp. 189–210). Philadelphia: W. B. Saunders Company. Overdorf, J., Pachuki-Hyde, L., Kressenick, C., McClung, B., &
McClung, B. (2001). Reducing your risk of osteoporosis. A Guide to Lucasey, C. (2001). Osteoporosis: There’s so much we can do. RN,
Women’s Health (supplement to Nursing2001), April, 4–8. 64(12), 30–34.
McConnell, E. (2001). Myth & facts . . . about gout. Nursing2001, 31(5), 73. Pauldine, E. (2003). Taking a bite out of Lyme disease. Nursing2003,
McConnell, E. (2002a). Assessing neurovascular status in a casted limb. 33(4), 49–52.
Nursing2002, 32(9), 20. Preboth, M. (2001). Lyme disease: New guidelines. American Family
McConnell, E. (2002b). Myths & facts . . . about compartment Physician, 63(10), 2065–2067.
syndrome. Nursing2002, 32(2), 92. Queensland Government. (2009). Introduction to stump care.
MedlinePlus®. (2007). Rhabdomyolysis. Retrieved April 7, 2009, from Retrieved April 8, 2009, from http://www.health.qld.gov.au/qals/
http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm docs/stump_care.pdf
MedlinePlus®. (2009). Lyme disease. Retrieved April 7, 2009, from Reeser, J. (2007). Stress fractures. Retrieved April 7, 2009, from http://
http://www.nlm.nih.gov/medlineplus/print/lymedisease.html emedicine.medscape.com/article/309106-overview
MMWR Weekly. ( June 15, 2005). Lyme disease—United States, Rogers, D. (2003). New meaning for safe sex. RN, 66(1), 38–41.
2003–2005. Retrieved April 7, 2009, from http://www.cd.gov/ Rupert, S. (2002). Pathogenesis and treatment of rhabdomyolysis.
mmwr/preview/mmwrhtml/mm5623al.htm Journal of the American Academy of Nurse Practitioners, 14(2), 82.
Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Sauret, J. M., Marinides, G., & Wang, G. K. (2002). Rhabdomyolysis.
Nursing Outcomes Classification (NOC) (4th ed). St. Louis, MO: American Family Physician, 65(1), 907.
Elsevier−Health Sciences Division. Spratto, G., & Woods, A. (2009). 2009 PDR nurse's drug handbook.
National Institute of Allergies and Infectious Diseases (NIAID). Clifton Park, NY: Delmar Cengage Learning.
(2008). Lyme disease. Retrieved April 9, 2009, from http://www3 Sullivan, M., & Sharts-Hopko, N. (2000). Preventing the downward
.niaid.nih.gov/topics/lymeDisease/ spiral. AJN, 100(8), 26–31.
National Institute of Arthritis and Musculoskeletal and Skin Diseases The Ohio State University Medical Center. (2008). External fixator.
(NIAMS). (2006a). Osteoarthritis. Retrieved April 9, 2009, from Retrieved July 27, 2009 from http://medicalcenter.osu.edu/
http://www.niams.nih.gov/Health_Info/Osteoarthritis/default.asp PatientEd/Materials/PDFDocs/surgery/ortho/externalfixation
National Institute of Arthritis and Musculoskeletal and Skin Diseases .pdf
(NIAMS). (2006b). Questions and answers about gout. Retrieved The TMJ Association. (2009). Changing the face of TMJ. Retrieved
April 9, 2009, from http://www.niams.nih.gov/Health_Info/Gout/ April 9, 2009, from http://www.tmj.org/
default.asp University of Iowa Health Care. (2008). Cast care. Retrieved
National Institute of Neurological Disorders and Stroke (NINDS). April 8, 2009, from http://www.uihealthcare.com/topics/
(2008). Carpal tunnel syndrome fact sheet. Retrieved April 9, bonesjointsmuscles/bone3418.html
2009, from http://www.ninds.nih.gov/disorders/carpal_tunnel/ Wade, C. (2000). Keeping lyme disease at bay. AJN, 100(7), 26–31.
detail_carpal_tunnel.htm Walls, M. (2002). Orthopedic trauma. RN, 65(7), 52–56.
National Osteoporosis Foundation (NOF). (2008a). Osteoporosis Wise, S. (in press). Assessing the musculoskeletal system.
bone density. Retrieved April 9, 2009, from http://www.nof.org/ Yarnold, B. (1999). Hip fracture. AJN, 99(2), 36–40.
osteoporosis/bonemass.htm Zdeblick, T. (2009) Compression and wedge fractures. Retrieved April
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Retrieved April 9, 2009, from http://www.nof.org/men/index.htm article1441.html

RESOURCES
American Occupational Therapy Association, Inc., National Osteoporosis Foundation, http://www.nof.org
http://www.aota.org OrthoIllustrated Orthopaedic Surgery Patient
American Physical Therapy Association, Education, http://www.orthoillustrated.com
http://www.apta.org Osteoporosis and Related Bone Diseases,
Arthritis Foundation, http://www.arthritis.org http://www.osteo.org
National Amputation Foundation, The TMJ Association, Ltd., http://www.tmj.org
http://www.nationalamputation.org
National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS), http://www.niams.nih.gov

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 10
Neurological System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the neurological system:
Adult Health Nursing • Musculoskeletal System
• Oncology • Endocrine System
• Cardiovascular System • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Identify basic functional areas of the human neurological system.
• Perform a neurological screening and a basic neurological examination.
• Prepare a client for common neurological diagnostic examinations.
• Derive a Glasgow Coma Scale score for a client.
• Recognize common symptoms of neurological disorders.
• Plan interventions for a client with a neurological disorder.

KEY TERMS
affect cephalalgia Lasegue’s sign
agnosia chorea meningitis
anosognosia coprolalia mentation
aphasia decerebration neuralgia
areflexia dysarthria neurogenic shock
ataxia dysphagia neurotransmitter
aura emotional lability nuchal rigidity
automatism encephalitis nystagmus
autonomic nervous fasciculation orientation
system(ANS) Glasgow Coma Scale paraplegia
awareness graphesthesia peripheral nervous
bradykinesia hemiparesis system (PNS)
central nervous hemiplegia postictal
system (CNS) homonymous hemianopia quadriplegia

305
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306 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

sclerotic spinal shock tetraplegia

somatic nervous system status epilepticus unilateral neglect
(SNS) stereognosis vertigo

of the brain communicate through nerve fibers in the corpus

INTRODUCTION callosum. A predominate hemisphere exists for special tasks
The human neurological system (called nervous system) is so that confusion does not occur. The right side specializes in
highly complex, controlling and integrating all other body the perception of physical environment, art, nonverbal com-
systems. This system controls motor, sensory, and autonomic munication, music, and spiritual aspects. The left hemisphere
functions of the body. This is accomplished by coordination generally specializes in analysis, calculation, problem solv-
and initiation of cellular activity through the transmission of ing, verbal communication, interpretation, language, reading,
electrical impulses and various hormones. and writing.

The Spinal Cord

ANATOMY AND PHYSIOLOGY The spinal cord is a continuation of the brainstem. It exits
REVIEW the skull through the foramen magnum, an opening in the
base of the skull. The spinal cord is approximately 45 cen-
The nervous system is divided into the central nervous timeters, or 18 inches, in length and is the thickness of one
system (CNS), consisting of the brain and spinal cord; the finger. The cord is divided into right and left halves and has a
peripheral nervous system (PNS), which consists of the shallow groove, called the posterior median sulcus, on the dor-
cranial nerves and spinal nerves; and the autonomic ner- sal side and a deep groove, called the anterior median fissure,
vous system (ANS), which is part of the peripheral nervous on the ventral side (Figure 10-3A). The cord tapers to a thin
system and consists of the sympathetic and parasympathetic tip, called the conus medullaris, at the first lumbar vertebrae,
systems. and terminates as a thin cord of connective tissue, called the
filum terminale, which continues as far as the second sacral
Central Nervous System vertebrae (Figure 10-3A and B). The vertebral column pro-
vides vertical support for the cord. The meninges cover the
The CNS comprises the brain and the spinal cord (Figure 10-1). spinal cord, providing protection. Reflex activity is initiated
within the spinal cord.
The Brain There are 31 pairs of spinal nerves originating from
the spinal cord. Each pair contains a dorsal, or posterior,
The brain, composed of gray matter and white matter, con- nerve root and a ventral, or anterior, nerve root (Figure
trols, initiates, and integrates body functions through the use 10-3C). The dorsal nerve roots carry sensory impulses from
of electrical impulses and complex molecules. The gray mat- the body to the brain; the ventral nerve roots carry motor
ter, on the outer part of the brain, contains billions of neurons. impulses from the spinal cord to the body. The spinal cord
Neurons, the basic cells of the nervous system, have three has an H-shaped appearance of gray matter within the white
major components: the cell body, the axon, and the dendrites matter (Figure 10-3D). The horns forming the H shape are
(Figure 10-2). The axon carries impulses away from the cell referred to as the anterior (ventral) horns, the posterior
body, and the dendrites carry impulses toward the cell body. (dorsal) horns, and the lateral horns. These horns con-
The cell body controls the function of the neuron. Functions tain the cell bodies of neurons that innervate the skeletal
include the conduction of impulses and the release of neu- muscles.
rotransmitters. Neurotransmitters are chemical substances
that excite, inhibit, or modify the response of another neuron
(Hickey, 2008). Neuroglial cells are in the central and periph- Cerebrospinal Fluid
eral nervous systems and are not neurons. They protect, sup- Cerebrospinal fluid (CSF) is produced primarily in the chor-
port, and nourish the neurons. oid plexus. Five hundred milliliters of CSF are produced daily,
The white matter of the inner structures of the brain con- with excess being reabsorbed by the arachnoid villi in the
tains association and projection pathways that transmit nerve subarachnoid space. The circulation of CSF is from the lateral
impulses to communicate information to the different areas of ventricles to the third and fourth ventricles. From there, it
the brain. These communication pathways are necessary for enters the subarachnoid space to flow around the spinal cord
integration of brain activity (Hickey, 2008). and the brain.
The brain is contained within the skull, or cranium, which Cerebrospinal fluid absorbs shock and bathes the brain
is a bony, rigid box that protects the brain tissue. There are and spinal cord. It contains glucose, protein, urea, and salts.
three coverings of the brain, called meninges. They are the These nutritive substances are delivered to the CNS cells, and
dura mater, arachnoid mater, and pia mater (Figure 10-1A). the waste and toxic substances are removed.
These coverings provide protection, support, and small
amounts of nourishment.
The brain is divided into two hemispheres. The right side Peripheral Nervous System
of the brain receives information from and controls the left All of the nerve tissue outside of the CNS is part of the periph-
side of the body. The left hemisphere receives information eral nervous system (PNS). The PNS consists of the cranial
from and controls the right side of the body. Both hemispheres nerves and the spinal nerves and has both sensory and motor

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 CHAPTER 10 Neurological System 307

Periosteum Meninges
Fat Bone
Skin
Dura mater
Arachnoid mater
Pia mater Lateral Corpus Cerebrum
Foramen ventricle callosum
of Monroe Skull
Frontal
Parietal lobe
lobe
Subdural Convolutions (gyri)
space

Sulci

Choroid plexus
A Falx Subarachnoid (third ventricle)
cerebri space
Superior
sagittal sinus Third ventricle
Arachnoid
villi
Occipital
lobe
Temporal
lobe
Pituitary Cerebral aqueduct
gland
-Midbrain Fourth ventricle
Brain stem -Pons
-Medulla Choroid plexus
oblongata (fourth ventricle)
Frontal lobe Foramen
-Higher intellectual function Parietal lobe Spinal Cerebellum
-Primary somatic sensory area magnum
-Speech production cord
-Ipsilateral motor control

Wernicke’s area
-Auditory comprehension
Broca’s area
-Motor speech

Occipital lobe
-Vision
-Visual perception

Temporal lobe
-Hearing
-Memory
-Speech perception

COURTESY OF DELMAR CENGAGE LEARNING

Brain stem
-Respiratory and cardiac regulation Diencephalon
-Level of awareness -Body temperature regulation
-Reticular activating system (RAS) -Pituitary hormone control
Includes: -Autonomic nervous system
responses
-Midbrain Includes:
-Pons -Thalamus
-Medulla Spinal cord -Epithalamus
oblongata -Hypothalamus
Cerebellum
-Coordination

Figure 10-1 The central nervous system includes the brain, spinal cord, and meninges. A, Structures of the Brain; B, Functional
Area of the Brain.

components. The PNS can be divided into the somatic ner- Although always identified by Roman numerals, the cranial
vous system and the ANS. The somatic portion connects nerves also have names.
the CNS to the skin and skeletal muscles. It is involved in
conscious activities, such as walking. The autonomic portion
connects the CNS to visceral organs such as the heart, stomach, Spinal Nerves
intestines, and various glands. It is involved in unconscious Thirty-one pairs of spinal nerves exit from the spinal cord
activities, such as breathing. through the vertebral column: cervical, 8 pairs; thoracic, 12
pairs; lumbar, 5 pairs; sacral, 5 pairs; and coccyx, 1 pair. The
Cranial Nerves dorsal, or posterior, nerve roots carry sensory impulses to
The 12 pairs of cranial nerves have sensory, motor, or mixed the brain. The ventral, or anterior, nerve roots carry motor
functions. Table 10-1 lists functions and describes assess- impulses from the spinal cord and brain to the muscles.
ment of cranial nerves. The cranial nerves originate from the Motor and sensory impulses are transmitted from the body
brain or brainstem, with most originating from the brainstem. and internal organs.

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308 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Dendrites
ASSESSMENT
A complete health history and a neurological screening assess-
ment allow the nurse to identify areas of dysfunction in order
Nucleus to focus the neurological assessment. Observation (inspection)
is necessary for most of the assessment; palpation, auscultation,
and percussion are also used.
Neuron soma
(cell body)

Health History
Myelin sheath A baseline assessment is essential to ascertaining changes in
neurological functioning. Any change from the baseline assess-
Axon ment must be identified and early intervention initiated. A
thorough health history includes asking the client about head-
Node of Ravier aches, clumsiness, loss of or change in function of an extremity,
seizure activity, numbness or tingling, change in vision, pain,
extreme fatigue, personality changes, and mood swings.

Neurological Assessment
COURTESY OF DELMAR CENGAGE LEARNING

The neurological screening involves assessment of level of

consciousness and verbal responses to specific questions;
selected cranial nerves for eye movement and visual acu-
ity; muscle strength; movement; gait for motor function;
and tactile and pain sensation of extremities for sensory
Terminal branches
screening.
A complete nursing assessment of neurological function
Figure 10-2 Neuron (Nerve Cell) Structure includes assessment of the following areas: cerebral function,
cranial nerve function, motor function, sensory function, and
reflexes. Neurological nursing assessment is discussed in more
Reflex activity is a stereotypical response to a stimulus detail in the next section.
that is initiated by the nervous system (Hickey, 2008). The
three classifications of reflexes are muscle stretch, or deep
tendon; superficial, or cutaneous; and pathological (see Cerebral Function
section on assessment of reflexes). Reflex activity requires Areas of assessment of cerebral function include level of
the function of five areas in the nervous system: the sensory consciousness, mental status, intellectual function, emotional
fibers, the neuron relaying the impulse, the association center status, pupil reaction, and communication.
in the brain, the neuron relaying the motor impulse from the
brain to the body, and the specific organ involved. Disease
processes at any of these areas can cause an abnormal reflex
response. LIFE SPAN CONSIDERATIONS
Autonomic Nervous System Neurological Changes with Aging
The main function of the ANS is to maintain internal homeosta- Remember the following with regard to the
sis. There are two subdivisions of the ANS: the sympathetic sys- elderly client:
tem and the parasympathetic system. The sympathetic system, • Nerve impulse transmission slows.
activated by stress, prepares the body for the “fight-or-flight”
• Cardiovascular system changes that lead to a
response. The sympathetic system causes increased heart rate,
increased blood pressure, vasoconstriction, decreased peri- decreased oxygen supply to the brain affect
stalsis, dilated pupils, increased secretions of epinephrine and mental acuity, sensory interpretation, and motor
sweat, and decreased secretions of digestive juices and saliva ability.
(Table 10-2). • The amount of neurotransmitters produced
The parasympathetic system conserves, restores, and diminishes, and the enzyme activity that
maintains vital body functions, slowing heart rate, increas- degrades neurotransmitters increases.
ing gastrointestinal activity, and activating bowel and bladder
• Changes in neurotransmitters affect sleep,
evacuation.
The sympathetic and parasympathetic systems work temperature control, and mood.
antagonistically to regulate the smooth muscles, the heart, • The brain tends to atrophy, leaving the cortical
and the glands of the body. When one system increases an bridging veins, which connect the brain to
action, the other system decreases the action. Thus, when the meninges, vulnerable to trauma and
one stimulates, the other inhibits; when one dilates, the other bleeding.
one constricts, and so forth. Both systems function simultane-
ously, but one can dominate the other as needed.

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 CHAPTER 10 Neurological System 309

Thalamus
Cerebellum

C1
C2
C3 Conus medullaris
Cervical C4
enlargement C5
C6
C7
C8
Cauda equina
T1
T2
A T3 B
T4
T5
T6
T7
T8
T9
Lumbar T10
enlargement T11
T12
L1 Filum terminale Coccyx
L2
Filum L3
terminale L4
L5
S1
S2
S3
S4
S5
Coccyx

Gray White matter

Gray matter Anterior median
matter
fissure
White matter
Filaments of
Dorsal root dorsal root

C D

COURTESY OF DELMAR CENGAGE LEARNING

Filaments of
Ventral root ventral root

Spinal ganglion Spinal nerve

Figure 10-3 A, Spinal Cord and Spinal Nerves; B, Conus Medullaris and Filum Terminale; C, Anterior View of Spinal Cord;
D, H-Shaped Appearance of Gray Matter and White Matter in the Spinal Cord

Level of Consciousness Level of consciousness is assessed Glasgow Coma Scale, eye opening, verbal response, and motor
by determining the client’s awareness and orientation and is response are scored using measurable criteria (Table 10-3).
the most important indicator of change in neurological status. The totaled scores indicate coma severity. A score of 15 indi-
Awareness is the person’s ability to perceive environmental cates a fully oriented person. A score of 3 is the lowest possible
stimuli and body reactions and then respond with thought score, indicating deep coma. A score of 7 or less is considered
and action. The client’s awareness is assessed through four a state of coma.
components: orientation, memory, calculation, and fund of Changes in the Glasgow Coma Scale indicate changes in client
knowledge (Lower, 2002). condition. To prevent further damage to the brain in instances of
A more objective assessment is made using the Glasgow decreasing scores, the nurse acts quickly. The physician must be
Coma Scale, an objective tool for assessing consciousness in notified immediately and measures taken to decrease intracranial
clients, most frequently in clients with head injuries. With the pressure (see section on increased intracranial pressure).

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310 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Table 10-1 Cranial Nerves

CRANIAL
NERVE FUNCTION ASSESSMENT EXPECTED FINDINGS
Olfactory (I) Sensory: smell Have client identify smells such as coffee or Correct identification of smell
alcohol with one nostril occluded; repeat for or ability to choose smell from
opposite nostril. a list of choices.

Optic (II) Sensory: vision Ask client to read printed material, identify Vision intact or correctable
number of fingers held in front of client, or with lenses; visual field intact.
read from Snellen eye chart. Test visual fields
by having client identify when the examiner’s
finger enters visual field.

Oculomotor (III) Motor: pupil Cranial nerves III, IV, and VI are tested Pupils are equal and round and
constriction together. Inspect for ptosis, or drooping of react equally to light. No ptosis
eyelid. Assess extraocular eye muscles by or double vision. Eyes move
having client follow the examiner’s finger to smoothly and consensually
each quadrant of the visual field. Assess for inward and downward. As the
accommodation by asking the client to look examiner’s finger moves away
at the examiner’s finger held 4 to 6 inches from the client, the pupil will
from the client’s nose, and then to follow the accommodate by dilating; as
finger to 18 inches from the client’s nose. Ask the finger moves closer; the
client about double vision. pupil will normally constrict.

Trochlear (IV) Motor: upper See oculomotor (III). Eyes should move smoothly
eyelid elevation, and consensually upward and
extraocular eye outward without nystagmus or
movement diplopia.

Trigeminal (V) Sensory: cornea, Test corneal reflex by lightly touching cornea Corneal reflex as evidenced
nose, and oral with a small piece of cotton. Check sensation of by rapid blinking when cotton
mucosa face by touching lightly with a cotton ball while swept across cornea. Feeling
Motor: the client’s eyes are closed and asking the client cotton ball on face indicates
mastication whether sensation is present. Check motor that facial sensation is intact.
function by having client clench jaws shut while Jaw movement symmetrical
the examiner palpates the contraction of the and able to overcome
temporalis and masseter muscles. resistance.

Abducens (VI) Motor: extraocular See oculomotor (III). Eyes move outward.
eye movement

Facial (VII) Motor: facial Ask client to smile, show teeth, wrinkle Facial movement symmetrical,
muscles; Sensory: forehead, or whistle. Have client close eyes sense of taste intact.
taste (anterior lightly and keep them closed against the
two-thirds of examiner’s trying to open them. Have client
tongue) identify salt and sugar when dabbed on tongue.

Acoustic (VIII) Sensory: hearing, Assess ability to hear ticking watch or Sense of hearing intact; no
equilibrium whispered voice. Observe gait for swaying. swaying or loss of balance.
Perform Romberg test (refer to assessment of
motor function).

Glossopharyngeal Sensory: Have client identify taste of salt and sugar Taste sensation intact; uvula
(IX) sensation to on back of tongue. Have client say “ah” and raises symmetrically; gag reflex
throat and taste assess for symmetrical position of uvula. Test intact; swallowing and speech
(posterior one- gag reflex by touching back of pharynx with intact.
third of tongue) tongue depressor. Observe swallowing ability
Motor: swallowing and speech patterns.

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 CHAPTER 10 Neurological System 311

Table 10-1 Cranial Nerves (Continued)

CRANIAL
NERVE FUNCTION ASSESSMENT EXPECTED FINDINGS
Vagus (X) Motor and sensory Test along with glossopharyngeal
nerve.

Spinal Motor: movement Place examiner’s hand on side Ability to move shoulder and head
accessory (XI) of uvula, soft palate, of client’s face and ask client to against resistance.
sternocleidomastoid turn head against resistance; have
muscle, trapezius client shrug shoulders against
muscle resistance of the examiner’s hand.

COURTESY OF DELMAR CENGAGE LEARNING

Hypoglossal (XII) Motor: tongue Ask client to stick out tongue and Tongue should be centrally aligned,
movement observe for symmetry, deviation able to push against resistance of
to side; have client push tongue tongue depressor; no fasciculations
against tongue depressor and (involuntary twitching of muscle
move tongue from side to side. fibers) should be present.

Table 10-2 Sympathetic and Parasympathetic Responses

SYSTEM SYMPATHETIC RESPONSE PARASYMPATHETIC RESPONSE
Neurological Pupils dilated Pupils normal size
Heightened awareness
Cardiovascular Increased heart rate Decreased heart rate
Increased myocardial contractility Decreased myocardial contractility
Increased blood pressure Vasodilation
Respiratory Increased respiratory rate Bronchial relaxation
Increased respiratory depth
Bronchial constriction
Gastrointestinal Decreased gastric motility Increased gastric motility
Decreased gastric secretions Increased gastric secretions

COURTESY OF DELMAR CENGAGE LEARNING

Increased glycogenolysis Sphincter dilatation
Decreased insulin production
Sphincter contraction

Genitourinary Decreased urine output Normal urine output

Decreased renal blood flow

Orientation is the person’s awareness of self in relation status, educational level, and social position. Mood is assessed by
to person, place, and time. Using open-ended communication observation and asking the client about moods and feelings.
techniques, instruct the client to “tell me your first and last
name and age,” “tell me the month, day, year, and day of the Intellectual Function Intellectual function is the ability of
week,” “tell me where you are (city, state, hospital),” in order the brain to perform thought processes. Ability to concentrate,
to ascertain the client’s level of orientation. The client also is memory function (both long-term and short-term), recall,
asked to open and close his eyes or open and close his fist. calculation activities, and fund of knowledge are all aspects of
intellectual function.
Mental Status Assessment of mental status requires observa- Nursing assessment of intellectual function involves ask-
tion of the client’s appearance, behavior, posture, mood, gestures, ing individuals to perform certain tasks, such as the following:
movements, and facial expressions. The nurse compares these • Repeating a series of numbers, such as 1, 3, 7, 1
behaviors to expected behaviors based on the client’s age, health • Telling what the individual ate for breakfast

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312 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Table 10-3 Glasgow Coma Scale

BEHAVIOR RESPONSE SCORE
Eye opening Spontaneous 4
response To verbal command 3
To pain 2
No response 1

Best verbal Oriented, conversing 5

response Disoriented, conversing 4 A
Use of inappropriate words 3
Incomprehensible sounds 2
No response 1

Best motor Obeys verbal commands 6

response Moves to localized pain 5
Flexion withdrawal to pain 4
Abnormal posturing— 3
COURTESY OF DELMAR CENGAGE LEARNING

decorticate
Abnormal posturing— 2
decerebrate
B
No response 1

Total 3 to 15 Figure 10-4 A, Unequal Pupils; B, Dilated, Fixed Pupils

(Images courtesy of Delmar Cengage Learning.)

• Adding two numbers, for example, 2 ⫹ 6 Pupils are evaluated for symmetry of size and for reaction to
• Reporting what is on the national news light. The nurse briefly shines a penlight into the client’s eye
The nurse determines the client’s ability to process thoughts by passing the light from the outer edge of the eye toward
by evaluating the responses to questions such as these. For pur- the center of the eye (Figure 10-5). Reaction is assessed as
poses of comparison, the client’s ability to perform these tasks being brisk, sluggish, or nonreactive; consensual reaction (the
before assessment should be ascertained by asking the family. opposite pupil responding at the same time) is also noted.
For example, if the client was math illiterate before the nursing Accommodation is assessed as described in Table 10-1 under
assessment, the client will still not be able to add or subtract. cranial nerve III.
The abbreviation PERRLA is used for documenting
Emotional Status Emotional status is assessed by observation pupils that are equal, round, and reactive to light and that
of the client’s affect (emotional response or mood). Is affect demonstrate accommodation. This abbreviation is used only
appropriate for the situation? Is affect labile (prone to rapid when pupil reaction is normal. If any part of the assessment
change)? Is affect consistent with verbal communication? is abnormal in one or both eyes, the assessment findings are
written out for clarity.
Pupil Reaction Size, equality, and roundness of pupils
are assessed (Figure 10-4). Size is measured in millimeters. Communication Both written and oral communication are
assessed. Various specialized areas of the nervous system are
involved in communication. The inability to communicate
verbally, termed aphasia, is caused by the inability to form
words or the inability to understand written or spoken words.
To assess communication function, various approaches are
CULTURAL CONSIDERATIONS necessary. Ask the client to follow a simple command such as
“Close your eyes.” Also use a written card instructing the cli-
Neurological Assessment ent to complete a simple task such as “Touch your nose.” Note
the ability to form words; appropriate use of words; speech
• Consider language and cultural norms when patterns, clarity, rate, and flow; and voice modulation. During
performing the mental status assessment. the health history, ask the client about health care expectations
• An interpreter may be required to ensure that to evaluate the client’s ability for verbal expression. Have the
the client understands the questions or directions. client write his name and address on paper to evaluate the
ability to write.

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 CHAPTER 10 Neurological System 313

Muscle Tone Muscle tone is assessed during palpation of

A
major muscle groups for size and symmetry, while at rest and
during passive movement. Muscle tone is described as normal,
flaccid, spastic, or rigid. Flaccid muscles are hypotonic, or
soft and flabby. Spastic muscles are at first resistant to passive
movement, but then release resistance. Rigid muscles may have
tremors but are constantly rigid. Rigidity is a more constant
state of spasticity, with fewer periods of release of resistance.
Muscle Strength To assess muscle strength, each extremity is
placed through passive movement. The client is then asked to
move the extremity, first against gravity, by lifting the extrem-
ity off the bed, then against resistance, by lifting against slight
resistance exerted by the nurse’s hand pushing on the extremity.
Strength is graded on a scale of 0 to 5 (Table 10-4).
B
Coordination Coordination, a function of the cerebellum,
is assessed by asking the client to perform repetitious move-
ment. The client should close her eyes and repeatedly, rapidly
touch her own nose with alternate index fingers (Figure 10-6).
Lower extremity coordination is assessed by asking the client

COURTESY OF DELMAR CENGAGE LEARNING

to run the heel of one foot down the opposite shin, and then
repeat with the other heel (Figure 10-7). Inability to perform
these movements is termed ataxia, incoordination of volun-
tary muscle action.
Balance Balance is evaluated by using the Romberg test.
The client stands with the feet together, arms extended in
front, and eyes closed. Balance is observed; a slight swaying
Figure 10-5 Pupil Assessment; A, Starting Position, with is normal.
Penlight to Side of Pupil; B, Moving Penlight Directly in Front
of Pupil Posturing Abnormal posturing occurs with injury to the
motor tract. Two types for which to observe are flexion
Cranial Nerve Function
Cranial nerve function essentially reflects brainstem activity. Table 10-4 Muscle Strength
A complete cranial nerve examination, if required, is usually
performed by the physician or advanced-practice nurse. SCORE DEFINITION
5/5 Full power of contraction
Motor Function
4/5 Fair or moderate power of contraction
The neurological screening includes assessment of muscle

COURTESY OF DELMAR CENGAGE LEARNING

strength, arm and leg movement, and gait. A complete motor 3/5 Just able to overcome force of gravity
function assessment is performed if a deficit is identified. 2/5 Can move, but cannot overcome power
A complete motor function assessment includes evaluating of gravity
muscle size, symmetry, tone, and strength; coordination; bal-
ance; and posturing. 1/5 Minimal contractile power
0/5 No movement
Muscle Size and Symmetry Muscle size and symmetry are
assessed by palpating major muscle groups of the arms and
legs and then comparing them to the muscle groups of the
opposite side of the body. Unilateral atrophy indicates a ner-
vous system problem.
COURTESY OF DELMAR CENGAGE LEARNING

PROFESSIONALTIP

Assessment of Pupils
To ensure accuracy in assessing direct light
reflex and consensual light reflex, the beginning
examiner focuses the beam of light a total of four
times, twice in each eye. Figure 10-6 Assessment of Coordination: Fingertip-to-Nose
Touch

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314 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

COURTESY OF DELMAR CENGAGE LEARNING

Image not available due to copyright restrictions
Figure 10-7 Assessment of Coordination: Heel Slide

(formerly decorticate) and extension (formerly decerebrate)

posturing (Lower, 2002). Flexion posturing is characterized
by flexion of the arms, adduction of the upper extremities,
and extension of the lower extremities. Lesions of the cerebral
hemispheres or internal structures of the brain cause flexion
posturing. Extension posturing is caused by brainstem injury
and is characterized by an arcing of the back, backward flexion
of the head, adduction and hyperpronation of the arms, and
extension of the feet (Figure 10-8).
Abnormal posturing may be present either at all times or Sensory Function
in response to stimuli such as loud noises, bright lights, or pain- A subjective examination of sensory function, performed
ful stimuli. The nurse notes whether bilateral or unilateral pos- with the client’s eyes closed, is generally done only when
turing is present, and, if intermittent, the cause of the posturing. a dysfunction is suspected. Different pathways are used to
The presence of either type of posturing is reported at once, transmit different sensory impulses. To evaluate all pathways,
because either represents an ominous sign of cerebral dysfunc- the examiner must test tactile sensation, pain and temperature,
tion. Extension posturing represents greater dysfunction than vibration, proprioception, stereognosis, graphesthesia, and
does flexion posturing, and any change from flexion to exten- integration of sensations.
sion posturing indicates a worsening of condition.
Tactile Sensation Tactile sensation is tested by using a cot-
SAFETY ton ball to lightly touch the client’s arms, hands, upper legs,
and feet. Comparison is done side to side. The client, with
Romberg Test eyes closed, indicates whether the cotton ball is felt.

Always stand in front of the client during the Pain and Temperature Sensations of pain and temperature
Romberg test, anticipating that the client are transmitted along the same pathways and are evaluated
might fall. using a sharp and dull touch. A paper clip or cotton-tipped
applicator is used.
Touch the client with the rounded end of a paper clip
or cotton-tipped applicator to test for dull sensation, and the
pointed end of a paper clip or uncovered end of the applicator
to test for sharp sensation. The client’s ability to distinguish
PROFESSIONALTIP sharp and dull is noted, again comparing both sides of the
body.
Assessing Coordination
Vibration Vibration is tested using a tuning fork. Strike the
Ensure that clients who wear eyeglasses have their tuning fork on the palm, holding only the handle, then place
glasses on before the assessment is performed. the end of the handle first on the client’s wrists and then on
the ankles and ask whether vibrations are felt (Figure 10-9).
The client’s eyes should be closed during the test.

PROFESSIONALTIP
Assessing Pain and Temperature
Sensory Function SAFETY
• Test upper and lower extremities Sensation
• Begin with the upper arms, moving down
to the hands; then work from thighs to feet Do not use a safety pin to test pain because skin
(proximodistal) integrity may be compromised.

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 CHAPTER 10 Neurological System 315

COURTESY OF DELMAR CENGAGE LEARNING

COURTESY OF DELMAR CENGAGE LEARNING
Figure 10-9 Assessment of Vibration Figure 10-11 Assessment of Graphesthesia

COURTESY OF DELMAR CENGAGE LEARNING

COURTESY OF DELMAR CENGAGE LEARNING

Figure 10-10 Assessment of Stereognosis Figure 10-12 Pathologic Reflex: Babinski

Proprioception Proprioception is the sense of joint position of muscles or muscle groups responding to brisk stretch-
in space. With the client’s eyes remaining closed, move a joint ing near the insertion site of the muscle (Smeltzer & Bare,
of the client’s finger or extremity up or down in space and ask 2008). Testing these reflexes is generally the responsibility
the client to distinguish the direction of movement of the digit of the physician or registered nurse, although the LP/VN
or extremity as being either up or down. should be familiar with these assessments, as abnormal
reflex responses are an early indicator of motor or sensory
Stereognosis Stereognosis is the ability to recognize an dysfunction.
object by feel. Place a familiar object such as a coin or key in the Superficial, or cutaneous, reflexes are elicited by irritating
client’s hand and ask what the object is. The sensation is a func- the skin on the area assessed. They are diminished or absent
tion of the brain, not of the spinal pathways (Figure 10-10). with dysfunction of the reflex arc.
The superficial reflex generally assessed is the plantar.
Graphesthesia Graphesthesia is the ability to identify letters, To assess the plantar reflex, the handle of the reflex ham-
numbers, or shapes drawn on the skin. Hold the client’s hand mer is used to stroke the outer aspect of the sole of the foot
and, with the stick end of a cotton-tipped applicator or a closed from the heel and across the ball of the foot to just below the
pen, trace an outline on the open palm, ensuring that the letter, big toe. Plantar flexion, or curling under of the toes, should
number, or shape is right side up for the client (Figure 10-11). occur.
Integration of Sensation Integration of sensation is a higher Abnormal Reflexes The absence of deep tendon reflexes
cortical function. A two-point discrimination test is performed in clients is considered an abnormal finding. A fanning of
by touching the client simultaneously on opposite sides of the the toes and dorsiflexion of the big toe in response to the
body with a sharp object and asking the client to ascertain the assessment of the plantar reflex is called a positive Babinksi’s
number of objects felt. The normal response is two. If only one reflex (Figure 10-12). This abnormal response indicates
is felt, the brain function of integration is abnormal. corticospinal disease and is the most important abnormal
superficial reflex.
Reflexes Refer to Box 10-1, “Questions to Ask and Observations
Both deep tendon reflexes and superficial reflexes are to Make When Collecting Data,” for guidance in completing
assessed. Deep tendon reflexes are involuntary contractions client neurological assessments.

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316 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

BOX 10-1 QUESTIONS TO ASK AND OBSERVATIONS TO MAKE WHEN COLLECTING DATA
Subjective Data Add 8 ⴙ 9.
Do you have headaches? On a scale of 0 to 10, with 0 Tell me a recent news event.
being no pain and 10 being the most pain you have Assess appropriateness of verbal responses to
experienced, rate your headaches. How long have you questions.
had these headaches?
Does the client have the expected behaviors based on
Describe the headache to me. What makes the the client’s age, health status, educational level, and
headache feel better? What make the headache feel social position?
worse?
Have the client write a complete sentence.
Point to the area of your head where you have
Ask the client to complete a verbal request, such as
headaches.
“Cross your arms.”
Have you had a seizure?
Check coordination by asking the client to touch his
If you have seizures, do you have an aura?
own nose with alternate index fingers.
What precipitates (causes) your seizures?
Ask the client to close his eyes, then place a common
Have you had any numbness or tingling? object in the client’s hand and ask him to identify the
Have you fallen recently? object.
Describe your sense of balance. Draw a number in the clients palm, and ask him to
Have you had any vision problems? identify the number.
Are there any activities that you have difficulty Asses the client’s visual field. As the examiner’s
completing? finger moves away from the client, does the pupil
Do you have the energy you need to accomplish daily accommodate by dilating? Constrict as the finger
activities? moves closer to the client? Do the eyes move
Have you or your family members noticed any mood smoothly and consensually upward, downward,
swings or changes in your personality? inward and outward? As the client’s eyes follow your
finger as you move it up, down, back, and forth in
How many hours do you sleep at night?
the path of the client’s visual field, does the client
Do you have back pain? On a scale of 0 to 10, with 0
see the finger at all times? Check the size, roundness,
being no pain and 10 being the most pain you have
equality, reaction, and accommodation of the client’s
experienced, rate your back pain. How long have you
pupils.
had the back pain?
Assess the client’s sense of smell by introducing
Describe the pain to me. What makes the back
nonoffensive odors to the client.
pain feel better? What make the back pain feel
worse? Do the client’s facial expressions match the
conversation?
Have you had any difficulty with any of your
extremities? Weakness? Lack of function? Check trigeminal nerve by swiping a piece of cotton
over the client’s check area.
How does the condition affect your life?
Can the client smile? Frown?
Has this condition affected your sexual relationships?
Observe the client’s posture. Does the client slump or
What do you do to cope with your condition?
sit erect?
Does the client answer questions appropriately?
Note the client’s gait and ability to balance. Is the
During the subjective data assessment, determine if gait symmetrical, and how does the client approach
the client answers questions appropriately. you?
Objective Data Assess muscle strength in all extremities. Do all
Assess client’s orientation to person, place, and time. extremities have full range of motion?
Assess level of consciousness. Assess superficial reflexes.
Is the client clean and neatly groomed? Does the client have a gag reflex?
Assess client’s intellectual function by asking the Can the client stick out his tongue?
client to: Complete the Glasgow Coma Scale.
Repeat a series of numbers, such as 6, 3, 7, 9.
Tell me what you had for breakfast.

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 CHAPTER 10 Neurological System 317

dura mater to this area. The dura mater can easily tear, and CSF
COMMON DIAGNOSTIC TESTS can leak from the ears or nose. Two tests determine if the drain-
Commonly used diagnostic tests for clients with symptoms of age is CSF; a dextrostick dipped in the liquid and the halo test.
nervous system disorders are listed in Table 10-5. Because CSF has a high glucose level, a dextrostick is placed
in the liquid. If the dextrostick reveals the presence of glucose,
the liquid is CSF. The drainage can also be checked, by placing
■ HEAD INJURY a drop on a white sheet. When the liquid dries, a yellow halo

H
appears around the edges of the pink or bloody drainage if it is
ead injuries involve trauma to the scalp, skull, or CSF (halo test). The internal carotid artery and cranial nerves
brain. can also be damaged easily with a basilar skull fracture.

SCALP BRAIN
Scalp injuries bleed profusely because of the abundance of Brain injuries are caused by primary injuries of acceleration–
blood vessels in the scalp. As with any break in skin integrity, deceleration force, rotational force, or penetrating missile.
infection is of major concern. The wound is cleansed and Acceleration injuries are caused by moving objects striking the
irrigated to remove foreign matter before closing the wound head, such as a baseball bat. Deceleration injuries result when
with sutures or butterfly dressings. the head is moving and strikes a solid object such as a car dash-
board. Rotational injuries are hyperextension, hyperflexion,
or lateral flexion of the head, which cause twisting of the cere-
SKULL brum on the brainstem, such as a whiplash injury. Penetrating
missile injuries are a direct penetration of an object, such as a
Skull injuries and fractures of the skull may occur with or with- bullet, into brain tissue (Urden, Stacy, & Lough, 2009).
out brain injury. A fracture is usually caused by extreme force.
Skull fractures are considered closed if the dura mater is intact
and open if the dura mater is torn. The clinical manifestation Open Injury
of skull fracture is localized pain. If the brain is injured, other Skull fractures and penetrating injuries are referred to as open
symptoms occur. head injuries. Hemorrhaging from the nose, pharynx, or ears;
Types of skull fractures are linear fracture, comminuted ecchymosis over the mastoid area (Battle’s sign); or blood in
fracture, depressed fracture, and basilar fracture. Linear fractures the conjunctiva may occur in conjunction with open head inju-
are nondisplaced cracks in the bone. Comminuted fractures ries. Raccoon eyes (ecchymosis around both eyes) indicates
occur when the bone is broken into fragments. Depressed frac- a basilar skull fracture. Cerebrospinal fluid may leak from the
tures have bone fragments pressing into the intracranial cavity. ears or nose. A computed tomography (CT) scan or magnetic
Basilar skull fractures are of the bones in the base of the skull. resonance imaging (MRI) determines the extent of injury.
Basilar fractures are of particular concern because of the Neurological deficits depend on the extent and area of injury.
proximity of the fragile sinus bones and the adhesion of the
Closed Injury
Table 10-5 Common Diagnostic Tests Closed head injuries are caused by blunt force to the head.
for Nervous System Disorders Coup injuries are caused by the impact of the head against an
object. Contrecoup injuries are caused by the impact of the
• Lumbar puncture (LP) brain against the opposite side of the skull (Figure 10-13).
• Electroencephalogram (EEG)
Types of closed head injuries are concussion, contusion,
and laceration. Concussions are transient neurological defi-
• Electromyogram (EMG) cits caused by shaking the brain. Clinical manifestations may
• Imaging procedures: computerized tomography (CT), include immediate loss of consciousness lasting from minutes
positron emission tomography (PET), single-photon to hours, momentary loss of reflexes, respiratory arrest for sev-
COURTESY OF DELMAR CENGAGE LEARNING

emission computed tomography (SPECT), magnetic eral seconds, and amnesia for the period immediately before
resonance imaging (MRI)
and after the event. Headaches, drowsiness, confusion, diz-
ziness, irritability, visual disturbances, and unsteady gait may
• Cerebral angiography also occur (Hickey, 2008).
• Brain scan Post-concussion syndrome may develop after the injury,
as manifested by headache and dizziness. Nervousness, irrita-
• Myelogram
bility, emotional lability, fatigue, insomnia, loss of mentation
(ability to concentrate, remember, or think abstractly), and
sometimes other neurological deficits occur. This syndrome
may last from several weeks up to a year (Hickey, 2008).
LIFE SPAN CONSIDERATIONS Contusions are surface bruises of the brain. Symptoms
depend on the area of injury. Frequently, the client is uncon-
Reflexes scious for a longer period than with a concussion. The client
The absence of the Achilles reflex in the elderly becomes conscious only to drift back into unconsciousness.
client is not considered abnormal. Pulse, blood pressure, and respirations are below normal.
Skin is cool and pale. Cerebral edema occurs with widespread
injury (see section on cerebral edema).

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318 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Contrecoup injury Torn subdural

from secondary vessels
impact

Blunt force

may or may not

cause bleeding
A B

Coup injury
from initial
impact

Bruising from Dura mater Bone

movement over
skull floor Arachnoid Epidural space
mater (potential)
Pia mater Subdural space
Subarachnoid space
Intracerebral space
Bruise on
surface of
brain

Dura mater
Subdural
hematoma
Dura mater Arachnoid
mater
Hematoma Pia mater

COURTESY OF DELMAR CENGAGE LEARNING

D E
Torn blood
vessel causing
bleeding
in epidural
space

Figure 10-13 Brain Injuries; A, Coup/Contrecoup; B, Concussion; C, Contusion; D, Epidural Hematoma; E, Subdural Hematoma

Return of consciousness may be followed by cerebral irri-

tability to stimuli. Headache and dizziness may be present for Hemorrhage
an indefinite period. Permanent damage causes either changes Intracranial hemorrhage, usually due to an arterial bleed, is
in mental function or seizure disorders. Prognosis ranges from a common complication of any head injury. Bleeding occurs
full recovery to death. in the epidural space, subdural space, subarachnoid space,
Cerebral laceration is the tearing of cortical tissue. Symp- ventricles, or intracerebrally. Neurological change is caused
toms of brainstem injury include deep coma from time of by pressure on the brain resulting from the space-occupying
impact, extension posturing, autonomic dysfunction, nonre- hemorrhage. With epidural hematoma (bleeding in the epi-
active pupils, and respiratory difficulty. The ability to relay dural space), momentary unconsciousness is followed by a
nerve impulses from high levels in the brain is lost. Diffuse conscious state of a few hours within that day, depending on
axonal injury (DAI) usually occurs in conjunction with brain- the rapidity of the bleeding. As the bleeding continues, neu-
stem injuries. This widespread damage to nerve cells in the rological status begins to deteriorate, with decreasing level of
white matter of the brain causes immediate coma, extension consciousness; headache; seizures; hemiparesis; decerebra-
posturing, and increased intracranial pressure (ICP). tion (severing spinal cord); and dilated, fixed pupils. This is
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 CHAPTER 10 Neurological System 319

a medical emergency, and the treatment is surgery to evacuate Neurological changes are exhibited because of cellular hypoxia
the hematoma, stop the bleeding, and relieve pressure on the and displacement of the brain, which compresses neurons,
brain. especially in the brainstem. These changes include dete-
Subdural hematomas (bleeding in the subdural space) riorating level of consciousness; decreased motor response
cause immediate pressure on the brain. Subdural hematomas are to commands; fixed, dilated pupils; and vital sign changes
acute (within 48 hours of injury), subacute (from 2 to 14 days known as Cushing’s triad or reflex. Cushing’s triad refers to
after injury), or chronic (from 2 weeks to months after injury). bradycardia, widening pulse pressure along with increasing
Common symptoms are headache, drowsiness, slow menta- systolic pressure, and respiratory irregularities. Respiratory
tion, and confusion. The symptoms slowly progress as the changes include periods of apnea, decreased respiratory rate
size of the subdural clot increases, causing increased pressure and depth, and irregular respirations.
on the brain. Small hematomas are usually reabsorbed. Large Causes of increased intracranial pressure are increased
hematomas require surgical removal. blood volume resulting from vascular vasodilation; increased
Subarachnoid (below the arachnoid) and intraventricular volume of brain tissue resulting from edema, infection, tumor,
(within the ventricles of the brain) hemorrhages are common or hemorrhage; or increased volume of CSF resulting from
in severe head injury. The symptoms include those listed for overproduction, decreased reabsorption, or interruption of
hematoma, as well as nuchal rigidity, stiffness or inability CSF circulation. If intracranial pressure continues to increase,
to bend the neck. Blood in the subarachnoid space interferes brain herniation will occur at the tentorial notch or through
with the reabsorption of CSF, further increasing intracranial the foramen magnum, resulting in death.
pressure.
Intracranial hematomas from contusions usually occur
in the temporal or frontal lobes; from shearing forces, they Medical–Surgical Management
usually occur deep in the brain. The hematoma usually Management of head injury is focused on early recognition
expands rapidly. The injury usually causes immediate uncon- and treatment of increasing intracranial pressure and mainte-
sciousness. Headache, deteriorating level of consciousness, nance of normal body functions.
hemiplegia, and dilated pupils are initial signs of an internal
hematoma. As intracranial pressure increases, herniation of Medical
the brainstem occurs, causing changes in pupils, respirations,
Intracranial pressure is monitored with an ICP device that
and vital signs. Craniotomy along with evacuation and control
has a small tube placed in the ventricles of the brain. CSF is
of bleeding may be performed depending on the condition of
drained through a ventricular drain (ventriculostomy) if the
the client, extent of cerebral contusion, and accessibility of the
intracranial pressure increases (Daniels, 2007). Suctioning
bleeding site.
may be necessary but is never done through the nose on a head
Signs and symptoms of increased intracranial pressure
injury client because of the possibility of CSF leakage. Oxygen
include deterioration in level of consciousness; confusion;
is given to maintain cerebral perfusion. Pulse oximetry and
difficulty in rousing; and, initially, restlessness. Other signs
arterial blood gases (ABGs) are checked.
and symptoms are changes in pupil size or reaction to light.
If the client has an endotracheal tube in place, the PaCO2
The pupil gradually dilates and becomes less responsive to
level can drop below normal. This decrease causes a slightly
light. Muscle weakness progressing to hemiplegia (paralysis
alkaline pH, which decreases vasodilation and, thus, intracra-
of one side of the body) or paraplegia (paralysis of lower
nial pressure.
extremities), and abnormal posturing occurs. Headache and
vomiting are experienced by some clients. Vital sign changes
generally do not occur until the increased intracranial pressure Surgical
has progressed to the point of involving the brainstem. An Decompression is performed surgically by placing burr holes
increase in systolic blood pressure and a widening pulse pres- in the skull to allow room for the expansion of the brain.
sure accompanied by a slowing pulse are the effects of pressure A space-occupying lesion such as a tumor, hematoma, or
on the brainstem. abscess is surgically removed. Excess CSF is drained from the
ventricles.
Cerebral Edema and Increased
Intracranial Pressure Pharmacological
Corticosteroids, such as dexamethasone (Decadron), are
The brain is contained in a rigid container, the skull. The only
given to reduce cerebral edema. Antacids, such as Mylanta or
normal opening to the adult skull is the foramen magnum at
the base of the skull. Intracranial pressure is a result of the
pressure exerted by the contents of the skull, which are the
brain, blood, and CSF. CLIENTTEACHING
Regulatory mechanisms maintain intracranial pressure Surgery for Head Injury
between 0 and 15 mm Hg. The Monroe-Kellie hypothesis
states that when one component of the cranial contents Inform the client of the following:
increases in volume, the volumes of the other components • The head is shaved in the area of the incision.
decrease in order to compensate and maintain intracranial • Edema of the head and face are present after
pressure between 0 and 15 mm Hg. As long as this ability to surgery but will gradually disappear.
compensate remains effective, no neurological changes occur.
In decompensation, the volume increase is so excessive that • A mechanical ventilator is used for a day or two
intracranial pressure cannot be maintained below 15 mm Hg after surgery.
by decreasing the volume of the remaining components.

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320 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Maalox, or histamine receptor antagonists, such as ranitidine a neurologic assessment together for consistency in assessing
(Zantac), are given to decrease both the side effects of corti- the neuropathy.
costeroids and stress-induced gastric acidity. Osmotic diuret-
ics, such as mannitol (Osmitrol), are administered to rapidly
reduce fluid in the brain tissue; muscle relaxants, sedatives, Subjective Data
barbiturates, or muscle-paralyzing agents are administered to Subjective data includes a history of what happened, including
decrease activity and reduce the oxygen need of the brain. type of trauma (acceleration, deceleration, or missile), site of
Antipyretic drugs are used to decrease body temperature blow, and any loss of consciousness, including timing, length,
and the metabolic needs of the brain, thereby reducing the vol- and ability to be roused.
ume of blood sent to the brain to supply oxygen and glucose.
Anticonvulsants are given to prevent or treat seizure activity.

Activity Objective Data

A neurological screening is done to obtain a baseline neu-
Activity is limited to keep the metabolic needs of the brain to rological status; then, a more in-depth neurological exam is
a minimum. Increased metabolic needs require more oxygen performed to identify any early signs of increasing intracranial
and glucose supplied by increases in blood volume in the cra- pressure.
nium, which further increases intracranial pressure. Frequent assessment of neurological status, including
level of consciousness, motor function, eye movement, pupil
Nursing Management size and reaction, protective reflexes, and vital signs, allows
Frequently monitor level of consciousness, eye movements, for early recognition of and intervention for increasing intrac-
pupil changes, vital signs, I&O, pulse oximetry and Glasgow ranial pressure. Nursing observation also includes assessing
Coma Scale score. Monitor the ICP if a device is in place. for double vision, headache, nausea, and bleeding from any
Maintain airway patency and administer oxygen as ordered. orifice. Ipsilateral pupil reaction (reaction of the pupil on the
Keep head of bed at 30 to 40 degrees and client’s head posi- same side as the injury or lesion) occurs as a result of pressure
tioned at midline. Watch for signs of arm/leg muscle weak- on the oculomotor nerve caused by increased intracranial
ness, muscle twitching, nausea or vomiting, and visual or pressure or cerebral edema. Assess for factors that cause
hearing disturbance. Fluids often are restricted. increased intracranial pressure.
If a client is undergoing intracranial surgery, assess the
NURSING PROCESS teaching needs of the client and family. Also assess the emo-
tional and psychosocial needs and support systems.
Assessment Longer-term care involves assessment of bowel elimina-
tion status to prevent the need for straining, skin assessment
Nursing assessment for any head injury is focused on neuro- to prevent skin breakdown, and assessment for complications
logical status. At the nursing shift change, nurses may complete of immobility.

Nursing diagnoses for a client with a head injury include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Tissue/ The client will demonstrate Assess neurological status of client every 15 to 60 minutes.
Perfusion (Cerebral) improvement or mainte- Note findings on Glasgow Coma Scale. Compare findings to
related to disruption in nance on Glasgow Coma previous assessments to uncover changes in condition.
cerebral blood flow Scale. Administer oxygen as ordered to supply a high concentration of
oxygen to the brain.
Position client with head of the bed at 30 to 40 degrees and
client’s head at midline to promote venous drainage from the
head.
Minimize physical activity to prevent increasing metabolic
demands.

Ineffective Breathing The client will have an Assess respiratory status every 15 to 60 minutes. Administer
Pattern related to effective breathing pattern. oxygen as ordered to maintain blood oxygen concentration.
neurological impairment Provide mechanical ventilation if necessary.
of respiratory status or Continually assess ABG levels or pulse oximeter readings to
mechanical ventilation identify need for assisting respirations to prevent vasodilation in
the brain and increasing intracranial pressure.

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 CHAPTER 10 Neurological System 321

Nursing diagnoses for a client with a head injury include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Interrupted Family The client and/or family Assess family’s coping mechanisms. Involve the family in client
Processes related to will demonstrate effective care as appropriate.
sudden crisis coping mechanisms. Provide information about the client in an ongoing fashion.
Provide teaching about the injury and pathophysiology involved.
Prepare family for possible outcomes of the injury, such as
paralysis or death.
Collaborate with clergy, social services, mental health
counselors, and support groups.
Teach the family to report increased drowsiness, arm/leg
weakness, muscle twitching, nausea or vomiting, visual or
hearing disturbances, and so on.
Inform the family that the client is not aware of the symptoms
and that signs and symptoms of the head injury are not
immediately apparent.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ BRAIN TUMOR Pharmacological

B
Dexamethasone (Decadron) is given to decrease cerebral
rain tumors are space-occupying intracranial lesions, edema. Phenytoin (Dilantin) is given to prevent seizure
either benign or malignant. Brain tumors are classified by activity. Antacids and H2 blockers, such as cimetidine (Tag-
location or tissue type. Intracranial lesions are primary lesions, amet) or ranitidine (Zantac), are given to prevent gastric
which develop initially in brain tissue; extensions of tumors of irritation. Analgesics, nonsteroidal anti-inflammatory drugs
the meninges, cranial nerves, or pituitary gland; or metastatic (NSAIDs), or codeine are used for headaches, and stool
lesions from tumors originating in other body systems. softeners are administered to prevent straining. A protec-
The etiology of primary lesions is unknown. Clinical tive mechanism called the blood–brain barrier prevents
manifestations differ according to the area of the lesion and the many potentially harmful substances from reaching the
rate of growth. Intracranial pressure increases as compensatory brain tissue or CSF. It prevents chemotherapeutic agents
mechanisms are no longer able to balance tumor growth. Clin- from reaching the brain except in very large doses that are
ical manifestations commonly include alteration in conscious- not well tolerated by other body systems. Antineoplastic
ness, decreased mental functioning, headaches, seizures, or agents are administered on the basis of tumor type and
vomiting (sometimes sudden and projectile). Other signs and whether the client meets the requirements for receiving
symptoms are relative to the functions of areas involved, such the drug. Antineoplastic alkylating agents (carmustine
as visual problems resulting from occipital lobe tumors. [BICNU, Gliadel], lomustine [CCNU], and semustube
Diagnostic evaluation is by CT scan, MRI, or electroen- [Methyl-CCNU]) inhibit cell division in rapidly replicat-
cephalogram (EEG). Total body scans, chest x-rays, and nee- ing cells. Temozolomide (Temodar) crosses the blood–
dle biopsies of the tumor are performed to identify the type of brain barrier and is used for clients with gliaoblastoma
tumor and, thus, serve as a basis for medical treatment. multiforme.
Another alternative way of administering chemothera-
Medical–Surgical Management peutics is to use the intrathecal (directly into the spinal
canal) route. Sometimes chemotherapy disk-shaped wafers
Medical are left in the cavity after tumor removal. The wafers
Medical management is based on tumor type, growth rate, and release the chemotherapy drug over the next few days
assessment of the client. Radiation therapy is used for specific (Mayo Clinic, 2008). The surgical insertion of an Ommaya
tumor types or for inoperable tumors. The goal is to destroy the reservoir under the scalp can also allow direct insertion of
tumor cells that are more susceptible to radiation than are nor- chemotherapy into the CNS.
mal cells. Radiation is used with surgery and chemotherapy.
Nursing Management
Surgical Prepare client and family for surgery in a caring, compas-
Surgical intervention removes tumors (benign or malignant) to sionate manner. Explain procedures, including shaving the
decrease the space occupied by the lesion or obtains tissue for head. The client generally will stay in the ICU for several
biopsy. Some CSF is removed to relieve increased pressure. days.

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322 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

including changes in personality or judgment, serves as the

NURSING PROCESS basis for providing emotional support.
Assessment Objective Data
Subjective Data Assess functional ability, mobility, and mental status, includ-
Ask the client about fatigue, pain, headache, weakness, and ing motor strength, gait, ability to perform activities of daily
ability to perform daily activities. Note sensory/perceptual living (ADLs), and level of consciousness. Note signs of neu-
alterations such as hearing, visual, tactile, kinesthetic, or olfac- rological changes, deficits, or increased intracranial pressure,
tory changes. Assess the client’s pain and evaluate effective- such as restlessness, changes in logic, changes in vital signs,
ness of interventions. A thorough psychosocial assessment, pupil responses, speech abnormalities, seizure activity, or
changes in respiratory patterns.

Nursing diagnoses for a client with a brain tumor include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to fear of The client will demonstrate Allow client to verbalize feeling of anxiety and discuss
unknown and treatment effective use of coping coping patterns previously used. Observe for verbal and
plans mechanisms. nonverbal cues of anxiety.
Provide emotional support by listening and guiding
client to explore feelings of helplessness, fear of the
unknown, and potential impending death. Maintain a
calm demeanor.
Teach client and family about diagnostic tests, treatments,
and expected outcomes.
Collaborate with pastoral care, physician, social services,
and family to provide emotional support.
Teach relaxation exercises and techniques such as slow,
deep breathing and progressive muscle relaxation.
Administer tranquilizers and sedatives as ordered.

Disturbed Sensory The client will maintain sensory Maintain communication.

Perception (visual, perceptions. Provide a safe environment.
auditory, kinesthetic,
tactile) related to Provide orientation and appropriate stimuli.
displacement/ Encourage some social interaction.
compression of brain
tissue

Imbalanced Nutrition: The client will maintain weight Assess client’s weight every other day.
Less than Body within 5 pounds of initial Provide frequent small feedings of high-calorie and
Requirements related to weight. high-protein foods. Offer foods of client’s choice. Use
side effects of treatment nutritional supplements to maintain weight. Offer fluids
and disease process frequently.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

(NSA, 2002c). Stroke is the third leading cause of death in the

■ CEREBROVASCULAR United States, with nearly 144,000 deaths each year (NSA,
2009a). Approximately 795,000 strokes will occur in 2009
ACCIDENT/TRANSIENT (NSA, 2009a). Refer to Figure 10-14 and complete the Stroke
ISCHEMIC ATTACKS Risk Scorecard to evaluate your stroke risk (NSA, 2009b).

C
Strokes are caused by ischemia (oxygen deprivation)
erebrovascular accident (CVA), or stroke, is a “brain resulting from a thrombus, embolus, severe vasospasm, or
attack.” It happens in the brain rather than the heart and cerebral hemorrhage. Blood supply to the brain is interrupted,
causes a sudden loss of brain function accompanied by neuro- causing neurological deficits of sensation, movement, thought,
logical deficit. It is a medical emergency and immediate treat- memory, or speech. The loss of function can be temporary or
ment is crucial for the best outcome just as it is for a heart attack permanent.

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 CHAPTER 10 Neurological System 323

Text not available due to copyright restrictions

Transient ischemic attacks (TIAs) are mini-strokes and Clinical manifestations of TIA or CVA vary according to
frequently precede a stroke. A TIA is a temporary or transient the location of interrupted blood supply in the brain. As with
episode of neurological dysfunction caused by temporary head injury, the specific functions of the involved area of the
impairment of blood flow to the brain. The loss of motor or brain are interrupted, causing the symptoms. Common neu-
sensory function may last from a few seconds to minutes to rological deficits are motor deficits of hemiplegia (paralysis of
24 hours. The classic symptoms are sudden blurring of vision one side of the body on the side opposite of the brain lesion),
or blindness, loss of balance or coordination, difficulty speak- hemiparesis (weakness of one side of the body), dysarthria
ing or understanding simple statements, and weakness/numb- (impairment of speech caused by muscle dysfunction), and
ness/paralysis in the face, arm, or leg (NSA, 2002b, 2008). dysphagia (impairment of swallowing muscles). Emotional

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324 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

CLIENTTEACHING PROFESSIONALTIP
Stroke-Prevention Guidelines Risk Factors for Stroke
• Have an annual blood pressure check. • The major risk factor for stroke is hypertension.
• Be aware of cholesterol level. • Other risk factors are diabetes mellitus,
• Consume lesser amounts of sodium (salt) and fat. atherosclerosis, aneurysm, cardiac disease, high
• Exercise daily. blood cholesterol, obesity, sedentary lifestyle,
• Do not smoke. smoking, stress, drug abuse (especially of
cocaine), and use of oral contraceptives. Clients
• If you drink alcohol, do so in moderation.
with more than one risk factor are at even
• Check with a doctor for symptoms of atrial greater risk.
fibrillation.
• One in twenty people who have a TIA will have
• Check cholesterol level. a stroke within 2 days (NSA, 2009b)
• Control diabetes.
• Check with a doctor for circulation problems.
• See a doctor immediately with any stroke-like
Most clients experience initial bowel and bladder dys-
function. With early recognition of the problem and use of
symptoms.
bowel and bladder retraining programs, however, most clients
(National Stroke Association, 2009) regain continence of bowel and bladder.
Differences in the affected side of the brain have been
identified. Clients with left-side CVA tend to have communi-
cation deficits of aphasia, or inability to communicate. These
clients tend to be slow and cautious in behavior and have
lability (loss of emotional control), inability to control intellectual impairments such as memory deficits or loss of
behavior, and inability to process multiple pieces of informa- problem-solving skills. Defects in the right visual field occur,
tion are also common manifestations of a stroke. and hemiplegia occurs on the right side.
Sensory deficits include visual deficits of double vision, Clients with right-side CVA have left-sided paralysis and
decreased visual acuity, and homonymous hemianopia, defects in the left visual field. Spatial–perceptual defects, called
the loss of vision in half of the visual field on the same side of agnosia, cause the inability to recognize familiar objects such
both eyes. Other possible sensory deficits include decreased as a hairbrush. These clients demonstrate poor judgment and
sensation to touch, pressure, pain, heat, and cold. The client impulsive behavior and are unaware of the deficits. This is
also may be confused and disoriented. called anosognosia, which is gross or unconscious denial of
Intellectual deficits include memory impairment, poor the stroke or neurological deficit. Furthermore, these clients
judgment, short attention span, difficulty organizing thoughts, are easily distracted and usually show unilateral neglect,
and inability to reason or calculate. Emotional deficits include or the failure to recognize or care for the affected side of the
depression and decreased tolerance to stressors. body.

MEMORYTRICK
Indicators of a Stroke

Mnemonic Mnemonic Hint Action Stroke Symptom

S Smile Ask the client to smile. One side of the face may droop.
T Talk or speak Ask the client to say a simple The speech is slurred or garbled.
sentence, e.g., The grass is green.
R Raise both arms Ask the client to raise both arms. One arm is weak and falls downward.
T Tongue Ask the client to stick his tongue out. Tongue moves to one side.
T Time If any of these signs are present in a
nonhospitalized client, call 911 to
transport the client to an acute facility
Adapted from National Stroke Association (NSA). (2009a). Stroke 101. Retrieved on June 3, 2009 at http://www.stroke.
org/site/DocServer/STROKE_101_Fact_Sheet.pdf?docID=454; and Santa Rosa County Citizen Service Center. (2009) Blood Clots/
Stroke – They now have a fourth indicator, the tongue. Retrieved on June 3, 2009 at http://www.santarosa.fl.gov/hr/
documents/identiyastroke.pdf

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 CHAPTER 10 Neurological System 325

PROFESSIONALTIP
Post-CVA Care
Medication and Cerebrovascular
Accident • Consult with the family to evaluate the home
for safety and use of wheelchair or walker, if
Calcium channel blockers should not be used for
needed.
the client with CVA because they dilate blood
vessels and increase cerebral perfusion. • Evaluate the client’s ability to perform self-care
so that assistive devices or personal assistance is
obtained.
• Determine whether a hospital bed or
Cerebral edema and increased intracranial pressure may
further complicate neurological status. Cerebral edema maxi- other medical equipment will need to be
mizes in 3 to 5 days following CVA. Neurological deficits rented.
begin to resolve within 2 days as cerebral edema decreases.
Gradual progression in the return of various functions from
proximal to distal can occur for 1 to 2 years. To prevent further loss of function, a focus on rehabilita-
tion begins on admission. After a stroke, all effort is made to
maintain self-care and mobility.
Medical–Surgical
Management Surgical
Surgical removal of the thrombus (thrombolectomy) or
Medical embolus (embolectomy) may be necessary to relieve pressure
Medical management of the client with CVA is directed on the brain.
toward airway maintenance and supportive therapy during
the first 24 to 48 hours. Early diagnosis of the cause and type Pharmacological
of stroke is necessary to determine the appropriate treatment.
Maintaining adequate cerebral perfusion and preventing cere- Antihypertensive agents are used to control blood pressure.
bral edema reduce neurological deficit. Respiratory failure is Anticoagulants, aspirin, heparin, or Coumadin are used to
treated with mechanical ventilation; temperature is regulated, prevent further clot formation in cases of stroke caused by
with the help of a hypothermia blanket if necessary. (See the thrombi. To dissolve the clot, thrombolytic agents such as
section on increased intracranial pressure for information on alteplase (Activase), anistreplase (Eminase), streptokinase
prevention and treatment.) (Streptase), or urokinase (Abbokinase) are given within 3 hours
of the stroke. A stroke caused by bleeding would not be treated
with thrombolytic agents. Dexamethasone (Decadron) is be
used to reduce intracranial pressure. Anticonvulsants such as
PROFESSIONALTIP phenytoin (Dilantin) is used if convulsions are present.

Caregivers for Client with CVA

Diet
Fluid is restricted for a few days after a CVA. The client will,
• Give the CVA client ample time to process and however, be given intravenous fluids or tube feedings. The gag
then answer the question before proceeding reflex is assessed to identify choking risk and food restrictions
with more conversation. implemented accordingly.
• To provide consistency in understanding the
needs of a client with a CVA, assign the same Activity
caregiver to the client whenever possible. In cases of an embolic or thrombolic stroke, the client’s bed is kept
flat with the head midline to increase cerebral perfusion. In the
event of a hemorrhagic stroke, the head of the bed is elevated to
decrease cerebral perfusion. The type of CVA and the physician’s
judgment determines the length of time the client stays in bed.

COLLABORATIVECARE Nursing Management

Maintain a patent airway and fluid and electrolyte balance.
Post-CVA Care Administer oxygen and medications as ordered. Monitor vital
Depending on the location of the CVA and the
signs, neurologic status, I&O, pulse oximetry, and ABGs. Ensure
adequate nutrition. Provide careful mouth and eye care. Keep
extent of neurologic deficit, collaboration with
client’s body in correct alignment, using a footboard to prevent
physical, occupational, and speech therapists foot drop and contractures. Turn client at least every 2 hours
is necessary for the client to reach the optimal to prevent pneumonia. Perform and assist client to perform
functional level of recovery. range of motion (ROM) exercises using the unaffected side to
exercise the affected side. Communicate with the client; often

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326 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

an unresponsive client can hear. Set realistic short-term goals. pain, numbness, tingling, and sensory deficits of vision or
Involve the client’s family in client care when possible. hearing.

NURSING PROCESS Objective Data

Assessment Give specific attention to the objective assessment findings
of level of consciousness, respiratory status, hemiparesis,
Subjective Data hemiplegia, mobility, and cognitive perceptual functioning,
Subjective data include client statements regarding how the including the inability to think clearly and the ability to under-
client is feeling, frustration level with limitations, reports of stand the condition.

Nursing diagnoses for a client with a CVA include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client and/or family will Assess client’s and family’s needs for discharge teaching
related to home care verbalize or demonstrate and knowledge level about necessary home care. Develop a
home health care multidisciplinary plan for client and family teaching.
management. Provide education in verbal, written, and picture forms to
accommodate the varying possible impairments from the stroke.
Teach small segments of information at a time and reinforce
teaching, then, to ascertain effectiveness of teaching, have
client and family return demonstrate or verbalize knowledge.
Primary areas of teaching are medication administration;
dosages, actions, and side effects to report to the physician;
mobility needs; self-care needs; safety factors; communication;
swallowing; elimination; and skin care.

Impaired Verbal The client will communicate Assess communication deficits and consult a speech therapist to
Communication related needs to the caregiver. determine a method of communication, if deficits are apparent.
to neuromuscular Allow time for the client to attempt to communicate needs;
impairment anticipate needs to prevent client frustration in trying to
communicate.
Use gestures, pictures, and closed questions (those requiring
only a “yes” or “no” answer). Provide paper and pencil if
dominant side is unaffected.

Unilateral Neglect The client will move Adapt environment to prevent injury of the client with unilateral
related to neuromuscular paralyzed extremities with neglect by positioning water and personal items on the
impairment assistance from functioning unaffected or unneglected side. Approach the client from the
extremities. unneglected side.
Gradually cue client to remind to tend to the neglected side.
Remind client of safety factors such as arm trailing over edge
of wheelchair or close proximity of a wall on the neglected
side.
Teach client and family to place small bites of food on
unaffected side and to check for food in the cheek on the
affected side after meals.
Instruct client to scan environment for safety factors at all
times.
Teach client how to dress and tend to neglected side. Place
arm either in a sling if client is ambulatory, or on a wheelchair
tray if client is in a wheelchair.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 10 Neurological System 327

■ EPILEPSY/SEIZURE Pharmacological
The primary method of controlling seizure activity is phar-
DISORDER macological. Seizure activity is controlled with an anticon-

E pilepsy is a disorder of cerebral function in which the

client experiences sudden attacks of altered consciousness,
motor activity, or sensory phenomenon. Convulsive seizures
vulsant agent or a combination of anticonvulsants in 75%
of clients (Hickey, 2008). Phenytoin (Dilantin), phenobar-
bital (Phenobarbital), carbamazepine (Tegretol), valproic
are the most common type. Most recurrent seizure patterns are acid (Depakene), and primidone (Mysoline) are often used.
caused by epilepsy. Most clinicians and authors use the term Anticonvulsant agents are started one at a time in gradually
“seizure disorder” for epilepsy or seizures (Hickey, 2008). increasing doses. The client’s blood level is monitored for
A seizure is initiated by an electrical disturbance in the therapeutic range, and the client is assessed for side effects of
neurons, which, in turn, causes an aberrant discharge of elec- the drug and signs of drug toxicity, such as drowsiness, dizzi-
trical activity from any part of the cerebral cortex and possibly ness, gastric distress, rash, blood dyscrasias, and ataxia.
from other areas of the brain (Samuels, 2004). This electrical The goal is to obtain seizure control with minimal side
discharge may cause involuntary episodes of loss of conscious- effects. Any anticonvulsant is gradually discontinued. Abrupt
ness, excessive muscular movement or loss of muscle tone,
and changes in behavior, mood, sensation, and/or perception
(Smeltzer, Bare, Hinkle, & Cheever, 2008).
The etiology of the electrical disturbance may be birth SAFETY
trauma, hypoxia, infection, tumor, alcohol toxicity, drugs, drug
withdrawal, carbon monoxide or lead poisoning, vascular Precautions During a Seizure
abnormalities such as CVA, hypoglycemia electrolyte imbal- If the client is in bed:
ance, or fever. Often, the cause is idiopathic, or unknown. • Be sure the side rails are up.
Seizures are classified as generalized or partial. In general-
ized seizures, the entire brain is affected simultaneously, caus- • Put padding (blankets) on the side rails to
ing bilateral, symmetrical reactions. Generalized seizures are prevent injury.
classified as tonic and/or clonic (grand mal), absence (petit If the client is out of bed:
mal), or myoclonic. • Carefully ease the client to the floor.
Tonic–clonic seizures involve rigid tonic contractions of mus- • Move nearby objects so that the client will not
cles and loss of postural control followed by a clonic stage of inter-
be injured.
mittent contraction and relaxation. Incontinence of stool or urine
is common. Absence seizures involve loss of conscious activity • Place a soft item beneath the client’s head.
without the muscular involvement of tonic–clonic seizures. Myo- Whether the client is in or out of bed:
clonic seizures are very mild, sudden, involuntary contractions of a • Never leave the client alone.
muscle group or rapid, forceful movements. They usually occur in • Do not restrain the client.
the trunk or extremities and involve no loss of consciousness.
Partial seizures initiate in a focal point in the brain and • Do not attempt to put anything in the client’s
involve the function of those specific neurons. Partial seizures mouth after the seizure has begun.
are either simple or complex. In simple partial seizures, the • Loosen any restrictive clothing around the
area affected may be a hand, a finger, the ability to talk, or a client’s neck.
sense such as smell. Consciousness is not lost. • Turn the client’s head to the side.
Complex partial seizures generally involve loss of conscious-
ness and produce cognitive, affective, psychosensory, or psycho- • Monitor seizure activity carefully, noting
motor symptoms. The client performs inappropriate purposive the exact time that the seizure began and
behaviors, called automatisms, or mechanical, repetitive motor ended.
behaviors performed unconsciously, such as lip-smacking. Auras, After the seizure:
peculiar sensations that precede a seizure, may take the form of a • Call the client by name and ask to perform a
taste, smell, sight, or sound; dizziness; or a “funny” feeling. After simple command.
the seizure, the client typically cannot remember the episode.
Diagnostic testing to determine the type of seizure activity • Test the client’s memory by asking to remember
includes an EEG to identify abnormal electrical activity and/or two words.
the focal point of the seizure. Sleep and video EEGs document • Ask the client whether an aura was experienced
changes in electrical activity of the brain. CT scans identify or before the seizure.
rule out lesions, degenerative changes, or vascular abnormalities. • Check the oral cavity—especially the
tongue—for injury.
Medical–Surgical Management • Offer comfort and reassurance, as the client is
Surgical frightened and embarrassed.
Surgical intervention is indicated for a very small percentage • Document everything observed.
of clients; those for whom pharmacological treatment has not • Keep the client in a side-lying position if the
been effective and when the focal points are identified. Micro- client remains lethargic.
surgery is used to irradiate focal points of abnormal electrical
discharge caused by tumor, vascular abnormality, or abscess.

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328 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

PROFESSIONALTIP NURSING PROCESS

Assessment
Long-Term Use of Dilantin
Subjective Data
The client on Dilantin requires good oral hygiene Include client statements of experiences before the seizure and
because of hyperplasia of the gums, which become activity the client was performing when the seizure occurred.
edematous and enlarged. Determine whether an aura was experienced and the sensa-
tions that were manifested, and ascertain if the client has a
prior history of seizure disorder.
withdrawal can cause status epilepticus, an acute prolonged
episode of seizure activity lasting at least 30 minutes with Objective Data
or without loss of consciousness (Smeltzer, Bare, Hinkle, & Assessment of the nature of the seizure and sequencing of
Cheever, 2008). Status epilepticus is a medical emergency that events is important in determining cause and management of
results in respiratory arrest and irreversible brain damage. seizure activity. During the seizure, assess the client’s respira-
tory status and observe for muscular stiffness or flaccidity,
Diet the position of the eyes and head, the size and equality of the
Nutritionally balanced meals are required. The client should pupils, automatism, any cry or sounds made, and incontinence
not consume alcohol. of urine or stool. Note the duration of the phases of the sei-
zure, total duration, and whether unconsciousness occurred.
Activity Note if the onset of seizure activity was observed, along with
Adequate rest is required. Driving, operating machinery, and what the client was doing when the seizure began.
swimming are not allowed until seizures are controlled. After the seizure, assess airway and observe the client for
postictal (after a seizure) signs of paralysis of arms or legs,
Nursing Management inability to speak, sleep following seizure, difficulty in awaken-
ing from sleep, confusion, or general dazed affect (Smeltzer,
Monitor for toxic signs of anticonvulsant medications. Stress Bare, Hinkle, & Cheever, 2008; Hickey, 2008). The postictal
importance for compliance with prescribed medication sched- phase lasts from several minutes to hours. Assess the client
ule. Encourage scrupulous oral hygiene. Warn client not to for signs of injury and vital signs. Clients on anticonvulsant
drink alcoholic beverages. Encourage client to have anticon- therapy are assessed thoroughly because of the wide variety of
vulsant medication blood level checked regularly. side effects involving multiple body systems.

Nursing diagnoses for a client with a seizure include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Airway The client will maintain Following tonic–clonic activity, turn client to the side to
Clearance related to an effective airway during allow secretions to drain from the airway. Prepare to suction
mucus accumulation seizure activity. oropharynx if necessary to clear airway.
during the seizure Assess skin color and respiratory rate and depth during and
and uncontrollable following seizure. Administer oxygen as needed.
tonic–clonic muscle
Insert oral airway or epistick if client’s jaw is not clenched.
contractions involving the
Never insert an object if the jaw is already clenched. Do not
respiratory muscles
place fingers between client’s teeth. Loosen restrictive clothing.

Risk for Injury related to The client will be free of During seizures in bed, use blankets or protective pads to pad
seizure activity injury related to seizure side rails.
activity. If client is standing or sitting, ease client to the floor when
seizure activity begins. Place client in a supine position, but do
not physically restrain client.
Remove objects from around client so that he will not hit them.
After the seizure, assess airway and turn client to the side
to allow secretions to drain from the mouth. Observe client
for injuries (e.g., tongue lacerations; broken bones; body
lacerations or bruising).
Maintain a low-stimulus environment to prevent further seizure
activity.

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 CHAPTER 10 Neurological System 329

Nursing diagnoses for a client with a seizure include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Teach client about ways of maintaining a safe environment,
including driving restrictions; lying down in a safe area if an
aura is experienced; showering instead of tub bathing; either
avoiding swimming or swimming with a partner if the physician
allows; and wearing a medical identification tag.

Ineffective Coping related The client will verbalize Allow client to verbalize fears and concerns. Explore coping
to anxiety secondary fears and concerns about mechanisms with client.
to seizure disorder and seizure activity; and will use Collaborate with mental health counselor or clergy to assist
altered self-concept effective coping methods. client in development of coping mechanisms.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

the spinal cord. Symptoms are weakness of the lower extremities

■ HERNIATED and unsteady gait. Spasticity and hyperactive reflexes develop in
the lower extremities. Difficulty in voiding and sexual dysfunc-
INTERVERTEBRAL DISK tion occur.

H
Degenerative spinal cord disease can follow compression
erniated intervertebral disks are a major cause of chronic from a herniated disk. Spinal cord tumors and herniated lum-
back pain. Most clients with herniated disks are 30 to bar disk are differential diagnoses that are ruled out through
50 years of age. Most herniated disks occur in the lumbar the use of MRI or CT scans.
or cervical spine because of the flexibility of these regions
(Hickey, 2008). This can occur either suddenly from trauma,
lifting, or twisting or gradually from aging, osteoporosis, or Medical–Surgical Management
degenerative changes. Most herniated disks are caused by Medical
trauma, such as falls, accidents, or repeated lifting. Degenera-
tive changes related to arthritis, aging, or repeated minor inju- Conservative medical treatment, i.e., providing rest, stress reduc-
ries predispose the client to herniated intervertebral disks. tion and immobility of the spine, and pain relief, often is tried
The intervertebral disk is a cartilaginous cushion between for several weeks. Physical therapy is ordered, with exercises to
vertebral bodies (Figure 10-15). In herniation, or rupture of strengthen back muscles and possibly ultrasound treatments.
the disk, the nucleus pulposus protrudes into the fibrous ring, Spinous
the annulus fibrosus. This protrusion presses on the spinal Lamina process Intervertebral
cord and nerve roots, causing pain, motor changes, sensory disk
changes, and alterations in reflexes. Transverse Cauda
The nerve root affected and the degree of compression process equina
leads to specific symptoms. Ninety percent to 95% of lumbar A
herniations occur at the L-4 to L-5 and S-1 levels (Hickey,
2008). Low-back pain that radiates across the buttock and down
Spinal
the leg along the path of the sciatic nerve is the most common Vertebral
nerve
symptom. The affected leg tingles and is numb. Sneezing, strain- body
ing, stooping, standing, sitting, blowing the nose, and jarring Intervertebral
disk
movements aggravate the pain. Positions of comfort are lying on
the back, with knees flexed and a small pillow under the head, or
lying on the unaffected side, with the affected knee flexed. Pressure
Motor weakness is experienced. Paresthesia and numb- Pressure (body weight)
ness of the leg and foot occur. Knee and ankle reflexes are Spinal nerve on spinal
diminished or absent. Lasegue’s sign, pain experienced subject to cord and
upon gentle raising of the fully extended leg of the supine- pressure nerve root
positioned client to 20 to 60 degrees, stems from stretching Herniated
COURTESY OF DELMAR CENGAGE LEARNING

disk
of the inflamed sciatic nerve. With a low-back herniated disk, B
however, the client is unable to extend the knee because of
severe pain radiating down the hip and leg. Symptoms vary
with the area and degree of nerve root compression.
Cervical herniation commonly occurs at levels C-5 to C-6 Herniated nucleus
or C-6 to C-7. Symptoms of lateral herniation include pain pulposus compresses
and paresthesia in the neck, arms, and shoulders. Loss of mus- the nerve root
cle strength and reflexes also occur, as does muscle atrophy.
Because of anatomic position, cervical disks herniate cen- Figure 10-15 A, Normal Intravertebral Disk; B, Herniated
trally more frequently than do lumbar disks, thereby compressing Disk

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330 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

A transcutaneous electrical nerve stimulation (TNS) unit may The client may not lift or carry more than 5 pounds for
also be used to decrease pain. at least 8 weeks. Twisting movements are avoided. The client
cannot drive a car until the surgeon permits. Sitting is limited
Surgical during the early postoperative period; the client either stands
or lies down. Physical therapy is focused on muscle strength-
Surgery to remove the herniated disk is performed when ening and client comfort. Heat therapy, ultrasound, and exer-
neurological deficit or pain are not responsive to conserva- cises promote comfort and healing.
tive treatment or when symptoms require immediate surgical
intervention.
Nursing Management
Pharmacological Preoperatively, monitor neurological status and vital signs.
Narcotic analgesics, such as hydrocodone bitartrate with acet- Encourage client to cough, deep breathe, use incentive spirom-
aminophen (Vicodin), and nonnarcotic analgesics, such as tra- eter, and move legs as allowed. Provide adequate fluids to pre-
madol hydrochloride (Ultram), are ordered for pain control. vent renal stasis and constipation.
Antiinflammatory drugs, steroids, or NSAIDs, such as ibuprofen Postoperatively, monitor vital signs, neurovascular status
(Motrin) or naproxen (Anaprox), are prescribed to reduce the of legs, and check dressing for any bleeding. If drain is in place
inflammatory response. Clients in chronic pain sometimes benefit (e.g., Hemovac or Jackson-Pratt drain), check frequently and
from an antiepileptic drug, e.g., gabapentin (Neurontin), because empty at end of shift and record on I&O sheet. Use the log-
it treats neuropathic pain. Muscle relaxants, such as methocar- rolling technique for turning the client.
bamol (Robaxin), are given to reduce spasms of surrounding
muscles, which decreases the pain. Antianxiety medications, such
as diazepam (Valium), are given to decrease muscle tension and NURSING PROCESS
promote rest. Short-term oral corticosteroids may be ordered, or
local or epidural corticosteroid injections may be used Assessment
Subjective Data
Diet Assessment includes eliciting client statements about motor and
To decrease the workload on the involved muscles, weight sensory function, pain, and effectiveness of comfort measures.
reduction is advocated if the client is overweight. A high-pro-
tein diet with calcium, vitamin D, and phosphorus is necessary Objective Data
for bone repair and prevention of osteoporosis. Fiber is neces-
sary for bowel function because constipation is a common Assessment entails a neurological evaluation of motor and
side effect of analgesics. sensory function of the extremities innervated below the her-
niated area. Reflex testing is a part of the nursing assessment in
some facilities. Assess range of motion (ROM) of the affected
Activity extremity. Assess the client’s knowledge about the disease
Bed rest, a support garment (back brace) or cervical collar, a process, the planned treatment including pain management
firm mattress, and traction are used to decrease stress on the and surgery, and the postsurgical care. Assess bowel and blad-
affected vertebrae. Postoperatively, log-roll turning prevents der elimination for potential nerve involvement or effects of
injury to the vertebrae and spine. immobility. Note gait alteration and bending limitations.

Nursing diagnoses for a client with a herniated intervertebral disk

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to The client will experience Assess pain intensity and location, as well as activities or position
nerve compression or increased comfort. when pain began. Have the client rate pain on a scale of 1 to 10.
surgical intervention Maintain activity level as ordered by physician. Provide
diversional activities.
Place client in position of comfort, usually on back, with
knees slightly flexed and a small pillow beneath head, or on
unaffected side, with affected extremity flexed and a pillow
between the legs.
Maintain immobility of vertebrae with corset, brace, or traction.
Apply moist heat as prescribed and administer medications
to relieve pain, relax muscles, and relieve inflammation and
anxiety, as ordered. Document effectiveness.

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 CHAPTER 10 Neurological System 331

Nursing diagnoses for a client with a herniated intervertebral disk

include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Physical The client will have no Assess for complications of immobility. Turn client every 1 to 2
Mobility related to nerve complications of immobility. hours. The client tends to limit position to one of comfort.
compression or surgical Assist the client to log roll, that is, move the body as a unit
intervention without twisting the back.
Ambulate as ordered by the physician.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

muscles, loss of spinal reflexes, loss of sensation, and absence

■ SPINAL CORD INJURY of autonomic function below the level of injury also occur.

S
The diaphragm is innervated at levels C3 through C5. Injuries
pinal cord injury (SCI) occurs from trauma to the spinal in this area cause partial or complete disruption of respiratory
cord or from compression of the spinal cord caused by function. The client does not perspire below the level of the
injury to the supporting structures. Each year, almost 12,000 injury. Bowel and bladder function is lost either for a few days
new spinal cord injuries occur. Most of the victims are males to months, or permanently, although this loss generally lasts
between the ages of 16 and 30 years. Leading causes of injury from 1 to 6 weeks.
in the order of prevalence are motor vehicle accidents; falls; As spinal shock resolves, reflex activity returns below the
acts of violence; and sporting accidents (Spinal Cord Injury level of injury. The client with a lower motor neuron injury
Information Network, 2009). continues to experience flaccid paralysis, areflexia, hypotonic
Numerous classification systems exist for SCIs. Spinal bowel and bladder function, and sexual dysfunction. Lower
cord injuries are classified by level of injury, mechanism of motor neuron injury causes paraplegia, or paralysis of lower
injury, or neurological or functional level (Figure 10-16). extremities.
The injury may be considered complete or incomplete. When Neurogenic shock, a hypotensive situation resulting
injury is complete, no impulses are carried below the level of from the loss of sympathetic control of vital functions from
injury. There is complete disruption of the spinal cord func- the brain, may occur during spinal shock. This happens in
tions, including motor (voluntary) movement, sensation, and clients with injury above the sixth thoracic vertebra. The cli-
reflexes to areas innervated by the spinal nerves at and below ent develops orthostatic hypotension, bradycardia, decreased
the level of the injury. In an incomplete injury, some of the cardiac output, loss of ability to sweat below the level of
spinal cord tracts are affected while others are able to carry injury, and poikilothermia (body temperature adjusts to room
impulses normally. temperature).
The mechanism of injury is usually an acceleration– Upper motor neuron injury results in spastic paralysis,
deceleration event that causes hyperflexion, hyperextension, loss of voluntary skeletal muscle movement, and reflexive
axial loading, or excessive rotation injury (Hickey, 2008). bowel, bladder, and sexual responses. Complete upper motor
Hyperflexion is the extreme forward movement of the head, neuron injury results in quadriplegia (tetraplegia), or
which causes compression of the vertebral bodies and damage dysfunction or paralysis of both arms, both legs, bowel, and
to the posterior ligaments and intervertebral disks, as shown bladder. Injuries above C5 affect respiratory function because
in Figure 10-17A. Hyperextension is the extreme backward of innervation of the diaphragm and accessory respiratory
movement of the head, causing injury to the posterior verte- muscles. Mechanical ventilation is required to keep the client
bral structures and the anterior ligaments, as shown in Figure alive. Fractures below the cervical vertebrae result in diaphrag-
10-17B. Axial loading or compression occurs when extreme matic breathing, if the phrenic nerve is functioning.
pressure is placed on the spinal column, such as in diving Once spinal shock has passed, the client with an injury
accidents or falls landed on feet or buttocks (Figure 10-17C). above the sixth thoracic vertebra is at risk for developing
Compression of the vertebrae shatters the vertebral body. autonomic dysreflexia or autonomic hyperreflexia. Autonomic
Compression fractures and posterior ligament injury can also dysreflexia is an emergency situation resulting in a hyperten-
be caused by excessive rotation, or turning the head beyond sive crisis (elevated systolic pressures of 260 to 300 mm Hg),
the normal range. bradycardia, severe headache, and possibly stroke or seizure
Classification of injury by cause includes concussion, activity. The cause is noxious stimuli such as a full bladder, a
contusion, laceration, transection, hemorrhage, or damage fecal impaction, a wrinkle in clothing, menstrual cramps, an
to blood vessels supplying the spinal cord. Immediately after erection, an ingrown toenail, a bladder infection, or sitting
injury to the spinal cord, an autodestructive process begins, on catheter tubing. Autonomic reflexes below the level of the
with chemical and vascular changes that lead to ischemia and injury cause vasoconstriction in this area. The controlling
necrosis of the spinal cord. impulses from the higher cortical levels do not transmit past
Spinal shock (cessation of motor, sensory, autonomic, the level of injury but cause bradycardia and vasodilation
and reflex impulses) and areflexia (the absence of reflexes) above the level of injury. Skin above the level of injury is warm
occur immediately upon transection of the spinal cord or and moist, but skin below the level of injury is cold, with goose
upon injury to the spinal cord. Flaccid paralysis of all skeletal flesh (Beare & Meyers, 1998; Hickey, 2008).

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332 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

C-2

C-2

Spinal
nerves
C-2 C1
C-3 2
C-3
3
C-4
C-4 4 3
T-2 C-5
T-2 5 4
T-3 T-3 C-6
C-5 Phrenic diaphragm nerve
T-4 T-4 6 5
T-2 T-5 T-2 7 6
T-5
T-6 8 7 Upper limbs Quadriplegia
C-6 T-6 T-7
T1 1 Paraplegia
T-7 T-8 2
C-8 C-7 2
T-8 T-9
T-10 3 3
T-9
C-7 T-11
T-10 4 4
T-12
T-11
L-1 5 5
T-1 T-12 L-2
T-1 6 Head
L-2
6
S-3
C-8 L-1 S-5 7 Sympathetic
7
outflow
A S-4
S-3
8 8 B
L-2 9 Temperature Blood
S-2
9 control vessels
Umbilicus
10
10
L-3 11
L-3 12 11
L1
2 12
3
4
5 1
L-5
S1
2
L-4 3 2
4
L-4 5
Cox 1 3
L-5

COURTESY OF DELMAR CENGAGE LEARNING

Lower limbs

5
S-1
1
S-1 2
3 Bladder
4 Bowel
Front Back 5 External
Motor genitalia
Sensory

Figure 10-16 Spinal Cord—Levels of Injury; A, Areas of Sensory Function (Dermatomes); B, Areas of Motor Function

The noxious stimuli must be removed, if possible, and the

client placed in a sitting position immediately. Assess blood Medical–Surgical
pressure immediately and monitor every few minutes until Management
within normal limits (Huston & Boelman, 1995). The drug of
choice, nitroprusside sodium (Nipride), is given if the conser- Medical
vative measure does not work. Nifedipine (Procardia) is also Medical management of the client with spinal cord injury begins
used. Prevent autonomic dysreflexia when possible, recognize before reaching the hospital. Further damage to the spinal cord
when it develops, and treat immediately. Once autonomic dys- is prevented by immobilizing the head, neck, and vertebral
reflexia is relieved, the client may develop hypotension from column with devices such as rigid cervical collars and splinting
the decreased sympathetic response and the residual effects of backboards. All trauma clients are treated as potential spinal cord
medication and positioning changes. A pattern of individual injuries. When the client reaches the emergency room, x-rays of
response to stimuli and of sympathetic response is soon iden- the spine are taken before removing the immobilizing devices.
tified for the client; however, the client with an upper motor Respiratory function is continuously assessed, and ventila-
neuron injury above T-6 is always at risk for developing auto- tory support is provided as necessary. The client may have multi-
nomic dysreflexia. Some clients experience the first episode ple injuries, necessitating astute diagnostic skills by the emergency
years after the injury. room physician. Assessment of the trauma client involves evaluat-
The extent of permanent injury cannot be determined ing for internal hemorrhaging, cardiac contusion, head injury,
immediately because of necrosis, edema, and spinal shock. hemorrhagic shock, and spinal shock resulting from the spinal
Functional loss depends on the level, degree, and type of cord injury. A thorough assessment is done to specifically evaluate
injury. the degree of deficit and to establish the level or degree of injury.

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 CHAPTER 10 Neurological System 333

Traction is used to maintain alignment of the spinal column.

Cervical tongs and halo devices are used to apply traction
and to immobilize the cervical spine (Figure 10-18). Under
local anesthesia, cervical tongs and halo rings are applied with
spring-loaded pins that are embedded into the scalp. Antisep-
tic solution is used to cleanse the scalp, and a local anesthetic
is injected into the insertion sites. Traction weights are applied
to the cervical tongs or halo rings after the insertion pins are
firmly embedded. Body casts, jackets, vests, or braces are used
to immobilize thoracic and lumbar fractures.

Surgical
Surgical interventions are performed for decompression,
realignment, and stabilization of the vertebral column, depend-
ing on the nature of the injury. A laminectomy is performed to
A decompress the spinal cord with fusion or placement of Har-
rington rods to stabilize the vertebral column. Realignment is
maintained by surgical manipulation of the vertebral column.
If the client has respiratory involvement, an endotracheal
tube is put in place to provide mechanical ventilatory support.
Following urgent treatment, a tracheostomy is performed to
continue ventilation.

Pharmacological
Nitroprusside sodium (Nipride) and nifedipine (Prodardia)
are ordered to reduce blood pressure in cases of autonomic
dysreflexia.

B
COURTESY OF DELMAR CENGAGE LEARNING

Figure 10-17 Acceleration/Deceleration Injuries;

A, Hyperflexion: The extreme forward movement of the head
causes compression of the vertebral bodies and damage to the
posterior ligaments and intervertebral disks; B, Hyperextension:
Extreme backward movement of the head causes injury to the
posterior vertebral structures and the anterior ligaments;
C, Axial loading or compression: Extreme pressure is placed on
the spinal column, such as in diving accidents or falls landing on
feet or buttocks

Blood pressure monitoring is crucial. A systolic BP below

90 mm Hg should be avoided or corrected as soon as possible
because one episode can send the client into shock and cause
permanent damage (Baker & Saulino, 2002).
Immobilization of the spinal cord continues to be the
focus of care during early medical management of the client. Figure 10-18 Halo Vest (Courtesy of DePuy AcroMed.)

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334 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

following facility protocol. For a client with a vest, jacket, or

brace, provide skin care under the device. Implement bowel
COLLABORATIVECARE and bladder training regimen. Monitor vital signs.

After a Spinal Cord Injury

NURSING PROCESS
The interdisciplinary team works together to
optimize the functional capabilities of the client. Assessment
The physical therapist works on activity level,
the occupational therapist on ADLs, the speech
Subjective Data
therapist on swallowing and communication,
Subjective assessment involves eliciting input from the
client regarding sensation, pain, and history of the accident.
and nursing coordinates the team and reinforces
Note how the client is coping with the injury, the result-
what the client has been taught. The focus is to ing disability, and the major lifestyle changes that have
prevent disabilities and maximize and strengthen occurred. Evaluate how the family or support system is cop-
functional ability. ing with the changes.
Objective Data
Activity In the acute phase of care of the client with a spinal cord injury,
Initially, immobilization of the spinal column is necessary. In the nursing assessment focuses on the critical factors of airway,
acute phase, ROM for all joints is performed to prevent mobility breathing, circulation, disability, and exposure.
loss and muscle contracture. As the spine is stabilized, the client’s Assess circulatory status by monitoring vital signs and
activity progresses to sitting up in a chair, performing strengthen- observing for complications of neurogenic shock; orthostatic
ing exercises, and increasing endurance. The nurse observes for hypotension; hypertensive episodes of autonomic dysreflexia;
the complication of orthostatic hypotension. and hemorrhaging.
Orthostatic hypotension is caused by the venous pool- Assess disability by performing a baseline neurological
ing of blood in the lower body and extremities resulting from assessment (as described under the Neurological Assessment
impairment of the sympathetic nervous system. The client section in this chapter).
becomes hypotensive and develops bradycardia and syncope. Exposure refers to removing the client’s clothing to
Asystole may even occur. Prevention of orthostatic hypoten- perform a thorough assessment of the client’s body for skin
sion also requires the application of full leg support stockings condition and for entrance and exit wounds. Monitor body
and pneumatic boots and the gradual lowering of the lower temperature because of the neurological deficit in temperature
extremities. Monitor the client’s vital signs throughout the regulation caused by dysfunction of the ANS.
mobilization process to ascertain tolerance to the procedure. Subacute assessment is based on the level of injury and
After spinal shock has subsided, active rehabilitation begins. neurological functioning of the client. With upper motor
neuron injuries, the client is at higher risk of developing auto-
Nursing Management nomic dysreflexia; thus, assessment includes monitoring for
these signs.
After stabilization, turn client frequently to prevent embolism, Assess all clients with spinal cord injury for skin condi-
pneumonia, and skin breakdown. Use log-rolling technique. tion, bowel and bladder function, respiratory status, and
Keep call light within client’s reach. Provide passive and active signs and symptoms of complications of immobility. Psy-
ROM exercises as allowed. Maintain adequate nutrition and chosocial assessment is very important to the well-being of
fluid intake. If client has a halo device, perform pin-site care the client.

Nursing diagnoses for a client with a spinal cord injury in the subacute
phase of care include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related The client will not Assess the client’s risk factors for additional injury.
to motor and sensory experience additional injury. Monitor skin condition for pressure areas or shearing injuries
deficits secondary to from sliding across sheets or the mats in physical therapy.
spinal fractures
Turn client frequently to prevent pressure areas. Use enough
personnel to turn client correctly to maintain alignment of
client’s spinal column.
Provide a call light that the client can operate; teach to call
nurse for assistance as necessary.
Reinforce wheelchair safety factors and observe client for use
of wheelchair.

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 CHAPTER 10 Neurological System 335

Nursing diagnoses for a client with a spinal cord injury in the subacute
phase of care include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Prevent falls when transferring client to wheelchair. Prevent foot
drop.
Provide passive and active ROM exercises.
Maintain adequate fluid intake and nutrition.
Provide routine care for halo device by opening vest on one
side to cleanse skin under vest at least daily and to assess for
skin breakdown. Repeat procedure on the other side.
Monitor pin sites of halo device every shift for placement.
Perform pin site care using facility protocol.

Powerlessness related The client will make Explain all procedures and care options. Allow client to
to changes in motor and decisions regarding care, participate in care decisions.
sensory function and in treatment, and future. Establish an open, trusting relationship with client to foster
lifestyle therapeutic communication.
Allow time for client to express concerns, anger, and fears.
Foster a positive environment for client to explore feelings and
accept disability.
Assess for signs and symptoms of depression.
Collaborate with mental health professional to provide
assistance in coping with lifestyle changes.
Collaborate with family and support people to include them in
the plan of care.

Autonomic Dysreflexia The client will state factors Teach client causes and symptoms of autonomic dysreflexia:
related to noxious that cause autonomic increased blood pressure, sudden throbbing headache, chills,
stimulation secondary to dysreflexia, describe pallor, goose flesh, nausea, and/or metallic taste in mouth.
overstimulation of ANS treatment, and notify the Prevent bladder distention and fecal impaction by implementing
nurse if experiencing a bowel and bladder training program.
symptoms of dysreflexia.
Observe for bradycardia, vasodilatation, flushing, and diaphoresis
above the level of spinal cord injury. If these symptoms occur,
immediately notify the physician and administer medications as
ordered to decrease blood pressure. Raise head of bed and lower
legs to reduce blood pressure. Then, remove the noxious stimuli,
which may include constrictive clothing, shoes, splints, or linens.
Assess client for a distended bladder and empty the bladder
if distended. Observe urine for signs of infection and obtain a
urine specimen for culture, if needed to identify the cause of the
reaction.
Check for fecal impaction using xylocaine viscous per
physician’s order to decrease stimulation.
Monitor blood pressure every few minutes.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

movement. The cause is unknown in most cases, but toxic-

■ PARKINSON’S DISEASE ity, hypoxia, or encephalitis may precede the onset of PD.

P
Vascular and genetic factors have been implicated. Drugs
arkinson’s disease (PD) is a chronic, progressive, degen- such as cocaine, haloperidol (Haldol), and chlorpromazine
erative disease affecting the area of the brain controlling (Thorazine) may cause a parkinsonian syndrome. The theory

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336 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

is that these drugs interfere with the synthesis or storage of

dopamine.
Typical signs and symptoms of PD are muscular rigidity,
bradykinesia (slowness of voluntary movement and speech),
resting tremors, muscular weakness, and loss of postural
reflexes. Muscular rigidity along with bradykinesia impairs the
person’s ability to perform daily activities and speech.
Rigidity is noted along with increased muscle tone when A B
the client is at rest. Stiffness of the trunk, head, and shoulders
is present. The rigidity causes loss of arm swing when walking.
A cogwheel phenomenon results from the muscle contrac-
tions breaking through the muscular rigidity. The alternating
rigidity and rhythmic contractions causes a jerking-like move-
ment. Motor impairment progressively affects facial expres-
sions, eye blink, and voice, causing a typical presentation of a
mask-like face and a monotone voice.
Resting tremors, usually in the upper extremities, are
present when the hand is motionless. The hand moves in a
“pill-rolling” motion. When the client is moving or sleeping,
the tremors are usually absent. Tremors also occur in other
areas, including the feet, lips, tongue, or jaw. The tremors usu-
ally begin unilaterally in one area and progress to other areas
and then to the opposite side of the body. Anxiety and concen-
tration tend to increase the degree of tremors.
The posture and gait of people with PD is characterized by
bowed head, forward-bent trunk, drooped shoulders, and flexed C D
arms. The gait is characterized by shuffling movement and small
steps. Balance is affected, resulting in a tendency to fall forward.
Figure 10-19 shows the classic posture of a client with PD.
Autonomic dysfunction includes drooling, dysphagia
(difficulty swallowing), excessive sweating, hyperactivity of
oil glands, and constipation. Orthostatic hypotension may
occur from loss of the peripheral autonomic response. Urinary
incontinence and frequency occur.
Mental changes may also occur. Intelligence is not
impaired, but problems with judgment and emotional stabil-
ity may occur. Dementia, depression, cognitive, perceptual, or
memory deficits may occur. The major cause of death is from
the complications of immobility or injury. Fatigue increases all
signs and symptoms. There is no definitive diagnostic proce-

COURTESY OF DELMAR CENGAGE LEARNING

dure for PD. The diagnosis is based on history, physical, and E
the client’s response to anti-Parkinson’s medications. Imaging
studies and EEG are performed to rule out other neurological
diseases. Position emission tomography (PET) scanning is per-
formed as a way of researching information about the degen-
eration of the neurons that make dopamine (National Institute
Neurological Disorders and Stroke, 2006c). In cases of early
onset, it is important to differentiate from Wilson’s disease, an
increased absorption of copper, for which testing is available. Figure 10-19 Progression of Parkinson’s Disease;
A, Flexion of Affected Arm; B, Shuffling Gait; C, Need for Sources
Medical–Surgical Management of Support to Prevent Falling; D, Progression of Weakness
to Point of Needing Assistance for Ambulation; E, Profound
Medical Weakness
The goals of medical management are to control the symptoms,
provide supportive therapy and maintenance, maintain function has been approved by the U.S. Food and Drug Administration
via physiotherapy, and provide psychotherapy as necessary. to reduce the severity of symptoms (National Institute of Neuro-
logical Disorders and Stroke, 2006c). In deep brain stimulation,
an electrode is placed in the thalamus, globus pallidus, or subtha-
Surgical lamic nucleus to deliver a specific current to the targeted brain
Surgical procedures are usually only used in clients who are unre- location. These jolts of electricity counter balance the hyperactiv-
sponsive to drug therapy. Ablation procedures (thalamotomy, pal- ity of these parts of the brain in clients with PD. Surgical interven-
lidotomy, and subthalamic nucleotomy) destroy areas of the brain tions are believed to be most effective in relatively young clients
to control intractable tremors or akinesia. The risk of causing with unilateral tremor. Still in the experimental stages are neural
permanent neurological deficits is high. Deep brain stimulation tissue transplants, gene therapy, and stem cell transplantation.

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 CHAPTER 10 Neurological System 337

Pharmacological
Drug therapy is used to control the symptoms of PD. Levodopa CLIENTTEACHING
(L-Dopa) is converted into dopamine in the basal ganglia to Parkinson’s Disease
replace the deficit of dopamine. Dopamine is not given orally
because it is metabolized before reaching the brain. L-Dopa, a Advise caregivers to:
precursor to dopamine, is given orally and reaches the brain to • Encourage the client to be as independent as
be converted into dopamine. possible.
Dopadecarboxylase inhibitors such as carbidopa-levodopa
• Protect the client from injury and unnecessary
(Sinemet) prevent the conversion of levodopa (L-Dopa) to
dopamine in peripheral tissue. Dopamine in the peripheral stress and fatigue.
tissue causes numerous side effects as well as decreases the Advise the client to:
amount of L-dopa available to the brain. Dopadecarboxylase • Use adaptive devices (e.g., cane, walker, feeding
inhibitors that do not cross the blood–brain barrier are used to utensils).
inhibit the enzyme that changes L-dopa to dopamine so that • Take medications at scheduled times to maintain
the conversion in the brain is not inhibited. level in the body.
Anticholinergic drugs, such as trihexyphenidyl hydrochlo-
ride (Artane), cycrimine hydrochloride (Pagitane hydrochloride), • Avoid taking multivitamins, foods high in
and benztropine mesylate (Cogentin), are administered to con- vitamin B6, and high-protein foods when taking
trol tremors and rigidity. Anticholinergics are used alone for mild levodopa.
symptoms or if levodopa is contraindicated. In other instances, • Prevent constipation by drinking plenty of
they may be administered in conjunction with levodopa. water and, possibly, using a stool softener.
• Have intraocular pressure measured frequently
if client has glaucoma.
PROFESSIONALTIP

Pallidotomy Amantadine hydrochloride (Symmetrel), an antiviral

agent, is effective in treating parkinsonian symptoms. The
Pallidotomy, an operation of the 1950s for PD, is mechanism by which the drug works is not known, but the
being used again. Improved surgical equipment and theory is that it either releases dopamine storage areas or
clients who no longer benefit from medications are delays the reuptake of dopamine.
causing a resurgence in the use of pallidotomy. Ethopropazine hydrochloride (Parsidol), a phenothiazine
derivative, is used in combination with other anti-Parkinson
Using MRI and stereotactic equipment, the physician drugs to alleviate symptoms. Dopamine agonist-ergot deriva-
can pinpoint the area of the brain that is causing the tives, such as pergolide mesylate (Permax), directly stimulate
unwanted symptoms. A probe is then inserted into the dopamine receptors to improve the use of available dop-
the brain through a small hole in the client’s head. amine. The monoamine oxidase inhibitor (MAOI), selegiline
A small lesion is made deep in the brain to interrupt hydrochloride (Eldepryl), inhibits dopamine breakdown. The
the electrical pathways that cause the rigidity and tricyclic antidepressants, amitriptyline hydrochloride (Elavil)
tremors. The surgery relieves symptoms but does not
and imipramine hydrochloride (Tofranil), alleviate depression
as well as other symptoms.
cure PD. Furthermore, associated risks such as paraly-
sis and bleeding must be considered (PDF, 2002). Diet
Puréed foods or tube feedings are required because of dysphagia.
Maintenance of weight may require high- or low-calorie diets. In
the early stages of PD, a diet high in antioxidants may alleviate
some symptoms. Free-radicals are attracted to cells that produce
dopamine. Antioxidants are chemicals that destroy free radicals,
Adaptations for the Client with thus allowing the release of dopamine. A diet that discourages
Parkinson’s Disease the formation of free radicals is high in complex carbohydrates
(such as those found in whole-grain breads and lentils), low in
• Arrange for bathroom facilities and bedroom on fat, and high in vitamins A and E. See Box 10-2 for foods high in
first floor. antioxidants. Large doses of supplemental vitamins A and E are
• Remove crepe- or rubber-soled shoes from also given. A high-fiber diet helps prevent constipation.
the client because they may drag on the floor,
especially on carpeting.
SAFETY
• Remove throw rugs or other obstacles over
which the client may trip. Mealtime
• Install handrails at steps, hallways, and bathroom.
The client with PD must be monitored for choking
• Have no highly waxed floors.
while eating because of dysphagia.
• Provide assistance to client as needed.

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338 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

function. Psychotherapy addresses the implications of living

BOX 10-2 FOOD HIGH IN ANTIOXIDANTS with a chronic disease, depression, and the possible psychiat-
ric side effects of the medication regimen.
Dark-colored fruits and vegetables:
Leafy green vegetables
Broccoli
Nursing Management
Tomatoes Encourage independence. Fatigue may cause more depen-
Carrots
dence. Assist to establish a regular bowel routine by encourag-
ing the client to drink at least 2,000 mL of liquids daily and eat
Garlic
high-fiber foods. Provide an elevated toilet seat. Assist client
Red kidney beans and family to express feelings and frustrations.
Pinto beans
Blueberries
Cranberries NURSING PROCESS
Strawberries
Plums Assessment
Apples
Subjective Data
Teas: Nursing assessment focuses on functional ability and activi-
Green tea ties. It includes eliciting client statements about symptom
Black tea control and emotional status. Ascertain bowel and bladder
elimination patterns.

Activity Objective Data

Ambulation with assistance is necessary to maintain joint mobil- Objective assessment involves evaluation of tremors, muscular
ity and prevent injury. Ambulate at the client’s pace because the rigidity, movement, posture, and gait for degree of impairment.
bradykinesia becomes worse when the client attempts to hurry. Assessment of swallowing ability is necessary to maintain ade-
quate nutrition and prevent aspiration. Evaluate mental/emo-
Other Therapies tional status for signs and symptoms of depression or dementia.
Physical therapy is directed toward maintaining joint mobility, Assess skin for diaphoresis, or excessive oil production;
posture, and gait. Occupational therapy focuses on maintain- skin integrity; and signs of injury from falls. Obtain supine,
ing optimal functioning in achieving ADL. Speech therapy is sitting, and standing blood pressures to assess for orthostatic
used to promote communication and maintain swallowing hypotension.

Nursing diagnoses for a client with Parkinson’s disease include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Physical The client will maintain Assess degree of muscle involvement by testing ROM,
Mobility related to muscle optimal mobility. muscular rigidity, tremors, and gait. Perform passive and active
rigidity, gait disturbance, ROM exercises to maintain function.
and bradykinesia Administer medications within the time window that provides a
constant therapeutic level for symptom control.
Ambulate, as client is able to tolerate. Frequently turn client
when in bed.

Bathing/Hygiene and The client will maintain Assess client’s ability to perform self-care. Encourage client to
Dressing/Grooming Self- optimal independence in perform as much self-care as possible.
care Deficit related to self-care. Consult with occupational therapy for methods to increase the
immobility, tremors, and ability to perform self-care. Assist with daily care that the client
bradykinesia is unable to perform alone.

Impaired Swallowing The client will swallow Position client sitting upright when eating with client’s head
related to neuromuscular with minimal choking slightly forward and never extended to facilitate swallowing.
Impairment and coughing and no Encourage client to take small bites.
aspiration.
Provide small bites of food or pureed foods to prevent client
from choking. Have suction equipment available during meals.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 10 Neurological System 339

■ MULTIPLE SCLEROSIS CLIENTTEACHING

M ultiple sclerosis (MS) is a chronic, progressive, degen-
erative disease of the CNS characterized by a loss of
myelin in the brain, spinal cord, or both and by the occurrence
Temperature Sensation
Because the client with MS has a decreased sense
of sclerotic (hardened) patches (Figure 10-20). The disease of temperature, advise to:
interferes with the conduction of impulses. The neurological • Be careful when cooking or otherwise around
deficit that occurs depends on which nerve cells are affected. the kitchen stove.
The cause of MS is unclear, but research suggests that it is an • Use a bath thermometer to test bath or shower
abnormal response to the body’s immune system. The disease water so as to prevent burning.
is more prevalent among people of Northern European ances-
try (NMSS, 2003). Diagnosis is usually made between the • Use only the low setting on a heating pad.
ages of 20 and 50 years. Women are affected two to three times
more often than are men (NMSS, 2003).
The white matter of the brain and spinal cord consists of
axons covered by a white, lipid substance called myelin. This trauma, or fatigue. Hot baths or strenuous exercise may aggra-
myelin sheath is an insulator that is involved in the conduction vate motor symptoms. Periods of exacerbation last hours to
of impulses. months. Commonly, the periods of exacerbation become
As sclerotic tissue replaces the myelin, neurological func- more frequent as the disease progresses. Complications such
tion returns. Nerve fibers begin to degenerate as periods of as urinary tract infection, pneumonia, pressure ulcers, con-
exacerbation become more frequent. Degeneration of the tractures, and depression frequently occur. As the disease
nerve fibers leads to permanent neurological deficits. progresses and permanent neurological deficits occur, the cli-
Signs and symptoms of MS vary according to the areas of ent becomes bedridden, has difficulty speaking and handling
demyelination. The client may have one symptom or a com- oral secretions, and/or develops emotional and intellectual
bination of symptoms. Periods of exacerbation and remission disturbances.
also make diagnosis difficult. Symptoms may vary from hour-
to-hour or day-to-day. Medical diagnosis is generally based on Medical–Surgical
history and on elimination of other possible diagnoses. Mag-
netic resonance imaging and CT scan can be used to identify Management
lesions of sclerotic tissue as the disease progresses. Cerebro- There is no cure or specific treatment for MS. Treatment goals
spinal fluid reveals increased white blood cells, protein, and are to limit exacerbations, prevent complications, and main-
immunoglobulin (IgG), a diagnostic indicator. tain functional level.
Client symptoms may be sensory, motor, or other dis-
turbances. Sensory symptoms include visual disturbances, Pharmacological
numbness, paresthesia (burning, prickling, tingling), pain, The treatment of choice for relapsing–remitting MS is inter-
and decreased sense of temperature. Motor symptoms include feron beta (Avonex, Betaseron). For 2 or 3 months, clients
decreased muscle strength, spasticity, paralysis, or bowel and usually experience flu-like symptoms after each injection. For
bladder incontinence or retention. clients who cannot take either of these two drugs, glatiramer
Ataxia (loss of balance or coordination), nystagmus acetate (Copaxone) is an option. The steroids adrenocortico-
(constant, involuntary eye movements in any direction), tropic hormone (ACTH) or prednisone (Delasone) are used
speech disturbances, tremors, and vertigo (dizziness) occur. to decrease periods of exacerbation. Muscle relaxants such
Other possible symptoms are sexual dysfunction and mood as dantrolene sodium (Dantrium) or baclofen (Lioresal) are
changes ranging from depression to euphoria. Profound used for muscle spasticity.
fatigue is common. The immunosuppressive agents azathioprine (Imuran),
Exacerbations are frequently precipitated by periods of cyclophosphamide (Cytoxan), or cyclosporine (Sandim-
emotional or physical stress, such as infections, pregnancy, mune) are administered to decrease immune response. Pro-
pantheline bromide (ProBanthine) is often used for urinary
A frequency and urgency. Bethanechol chloride (Urecholine)
Myelin
may be helpful for the client with a neurogenic bladder.
B sheath
Trimethoprim sulfamethoxazole (Bactrim or Septra) or nitro-
furantoin macrocrystals (Macrodantin) is given prophylacti-
cally when urinary tract infections are a problem.
COURTESY OF DELMAR CENGAGE LEARNING

CRITICAL THINKING

Multiple Sclerosis
Nerve
fiber What are the most important things to teach a
client with multiple sclerosis?
Figure 10-20 A, Normal Nerve Fiber and Myelin Sheath;
B, Multiple Sclerosis Destruction of Myelin Sheath

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340 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

for clients with limited motor involvement. Physical therapy

may be necessary to prevent contractures, maintain muscle
strength, or prevent loss of function from spasticity, or for gait
Adaptive Devices training. Passive/active ROM exercises should be done several
times per day. Occupational therapy may be used to maintain
To assist the client with MS in self-care: or attain self-care. Daily skills of cooking, doing laundry, or
• Purchase a raised toilet seat. maintaining a job may also be encouraged.
• Use a long-handled comb and shoe horn.
• Modify clothing so that the client can dress self. Nursing Management
Emphasize avoiding stress, infections, and fatigue. Encourage
independence and individualized ways of performing daily
activities. Stress the importance of a well-balanced diet, high
CLIENTTEACHING in fiber to prevent constipation. Encourage adequate fluid
intake and regular urination.
Risk of Falling
Advise the client with MS to:
• Use assistive devices such as a walker or cane. NURSING PROCESS
• Wear high-topped (above the ankles) shoes,
with laces. Assessment
• Watch feet when walking to know where they Subjective Data
are stepping. Subjective assessment includes eliciting client statements of
symptoms and an historical accounting of exacerbations and
remissions. Subjective data should include incidence of visual
disturbances, hazy vision, loss of central vision, or diplopia
Diet (double vision). Note symptoms of weakness, numbness,
A well-balanced diet complete with roughage is necessary to fatigue, bowel or bladder problems, sexual dysfunction, emo-
promote bowel elimination. Plenty of fluids are also neces- tional instability, vertigo, changes in gait, urinary incontinence
sary. If the client is obese, a dietitian should be consulted for or retention, constipation, or difficulty swallowing. Pain is not
meal planning to help the client lose weight while maintaining common.
adequate nutrition.

Activity Objective Data

The goal of maintaining the highest possible functional level Objective assessment includes observation of gait for spastic
must be individualized to each client. Daily exercise is necessary or ataxic gait and a complete neurological examination.

Nursing diagnoses for a client with MS include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Physical The client will maintain Assess motor status every 4 to 24 hours. Provide active and
Mobility related to optimal mobility within passive ROM every 8 hours. Ambulate client four times daily
muscle weakness, ataxia, physical limitations. with use of assistive devices as necessary.
spasticity, or perceptual Turn bedridden clients every 2 hours.
impairment
Use pillows, splints, high-topped (above the ankles) shoes with
laces to maintain proper body alignment.
Encourage client to perform daily activities as able given the
limitations of the disease.

Impaired Urinary The client will have Assess for bladder retention or incontinence. Catheterize as
Elimination related to adequate bladder necessary for retention or postvoid residual.
changes in innervation of elimination with minimal Maintain fluid intake of 1,000 cc per day.
the bladder postvoid residual, urinary
tract infections, and Develop bladder program to meet individual needs of client.
episodes of incontinence. Toilet client at scheduled times even if no urge to go.
Assess for signs and symptoms of urinary tract infection, such
as elevated temperature and burning on urination.

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 CHAPTER 10 Neurological System 341

Nursing diagnoses for a client with MS include the following: (Continued)

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Situational Low Self- The client will verbalize Assess client’s concept of self in relation to changes brought
esteem related to positive statements of about by the disease process.
neuromuscular and self-esteem. Teach client about the disease process. Allow client to verbalize
perceptual impairment feelings.
Assist client in methods of adapting to change.
Collaborate with other health care providers, such as mental
health counselors and physicians. Refer client to local support
groups (see Resources).

Sexual Dysfunction The client will seek Allow client to verbalize concerns.
related to changes in counseling concerning Suggest adaptations (planning time for sexual contact so as
sensation, genitalia, sexual dysfunction. to conserve energy; alternatives to sexual intercourse, such as
and musculature, and touching or holding).
psychological response
to diagnosis Refer client to appropriate health care providers.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with MS

D.B., a 37-year-old wife and the mother of two children, ages 3 years and 5 years, was diagnosed with
MS 2 days ago. She presents with decreased sensation (paresthesia) in the lower extremities and muscle
weakness of the right lower extremity. She has also experienced episodes of loss of central vision. Fatigue
has affected her ability to care for her children and perform household tasks. She states, “I do not know
what is going to happen to me.” She is crying and states, “I do not know about MS or how I am going to
take care of my children,” and “I cannot get my housework done, and my children need more from me
than I can give right now.”

Her employer is concerned about her ability to perform her teaching responsibilities, but because he
values her excellence as a teacher, he is willing to give her a few weeks off. She has bruises on her thigh,
face, and arm from a fall that she experienced several days ago. The client presents in an outpatient clinic
for follow-up care.

NURSING DIAGNOSIS 1 Deficient Knowledge related to disease process and lifestyle changes as
evidenced by client statements, “I do not know what is going to happen to me, I do not know about
multiple sclerosis or how I am going to take care of my children.”
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Disease Process Teaching: Disease Process

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

D.B. will verbalize knowledge Assess D.B.’s knowledge of Provides a frame of reference for
of the disease process, diagnosis, treatment regimen, D.B., helping her to relate new
pathophysiology, and lifestyle changes. Ask specific information and integrate it into
questions. her behavior.
(Continues)

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342 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

prognosis, and treatment, Begin teaching information Assists understanding about the
including the need to reduce about the pathophysiology and disease.
stressors in her life, eat signs and symptoms of MS.
a balanced diet, drink adequate
Discuss needed lifestyle changes, Helps understanding of necessary
fluids, and get adequate rest.
such as planning rest periods, changes in life.
avoiding stressors, eating a
balanced diet, and drinking
plenty of fluids.
Emphasize the importance of Helps identify activities that
keeping a diary of symptoms, exacerbate the symptoms.
activities, and feelings to identify
stressors that exacerbate symptoms.
Provide information about the Provides resources to strengthen
Multiple Sclerosis Society and offer D.B.’s knowledge base.
available pamphlets.
Provide the name and telephone Provides a great deal of
number of a contact from the local emotional support as well
MS support group or of another as practical solutions to
client who is willing to share. problems.

EVALUATION
D.B. verbalizes accurate information regarding the disease process, prognosis, and treatment. She states
that by reducing stressors, maintaining a balanced diet, taking in adequate fluids, and obtaining plenty of
rest, she can prevent exacerbations of MS.

NURSING DIAGNOSIS 2 Impaired Home Maintenance related to fatigue, neuromuscular impairment,

and difficulty in performing child care and household tasks as evidenced by client statements, “I cannot
keep my housework done, my children need more from me than I can give right now” and by objective
data including decreased sensation in lower extremities, muscle weakness, and fatigue
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Family Functioning Home Maintenance Assistance

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

By the next appointment, Allow D.B. to verbalize concerns Gives D.B. time to plan and
D.B. will identify concerns and about home maintenance organize tasks and responsibilities
solutions to accomplishing home management. within her ability to perform
maintenance management. home maintenance management.
Assist D.B. in identifying areas Can then investigate methods of
of concern, items that can be solving her home maintenance
delegated, and possible solutions. problems.
Assess the extended family’s May uncover opportunities that
ability to assist with home she had not considered.
maintenance management.

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 CHAPTER 10 Neurological System 343

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Ask D.B. to start identifying ways Helps focus on needed changes.
to decrease workload and to set
priorities for expending energy.
Collaborate with social services to Gives other possible solutions to
identify social agencies that can achieving home maintenance
be of assistance. management.
Plan activities around rest periods. Conserves strength and prevents
fatigue.
Identify peak energy times and plan Allows more to be accomplished.
activities with peak energy in mind.

EVALUATION
D.B. identifies that she is able to care for her children with the assistance of her husband and her mother,
but that she does not have the strength to maintain the housekeeping responsibilities. Following further
discussion of family commitments and availability of social supports, D.B. agrees to request weekly
assistance from the women’s group at her church.

NURSING DIAGNOSIS 3

Risk for Injury related to muscle weakness, decreased sensory perception (vision, tactile, kinesthetic), and
fatigue as evidenced by recent falls

NOC: Risk Control, Falls Occurrence, Safety Behavior: Home Physical Environment, Safety Behavior:
Personal
NIC: Fall Prevention, Environmental Management: Safety, Surveillance: Risk Identification

CLIENT GOAL
D.B. will remain free of injury.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Teach D.B. to identify risk-factors in 1. Avoids injury.

the environment.

2. Teach D.B. to identify risk factors of the 2. Reduces her risk of injury.
disease process.

3. Teach D.B. to avoid hot baths, hot tubs, and 3. Prevents exacerbation of weakness and
saunas because muscle weakness and decreased sensation, thereby reducing her
paresthesia is exacerbated by the heat. risk of injury.

4. Teach safety factors of wearing well-fitting, 4. Decreases the risk of falling by providing
oxford-style shoes. support for feet.

EVALUATION
Have injuries been prevented by increasing D.B.’s awareness of the risks involved with the disease process?

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344 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Riluzole (Rilutek) is the only drug currently approved for

■ AMYOTROPHIC LATERAL use in ALS treatment. Riluzole is believed to reduce damage to
motor neurons by decreasing the release of glutamate. Clinical
SCLEROSIS (LOU trials with ALS clients showed that riluzole prolongs survival
GEHRIG’S DISEASE) by several months, mainly in those with difficulty swallowing.

A
The drug also extends the time before a client needs ventila-
myotrophic lateral sclerosis (ALS) is a progressive, fatal tion support. Riluzole does not reverse the damage already
disease characterized by the degeneration of motor neu- done to motor neurons, and clients taking the drug must be
rons in the cortex, medulla, and spinal cord. The cause of the dis- monitored for liver damage and other possible side effects.
ease is not known, but a viral immune response or genetic defect
are suggested by current research. Age at onset is 40 to 70 years; Diet
men are affected two to three times more often than are women. A regular diet adapted to provide soft, easily chewed food is
Average time from onset to death is 3 years, but some clients maintained as long as the client can swallow. Tube feeding
with ALS have remained active 10 to 20 years after diagnosis. is required to prevent aspiration as chewing and swallowing
The upper and lower motor neurons degenerate and difficulties arise.
deteriorate, causing atrophy of the muscles innervated by
those neurons. The involved motor neurons are in the anterior
horns of the spinal cord and lower brainstem. The muscles Activity
of the hands, forearms, and legs usually atrophy first. As the Ambulation and other activities are encouraged as long as
disease progresses, most body muscles are affected. Muscle possible.
spasticity and reduced muscle strength result when upper
motor neurons are involved. Lower motor neuron involve- Other Therapies
ment causes muscle flaccidity, paralysis, and muscle atrophy. Physical and occupational therapy are used to maintain ROM
Sensory and intellectual function are not affected. Respira- and independence as much as possible. Speech therapy promotes
tory function, ability to communicate, and emotional lability maintenance of communication skills. Mental health counseling
are affected as the disease progresses. Drooling, inability to assists individual and family coping with the fatal disease.
handle oral secretions, and impaired swallowing occur.

Medical–Surgical Management Nursing Management

Encourage independence as long as possible. Assist with
There is no known cure for ALS. The focus of medical man- personal hygiene and getting in and out of bed. Provide good
agement is to treat the symptoms and to promote indepen- skin care, turn client often, keep the bed dry, and use pressure-
dence for as long as possible. relieving devices. Position client upright for meals and offer
soft, solid foods. When gastrostomy feedings are needed,
Pharmacological teach client or family how to administer them.
Muscle relaxants including diazepam (Valium), baclofen
(Lioresal), and dantrolene sodium (Dantrium) are used to
reduce spasticity. Quinidine is prescribed for muscle cramp- NURSING PROCESS
ing. Increased salivation is treated with trihexyphenidyl hydro-
chloride (Artane), clonidine hydrochloride (Catapres), or Assessment
amitriptyline hydrochloride (Elavil).
Subjective Data
Subjective data gathered include the client’s and family’s
PROFESSIONALTIP emotional status and knowledge status. The client may also
indicate chewing or swallowing difficulties as well as dyspnea
Advance Directives and fatigue.

Before the client with ALS becomes unable to Objective Data

communicate, suggest some advantages of Objective assessment includes evaluation of muscle weak-
drawing up a living will or giving someone ness, muscle atrophy, spasticity of upper extremities, flaccid
power of attorney for health care. paralysis, difficulty chewing and swallowing, and respiratory
status.

Nursing diagnoses for a client with ALS include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Physical The client will maintain the Provide active and passive ROM at least twice daily. Use
Mobility related to muscle highest possible functional assistive devices to prevent contractures, for ambulation, and
atrophy, weakness, and ability within limitations of for muscle strengthening.
spasticity the disease.

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 CHAPTER 10 Neurological System 345

Nursing diagnoses for a client with ALS include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Assess breath sounds for presence of congestion; skin for
pressure areas; and legs for thrombophlebitis.
Turn every 2 hours.

Impaired Verbal The client will communicate Prolong verbal communication with speech therapy
Communication related verbally or through an interventions consisting of voice projection and speech devices.
to weakness of muscles alternate communication Develop alternate methods of communicating prior to the
used for speech method as speech muscles loss of verbal skills, e.g., eye-blinking for “yes” and “no”;
deteriorate. communication boards, if any arm movement remains; and
computer programs can be used.

Ineffective Breathing The client will maintain an Assess breathing patterns frequently and observe for aspiration
Pattern related to adequate PaO2 level. and the loss of the swallow reflex. Assess breath sounds every
weakness of respiratory 4 to 8 hours, depending on the progress of the disease.
muscles and to fatigue Provide good pulmonary hygiene to prevent aspiration and
pneumonia by liquefying secretions and suctioning. Turn
from side to side to allow oral secretions to drain from mouth;
suction oral pharynx, as necessary.
Provide ventilation support, as ordered.

Powerlessness related to The client will inform Explore client and family emotional status and coping abilities.
loss of control over life; significant others of Allow client to verbalize feelings while still able to communicate
physical dependence; wishes while still able to and make decisions in daily care.
and presence of a fatal communicate, so as to
disease maintain some control over Promote discussion of client’s wishes with family, health care
decisions. team, and legal representative while client is still able to speak.
Provide client education about the disease process, support
groups, and counseling to provide support.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

is affected. The cells most affected are neurons that use acetyl-
■ ALZHEIMER’S DISEASE choline as the neurotransmitter. The size of the brain and the

A lzheimer’s disease (AD) is a progressive, degenerative

neurological disease wherein brain cells are destroyed.
The cerebral cortex atrophies, and neuron loss and changes
PROFESSIONALTIP
within the brain cells occur. The neurons of the frontal and
medial temporal lobes are affected, with resultant biochemical Sniff Test to Diagnose AD
and structural changes. Characteristic physiologic changes are
neurofibrillary tangles and amyloid plaques (deposits of pro- A new way to diagnose AD, PD, and other
tein), which interfere with the cells’ ability to transmit impulses. neurodegenerative disorders may be through
These changes are found in the association areas and scattered evaluating the client’s sense of smell. Measuring how
throughout the cortex. The hippocampus, that part of the deeply clients inhale a strong or unpleasant odor may
limbic system responsible for learning, memory, and emotions, be an early warning of brain dysfunction. A device
known as a Sniff Magnitude test may be able to
identify one of the earliest symptoms of some
neurodegenerative diseases, the loss of the sense of
smell. Clients with a normal sense of smell take only a
CULTURAL CONSIDERATIONS small inhalation before detecting strong or unpleasant
African Americans show a greater incidence rate of odors, while those with a damaged sense of smell
AD than the Caucasian population. Latinos appear will inhalation longer and deeper. The test is portable
to develop the symptoms almost 7 years earlier on and can be administered to clients with decreased
average than non-Latino Americans (Alzheimer’s intellectual and language abilities (Hally, 2007; Frank,
Association, 2008). Gesteland, Bailie, Rybalsky, Seiden, & Dulay, 2006).

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346 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

amount of acetylcholine both decrease. An increased amount Education and Referral Center, 2002). A CT scan may show
of aluminum is found in the brain tissue on autopsy (Hickey, evidence of brain atrophy, and a PET scan will show changes
2008; Smeltzer, Bare, Hinkle, & Cheever, 2008). in the metabolism of the cerebral cortex.
The cause of AD is unknown. Identified risk factors are The stages of AD are scaled from early to late. Different
advanced age, female gender, head injury, a history of thyroid dis- authors identify from three to six stages of the disease. The time
orders, and chromosomal abnormalities. More than five million frame for each stage varies from person to person. Table 10-6 lists
Americans have AD, a 10% increase from the last official tally in clinical manifestations of early, middle, and late stages of AD.
2002, and a number expected to more than triple by 2050 as the In late stages of the disease, an EEG may indicate general
elderly population increases (Alzheimer’s Association, 2008). slowing of brain waves. Definitive diagnosis is determined on
Diagnosis is difficult because of the variety in clinical autopsy with a brain biopsy. Although generally a disease of
manifestations and the lack of a test specific to AD. Diag- older people, AD occurs in people ages 40 to 50.
nosis is thus based on the clinical picture and the exclusion The personal freedom of the family caring for a member
of other conditions that cause similar clinical patterns, such who has AD becomes more limited as the disease progresses.
as overmedication, metabolic disorders, depression, thyroid Many clients with advanced AD cannot be left alone. Respite
imbalance, or brain tumors. Neuropsychological tests measur- care is important for the physical and mental health of the
ing memory, problem solving, attention, counting, and lan- caregiver. With respite care, someone else (e.g., another
guage assist physicians in diagnosing AD (Alzheimer’s Disease family member, a friend, or a hired professional licensed

Table 10-6 Stages of Alzheimer’s Disease

STAGE CLINICAL MANIFESTATIONS
Stage 1: Early Forgetfulness, often subtle and masked by client
Indecisiveness
Increasing self-centeredness; decreasing interest in others, environment, social activities
Difficulty in learning new information
Slowed reaction time
Beginnings of compromised performance at home and at work

Stage 2: Middle Progressing forgetfulness, inability to remember names of family members or close friends
Tendency to lose things
Confusion
Fearfulness
Easily induced frustration and irritability; sometimes, angry outbursts
Repetitive storytelling
Beginnings of communication problems (inability to remember words, apparent aphasia)
Inability to follow simple directions
Difficulty in calculating numbers
Beginnings of getting lost in familiar places
Evasive or anxious interactions with others
Physical activity (pacing, wandering)
Changes in sleep–rest cycle (with frequent activity at night)
Changes in eating patterns (possible constant hunger or none at all)
Neglect of ADL and personal hygiene, changes in bowel and bladder continence, and
dressing difficulties
Inability to maintain safety without supervision
Losses of social behaviors
Paranoia

Stage 3: Late Inability to communicate

COURTESY OF DELMAR CENGAGE LEARNING

Inability to eat
Incontinence (urine and feces)
Inability to recognize family or friends
Confinement to bed
Total dependence relative to care

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 CHAPTER 10 Neurological System 347

tartrate [Exelon], and donepezil hydrocholoride [Aricept])

slow the progression of the disease and enhance cognition
in early to middle stage AD. N-methyl-D-asparate (NMDA)
Safe Environment for the Client with AD Receptor Antagonist, memantine hydrocholoride (Namenda),
delays progression of symptoms in moderate-to-severe AD.
• Keep furniture in the same place. Other medications treat symptoms such as anxiety, depres-
• Orient client to surroundings and reorient as sion, and insomnia.
necessary.
• Keep floors free of clutter. Diet
• Provide adequate lighting. A high-fiber diet is used to prevent constipation. A high-
calorie diet is needed for hyperactive clients. Frequent feed-
• Monitor temperature of hot water and food. ings of high nutritive value are preferable to three meals a day.
• Maintain monitoring system to prevent outside
wandering.
• Prevent access to sharp items such as knives and
Nursing Management
razors; hot items such as coffee pot and heat- Maintain a safe, structured environment and a consistent daily
ers; poisonous solutions such as cleaning sup-
schedule for the client. Develop memory aids and cues to help
the client remember. Support family in adjusting to the client’s
plies, paints, medications, and insecticides; and
altered cognitive ability.
hazardous items such as power tools, guns, and
electric fans.

NURSING PROCESS
practical/vocational nurse or registered nurse) comes in to
care for the client with Alzheimer’s while the primary caregiver Assessment
gets away for a time. Respite care should be provided on a rou-
tine basis, such as every 2 or 3 weeks or as often as is feasible. Subjective Data
Data about sleeping and eating habits is collected. Each cli-
Medical–Surgical Management ent is assessed for individual signs and symptoms. The client
There is no curative treatment for AD. Management of the is an expert at hiding these deficits in the early stages of the
client is geared toward controlling undesirable symptoms and disease. A family interview is helpful in ascertaining health and
behaviors. personal history.

Pharmacological Objective Data

No drug can stop the progression of AD. Cholinesterase inhib- An objective neurological examination with particular atten-
itors (galantamine hydrobromide [Razadyne], rivastigmine tion to memory loss and gradual loss of thought processes
and impaired judgment is important. Eating patterns, bowel
CRITICAL THINKING and bladder control, aggressiveness, depression, ambulation,
agitation, restlessness, sleep patterns, vision, and hearing are
Parkinson’s and Alzheimer’s assessed. The client’s ability to provide self-care, manage
finances, drive, prepare meals, use the telephone, perform
What are the similarities between Parkinson’s housekeeping, communicate needs, and perceive the environ-
disease and AD? ment also are assessed. Attention is directed to assessing the
What distinquishes Parkinson’s disease from AD? support system, the family caregiver, support groups, and avail-
ability of respite care for the caregiver. The care of the caregiver
is often the focus of nursing care of the AD client.

Nursing diagnoses for the client with Alzheimer’s include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury The client will not Assess client’s ability to perceive environmental hazards. Teach
related to inability to experience injury. family to provide a safe home environment.
perceive danger in the Maintain a safe environment: eliminate clutter, position furniture/
environment, confusion, equipment in same place, monitor temperature of hot water and
impaired judgment, and food, maintain monitoring system to prevent wandering into
weakness adverse climate or into traffic, provide adequate lighting, orient
client and family to surroundings and reorient as necessary.
Ensure that the client wears well-fitting, tied shoes to reduce
risk of falls.

(Continues)

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348 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for the client with Alzheimer’s include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Thought The client will maintain Assess for cognitive, memory, and communication deficits.
Processes related to optimal cognitive ability. Develop memory aids and cues to help client remember.
neuron degeneration, Maintain a consistent environment and daily schedule.
sleep deprivation Approach client in a quiet, nonthreatening manner.
Do not confront client with reality if it will only upset and agitate
him. For example, do not tell a 90-year-old client who wants his
mother that she is dead.
Attend to nonverbal cues for unmet needs (e.g., pacing,
grimacing, crying, agitation). The client may be hungry, have a
full bladder, or be unable to ask to be repositioned.
Obtain a photo of client that can be recognized by the client.
A current photo of client may appear as a stranger to the client,
but a photo of the client at age 20 or 30 may be remembered.
Give simple, single instructions.

Disturbed Sleep Pattern The client will sleep 4 to Advise the client to avoid caffeine.
related to disorientation 5 hours each night. Maintain a quiet environment. Provide comfort measures.
or irritability Provide a night light.
Increase daytime activities to tolerance, and use exercise to tire
client.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CRITICAL THINKING
■ GUILLAIN-BARRÉ SYNDROME

G
Alzheimer’s Disease
uillain-Barré syndrome (GBS) is an acute inflammatory pro-
V. A. is a 73-year-old male client diagnosed 5 years cess involving the motor and sensory neurons of the periph-
ago with AD. He has been married for 52 years and eral nervous system. The cause of Guillain-Barré syndrome is not
owns a hardware store now managed by his son. known, but most cases are preceded by a nonspecific infection.
Spanish is his native language, but he is fluent in
There may be an autoimmune or viral basis for this syndrome.
Both spinal and cranial motor nerves are involved. The demyeli-
English. At this time he is having significant word-
nation process begins in distal nerves and ascends symmetrically.
finding difficulties and is unable to name common Remyelination occurs from proximal to distal (Hickey, 2008).
objects in both English and Spanish. He requires his Clinical manifestations occur in differing patterns but include
wife’s assistance to eat, bathe, toilet, dress, and take motor weakness and areflexia, or absence of reflexes. Character-
medications. He is able to walk independently. Until istically, motor weakness begins in the legs and progresses up the
2 weeks ago, his wife drove him to the hardware body. Respiratory failure results from loss of respiratory muscle
store daily, where he would interact with customers function. Cranial nerve involvement results in facial muscle deficits,
and restock nails, screws, and other small items. The difficulty in swallowing, and autonomic dysfunctions. Autonomic
last day at the store, though, he wandered out when functions possibly affected are cardiac rhythm, blood pressure
his son was occupied with customers and became regulation, gastrointestinal mobility, and urine elimination.
lost. He was found by the police 2 miles from the
Sensory involvement causes paresthesia and pain in the
hands and feet. The pain progresses up the body and may
store. His son now wants V.A. placed in a nursing
interfere with sleep.
home, but his wife feels that he should remain at The three stages of Guillain-Barré syndrome are acute
home until he “no longer knows who I am.” onset, lasting 1 to 3 weeks, the plateau period, lasting several
1. Identify V.A.’s stage of Alzheimer’s disease and days to 2 weeks, and the recovery phase, which involves remyeli-
explain the rationale. nation and may last up to 2 years.
2. Identify safety issues and appropriate nursing Diagnosis is based on the clinical picture of a recent viral
interventions. infection and motor and possibly sensory deficits, along with
characteristic diagnostic results. These results include both an
3. How can the nurse help the family reach consensus
elevated protein level in CSF without elevation of red blood
on appropriate placement and care for V.A.? cells or white blood cells and EMG showing slowed nerve
conduction velocity of paralyzed muscles.

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 CHAPTER 10 Neurological System 349

Medical–Surgical Management maintain optional self-care within the limitation of the disease
process. Pool therapy, or exercising in a swimming pool, main-
Medical tains and strengthens muscles.
The goal of medical management is prevention and treatment
of complications such as immobility, infection, and respiratory Nursing Management
failure. Monitor vital signs, LOC, pulse oximetry, ABGs, and for
Plasma exchanges decrease the severity and duration ascending sensory loss, which precedes motor loss. Turn client
of symptoms. Plasmapheresis is performed in severe cases. frequently and encourage coughing and deep breathing. Pro-
Complete plasma exchange removes the antibodies affecting vide skin care to prevent skin breakdown and position client to
the myelin sheath. Three to four exchanges 1 to 2 days apart prevent contractures. Perform passive ROM exercises. Apply
are initiated within the first 2 weeks of diagnosis of Guillain- antiembolism stockings and assess Homans’ sign. Provide eye
Barré. Plasmapheresis also is used late in the disease process and mouth care every 4 hours if there is facial paralysis. Moni-
for continued demyelination or lack of progress in remyelina- tor I&O and encourage adequate fluid intake. Offer prune
tion. Mechanical ventilatory support may be required. Blood juice and high-fiber diet to prevent constipation.
gas monitoring is used to assess respiratory function.
Surgical NURSING PROCESS
Those who develop respiratory failure require a tracheostomy
along with mechanical ventilation. Assessment
Pharmacological Subjective Data
Steroids, such as adrenocorticotropic hormone (ACTH) and Subjective data include client statements about return of sen-
prednisone (Detasone), and immunosuppressive agents, such sation, pain, respiratory function, and knowledge.
as azathioprine (Imuran) or cyclophosphamide (Cytoxan),
slow the demyelination process. Low doses of anticoagulants, Objective Data
such as heparin, prevent thrombophlebitis. Assessment includes the status of motor and sensory func-
tions, which are monitored continuously in the acute phase of
Diet the illness. Monitor progression of loss of function from distal
A balanced diet is necessary to prevent tissue and muscle to proximal with particular emphasis on respiratory status.
breakdown and to promote healing. If severe paralysis is pres- Decreased depth and quality of respirations and diminished
ent, a gastrostomy tube is used to provide adequate nutrition. breath sounds may be found. Monitor status of autonomic
functions by assessing blood pressure, cardiac rhythm, urinary
Activity elimination, and bowel sounds. Assessment for complications
Physical therapy maintains range of motion and muscle of immobility includes breath sounds, signs of thrombophle-
strength. Occupational therapy activities teach the client to bitis, loss of ROM, skin condition, and temperature.

Nursing diagnoses for a client with Guillain-Barré syndrome include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing The client will be Monitor respiratory status of client by assessing breath sounds,
Pattern related to loss adequately ventilated. respiratory rate, and respiratory quality. Position client to facilitate
of respiratory muscle maximal expansion of the chest wall for optimal breathing.
function Monitor oxygenation by assessing skin color, mental status,
pulse oximeter readings, and blood gas values. Administer
oxygen as ordered. Report failing respiratory status to the
physician. Provide mechanical ventilation for respiratory failure.

Impaired Physical The client will avoid Monitor status of motor and sensory functions in an ongoing
Mobility related to complications of fashion.
progressive loss of motor immobility (pneumonia, Have client turn, deep breathe, and cough every 2 hours.
function thrombophlebitis, pressure
areas, and loss of ROM). Suction client as necessary.
Perform respiratory assessment for diminished breath sounds
or congestion.
Monitor vital signs (blood pressure, pulse, respiration, and
temperature) every 4 to 8 hours.
Assess for calf tenderness, redness, or increased warmth. Monitor
for positive Homans’ sign, indicative of deep vein thrombosis.
(Continues)

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350 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for a client with Guillain-Barré syndrome include

the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Perform ROM to lower extremities every 2 to 4 hours.
Use PlexiPulse boots, which are intermittent-pumping boots
that promote return blood flow from the lower extremities.
Administer low doses of heparin or other anticoagulants as
prescribed.
Apply antiembolism stockings or alternating compression devices.
Assess condition of skin for pressure areas. Massage client’s
back and pressure points with lotion three times a day.
Use specialty mattress.
Assist client to sitting position in wheelchair two to three times
daily. Progress to ambulation as motor function returns. Apply
high-topped shoes to keep feet in correct alignment.

Dressing/Grooming The client will have self- Encourage self-care within the limitations of the neurological
Self-care Deficit related care needs met. deficits. Provide daily care needs that client is unable to perform.
to decreased motor Maintain muscle strength and ROM with physical therapy.
function Provide ROM to all extremities three to four times daily.
Initiate rehabilitation following acute phase of illness with
strengthening exercises, occupational therapy, and getting
client out of bed several times per day to build strength and
endurance.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ HEADACHE Migraine Headaches

H
Up to 18% of women experience migraine headaches each
eadache, or cephalalgia, the condition of pain in the year, compared to 6% of men (AHS, 2007). Migraine head-
head, is caused by stimulation of pain-sensitive struc- aches are vascular and recurrent. The initial vasoconstriction
tures in the cranium, head, or neck. Headaches are symptoms causes neurological symptoms or an aura before the vasodila-
rather than a disease. tion that causes the headache. The aura is a visual disturbance
The pain-sensitive areas of the intracranial structure typically consisting of brightly colored or blinking lights or a
include the peripheral nerves, cerebral vasculature, and parts of pattern moving across the field of vision. When only the aura
the dura mater. The external supporting structures of the skin, occurs, and there is no pain in the head, the migraine is termed
muscles, and nasal passages are also sensitive to pain. The skull, “silent.” Migraines generally are a throbbing on one side of the
brain tissue, and most of the meninges are insensitive to pain. head. Other symptoms include irritability, anorexia, nausea,
More than 45 million people in the United States each vomiting, and photophobia. Some migraine headaches are
year have chronic, recurring headaches (National Headache triggered by certain foods or chemicals.
Foundation, 2002). Headaches are generally classified as
either primary or secondary. Cluster Headaches
A cluster headache develops around or behind one eye and is
PRIMARY HEADACHES very severe. Generally, it awakens the person from sleep. The
affected eye may tear and the nose becomes congested on the
Primary headaches are not caused by an underlying medical same side. These headaches occur in clusters daily for weeks
condition. They include tension-type, migraine, and cluster or months, and then disappear for a year or more. Most cluster
headaches (AHS, 2007) (Table 10-7). headaches occur in men. Alcohol often triggers attacks.

Tension-Type Headache SECONDARY HEADACHES

The most common type of headache is the tension type (ACHE,
2007). The ache is steady rather than throbbing, affects both Secondary headaches are the result of pathological conditions
sides of the head, and occurs frequently, sometimes daily. such as aneurysm, brain tumor, or inflamed cranial nerves.

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 CHAPTER 10 Neurological System 351

Table 10-7 Primary Headache Patterns

TYPE AURA PAIN TYPICAL PATTERN DURATION
Tension None Steady ache Usually begins gradually in frontal or Hours
temporal areas; affects both sides of
the head; occur frequently, maybe daily

Classic Duration of 15 to 30 minutes; Throbbing, intense; Periodic, recurrent; usually begins Hours to
Migraine sensory, usually visual (bright unilateral; tenderness on awakening; begins in childhood days
spots, zig-zag lines), unilateral in scalp; muscle or early adolescence; tends to be
or bilateral numbness or contractions in neck familial; nausea and vomiting typical;
tingling in lips, face, or hand; and scalp followed sensitivity to light and sound
difficulty thinking; confusion by feelings of
or drowsiness; sometimes exhaustion
preceded by premonition
24 hours before

Cluster None Intense throbbing; Causes awakening two to three 30 minutes

unilateral pain in times during the night; accompanied to 2 hours
orbitotemporal area by watering eyes, nasal congestion,

COURTESY OF DELMAR CENGAGE LEARNING

runny nose, facial flushing over
the throbbing area; after cluster
headaches for days, weeks, or
months may be free of symptoms for
a year or more; same side of head
usually involved; usually in men

The headache is caused by compression, inflammation, or

hypoxia of pain-sensitive structures. Pharmacological
Management is either abortive, to stop the headache, or pro-
Medical–Surgical phylactic, to prevent reoccurrence or to decrease frequency of
headaches. Abortive therapy for migraine headaches includes
Management naproxen (Aleve), ibuprofen (Advil), sumatriptan (Imitrex),
rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan
Medical (Amerge), almotriptan (Axert), and older drugs like cafergot,
Medical management is based on the underlying cause of the containing ergotamine and caffeine (McGuire, 2002). Pro-
headache. A thorough history of headache pattern, dietary pat- methazine hydrochloride (Phenergan) controls nausea and
tern, and coping pattern is essential. Underlying pathology of vomiting.
brain tumor, aneurysm, and infection is ruled out. If pathology Prophylactic treatment includes the beta-blockers pro-
is identified, secondary headache is diagnosed and, therefore, pranolol hydrochloride (Inderal) and methysergide maleate
treatment is based on findings. If no cause is found, manage- (Sansert), which prevent dilation of the blood vessels and
ment of primary headache is based on symptoms. interrupt the serotonin mechanism. Clonidine hydrochloride
(Catapres) directly affects the ability of the blood vessels to
Surgical constrict or dilate. Tricyclic antidepressants, such as amitrip-
Surgical management includes repair of an aneurysm or resec- tyline hydrochloride (Elavil), block the uptake of serotonin.
tion of a brain tumor.
Diet
A strict food diary is kept to identify precipitating foods.
CLIENTTEACHING After all suspect foods are eliminated from the diet, skin test-
ing for allergies is performed. Introduction of suspect foods
Headaches is done one at a time to identify triggering foods. Alcohol,
Advise the client to: cured meats containing nitrates, aged cheeses, monosodium
• Keep a diary of headache history to ascertain glutamate (MSG), citrus fruits, chocolate, and red wines are
pattern.
common precipitating foods.
• Avoid foods that trigger headache.
Activity
• Reduce salt intake.
Activities that precipitate headaches are identified and elim-
• Practice relaxation techniques. inated if possible. Stressful situations are frequently pre-
cipitating agents. Biofeedback, relaxation techniques, stress

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352 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

reduction, and development of coping mechanisms are useful

in reducing the occurrence of headaches caused by stress and
tension.
CLIENTTEACHING
Dental Work on the Client with
Nursing Management Trigeminal Neuralgia
Nursing interventions focus on relieving pain and assisting the The client with trigeminal neuralgia should:
client in managing the pain. Identifying methods of decreasing • Plan to have dental work done during a period
pain, such as effective use of medications and managing the of remission.
environment to minimize stimulation from light, noise, and
• Inform the dentist of the condition.
activity, are also nursing priorities.
Assist the client to develop a plan for accomplishing daily • Maintain good dental hygiene, especially during
activities when incapacitated by a headache. Teach the client remission.
to keep a diary of headache history to determine patterns in
headache development. Assist the client in changing lifestyle
to decrease the incidence of headaches by minimizing stress,
avoiding certain foods, reducing salt intake during premen- Medical–Surgical
strual time frame, and using relaxation techniques. Management
Drug therapy, nerve blocks, and surgery are treatment modali-
■ TRIGEMINAL NEURALGIA ties for trigeminal neuralgia.
(TIC DOULOUREUX) Surgical
T rigeminal neuralgia is a condition of cranial nerve V and
is characterized by abrupt paroxysms of pain and facial
muscle contractions. Neuralgia is nerve pain. The pain fol-
Surgical approaches to relieve pain include percutaneous elec-
trocoagulation with radio frequency. This procedure affects
the pain-sensory fibers but causes little damage to the touch,
lows one of the three branches of the trigeminal nerve: the proprioception, and motor fibers. Longer-term relief or per-
ophthalmic, maxillary, or mandibular. The last two branches manent relief may be obtained.
are most commonly affected (Figure 10-21).
The etiology of trigeminal neuralgia is not known, but Pharmacological
injury, dental caries, dental work, and anatomic position of Phenytoin (Dilantin) and carbamazepine (Tegretol) are used
the nerves have been identified as possible causes. Pain begins to shorten the length of the paroxysmal pain. Nerve blocks
when trigger points are stimulated, causing periods of intense using alcohol and phenol injections into the nerve provide
pain and facial twitching lasting from seconds to minutes. temporary relief for 8 to 16 months.
These periods may last several weeks to months. Periods of
remission interspersed with exacerbations occur with increas-
ing frequency with advancing age (Hickey, 2008). Nursing Management
Goals of nursing interventions are relief of pain, prevention of
injury, prevention of self-care deficits, and promotion of social
interaction. The client with trigeminal neuralgia frequently
experiences such severe pain that grooming, talking, and eat-
ing are avoided. It is especially important to provide good oral
hygiene if the client is on phenytoin (Dilantin) because the
medication causes hyperplasia of the gums. Teach the client
to identify both the trigger points that stimulate the pain and
A
ways to avoid those areas without neglecting daily needs.
The client who has had surgery may have lost the mecha-
nisms that protect the eye from injury, and is taught not
to touch his eye and to observe for redness of the eye and
conjunctiva. Following surgery, the client may not feel pain
caused by dental caries, so routine visits to the dentist for oral
B
examination are needed.

■ ENCEPHALITIS, MENINGITIS
COURTESY OF DELMAR CENGAGE LEARNING

E ncephalitis is inflammation of the brain. Meningitis is

inflammation of the meninges. The most common cause
of encephalitis or meningitis is a virus. Bacteria, fungi, or
parasites also are causative factors. Meningococcal meningitis
is highly contagious. Contacts of the client are identified and
prophylactic medication is recommended. The virus or other
Figure 10-21 Areas of Face Innervated by the Trigeminal causative agent enters the brain either through the blood-
Nerve (CN-1); A, Ophthalmic; B, Maxillary; C, Mandibular stream as a direct extension of trauma or by nerve pathways.

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 CHAPTER 10 Neurological System 353

The inflammatory process causes demyelination of white The cells of the basal ganglia, which control move-
matter and degeneration of neurons. Cerebral edema, hem- ment, die prematurely. Cells in the cerebral cortex also die,
orrhage, and necrosis of brain tissue also occur. Clinical interfering with thought processes, memory, perception, and
manifestations vary depending on the causative agent, area judgment. Age of onset is usually 35 to 45 years, with death
of involvement, and degree of damage to nerve tissue. Fever, occurring 10 to 15 years following onset of symptoms (Smelt-
headache, nuchal rigidity, photophobia, irritability, lethargy, zer, Bare, Hinkle, & Cheever, 2008). Each child of a person
nausea, and vomiting are typical signs and symptoms. As the with Huntington’s disease has a 50% chance of inheriting the
disease progresses, level of consciousness decreases and other fatal gene. Everyone who has the gene will develop the disease
neurological dysfunctions occur, including motor weakness, (HDSA, 2002). However, there is no cure for this devastating
aphasia, seizures, behavioral changes, or even death. A lumbar progressive disease.
puncture is performed to test CSF for the causative agent, Clinical manifestations are chorea, abnormal involun-
presence of white blood cells or red blood cells, and elevated tary, purposeless movements of all musculature of the body.
protein level. A complete blood count identifies the presence Facial tic, grimacing, difficulty in chewing and swallowing,
of viral or bacterial infection. speech impairment, disorganized gait, and bowel and bladder
incontinence also occur. Mental or intellectual impairment
Medical–Surgical progresses to dementia. The client may experience paranoia,
hallucinations, or delusions. Emotions are labile, from out-
Management bursts of anger to profound depression, apathy, or euphoria.
A ravenous appetite is usually present, but because of the con-
Medical stant movement, the client is often emaciated and exhausted.
Treatment is supportive and based on presenting symptoms. Death usually results from heart failure, pneumonia, infection,
The aim of treatment is to prevent or decrease increased intra- or choking (HDSA, 2002).
cranial pressure and to minimize neurological deficits. Intrave- The entire family experiences this disease in an emo-
nous fluids are given to rehydrate the client. Clients are placed tional, physical, social, and financial way. Supportive care is
in isolation until the cause of meningitis can be determined. required as the family progresses through life with a loved one
with Huntington’s disease. Because of the hereditary factor,
Pharmacological genetic counseling is suggested.
Antibiotics or antiinfectives are administered in massive doses
as appropriate for the causative agent. They are given intrave- Medical–Surgical
nously or intrathecally into the spinal canal. Most viral agents
do not respond to antibiotics or antiinfectives. Glucocorticos- Management
teroids are administered to prevent cerebral edema. Osmotic Pharmacological
diuretics may be used to reduce cerebral edema. To prevent
seizures, anticonvulsants are often ordered. Antipyretics are A medication that decreases choreiform movement is the
often given to reduce fever. benzodiazepine, clonazepam (Klonopin). Do not stop clon-
azepam abruptly but taper off medication to avoid symptoms
Diet of withdrawal, especially if client has epilepsy. Assess client
for excessive fatigue. Antidepressants, such as desipramine
Optimal nutritional status is maintained to promote response hydrochloride (Norpramin) and fluoxetine hydrochloride
to the infection. (Prozac), and antipsychotics, such as fluphenazine hydrochlo-
ride (Prolixin), are used for emotional disturbances. Many
Activity people do better with minimal medication (HDSA, 2001).
A quiet environment with minimal stimulation from noise,
light, or client activity is maintained. Routine turning, ROM Diet
exercises, pulmonary hygiene, and skin care are required to The diet must be high in calories to provide for the high
prevent the complications of immobility. energy needs caused by the continuous movement. Chewing
and swallowing difficulties necessitate foods that are easy to
Nursing Management chew or foods cut into small pieces to prevent choking.
In the acute stage, monitor the client for changes in neurologi-
cal status, especially for changes in level of consciousness and Activity
for signs of increasing intracranial pressure. A quiet environ- Ambulation is maintained as long as possible. A safe environ-
ment decreases external stimulation. Observe the client for ment is maintained to prevent injury from falls or from sharp
seizure activity and protect from injury. Comfort measures objects. Driving is usually restricted when choreiform move-
such as oral hygiene, tepid baths, and administration of anal- ment or impaired judgment interferes with the ability to drive
gesics for relief of headaches are offered. safely.

■ HUNTINGTON’S DISEASE Nursing Management

H
Nursing interventions include a holistic approach to the cli-
untington’s disease (HD) is a chronic, progressive ent’s care. Collaboration with the social worker, the chaplain,
hereditary disease of the nervous system. It is character- the physician, and the mental health worker is necessary.
ized by a progressive involuntary choreiform movement and Teach the client and family about the disease process,
progressive dementia. the progress of the disease, and the genetic factors involved.

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354 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Safety factors are considered. Fall prevention measures, such disorder, with the affected individual having a 50% chance of
as removing throw rugs and small objects from the floor, passing the gene on to children.
and injury prevention measures, such as removing sharp or
dangerous objects such as guns and knives from the home,
are implemented. The hazard of choking also is addressed, by
teaching the family to cut the client’s food into small pieces, to Medical–Surgical
serve soft foods, and by teaching the Heimlich maneuver. Management
Pharmacological
Tics are controlled with clonadine (Catapres), haloperidol
■ GILLES DE LA TOURETTE’S (Haldol), or primozide (Orap). Coexisting ADHD is con-
SYNDROME trolled with clonidine (Catapres), methylphenidate (Ritalin),
or pemoline (Cylert). Clomypramine (Anafranil) or fluox-

G illes de la Tourette’s syndrome is a neurological move-

ment disorder that also has prominent behavioral mani-
festations. Clinical manifestations include motor tics and
etine (Prozac) are used to keep obsessive–compulsive behav-
iors under control (Kurlan, 1998). Acetaminophen (Tylenol)
may help the discomfort of muscle spasms.
involuntary repetitive movements of the mouth, face, head, or
neck muscles. The trunk and extremities may also be involved. Other Therapies
Motor tics take the form of forceful eye blinking or toe touch- As they age, clients learn to suppress tics in social situations.
ing. Vocal tics or repetitive involuntary vocalizations take Psychotherapy and family counseling are beneficial in coping
the form of sniffing, grunting, throat clearing, or coprolalia with social stigma and adjustment problems.
(involuntary and inappropriate swearing). Other complex
motor and vocal tics that also are present include copropraxia,
involuntary and effectively appropriate use of obscene ges- Nursing Management
tures; echolalia, involuntary repetition of the speech of others; The client and the family with Tourette’s syndrome need
and palilia, involuntary repetition of the person’s own speech. a great deal of emotional support and benefit from know-
The obsessive–compulsive symptoms of repetitive handwash- ing about the availability of support groups for clients with
ing or checking rituals also are exhibited. Attention deficit Tourette’s syndrome. The nurse instructs the client about the
hyperactivity disorder (ADHD) and obsessive–compulsive disease process and personal and behavioral expectations.
disorders may also coexist with Tourette’s syndrome. Behavioral modification techniques are generally effective;
Onset is before age 18 years, with males being more the nurse must know which modification techniques are being
commonly affected than females. Tourette’s is an inherited used and must follow through with consistent responses.

CASE STUDY
D.O., a 76-year-old retired farmer, was admitted to the emergency department with left-sided hemiplegia, difficulty
swallowing, and inability to speak. He was awake and watching the staff upon admission. He moved his right arm
to indicate that M.O. was his wife but was unable to speak or form sounds. M.O. stated that her husband was
working in the garden, picking tomatoes and cucumbers, when he fell to the ground 30 minutes before admission.
The department room nurse administered oxygen through nasal cannula at 2 liters per minute and obtained vital
signs. His blood pressure was 182/110 mm Hg, pulse was 88 beats per minute, respirations were 20 breaths per
minute, and temperature was 100.5°F. The emergency department physician ordered an MRI scan of the head,
a complete blood count, and prothrombin time (PT). The MRI indicated that D.O. experienced a CVA caused by
bleeding into the brain.
The following questions will guide your development of a nursing care plan for the case study.
1. List clinical manifestations other than the symptoms D.O. experienced that can occur with a CVA.
2. List subjective and objective data that a nurse would obtain.
3. Identify three individualized nursing diagnoses and goals for D.O.
4. D.O. is transferred to a general medical unit for 3 days, and then is transferred to a rehabilitation center for
intensive therapy. What pertinent nursing actions should a nurse perform in caring for D.O. in the acute set-
ting and the rehabilitation setting related to:
Mobility
Safety
Elimination
Skin integrity
Comfort and rest
5. What teaching will D.O. need before discharge from the rehabilitation facility?
6. List at least three client outcomes for D.O.

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 CHAPTER 10 Neurological System 355

SUMMARY
• The nervous system controls all bodily functions, from • A special interpretive area located at the junction of the
movement to thinking to processing information to temporal, parietal, and occipital lobes integrates somatic,
autonomic responses. auditory, and visual sensory interpretations.
• The frontal lobe of the cerebrum specializes in • The occipital lobe of the cerebrum is responsible for visual
emotional attitudes and responses, formation of thought interpretation and visual association.
processes, motor function, judgment, personality, and • Disorders of the nervous system cause complex
inhibitions. dysfunctions; the nurse uses assessment skills and quickly
• The parietal lobe of the cerebrum is a purely sensory recognizes changes in condition.
region for interpretation of all senses except smell; the • Teaching about injury prevention and the effects and
purpose is to analyze sensations, including pain, touch, and prognosis of the disorder are required to meet the physical
temperature, from receptors in the skin. and psychosocial needs of the client and family.
• The temporal lobe of the cerebrum houses Wernicke’s • Many neurological disorders potentiate injury. Nursing
area, the primary auditory association area, where words care includes providing the client and family with
that are heard are interpreted. Memory is also a function of necessary safety information.
the temporal lobe, especially memories that are highly • To maintain and restore functional ability, rehabilitation is
detailed or involve multiple sensations. initiated from the first contact with the client.

REVIEW QUESTIONS
1. The most important indicator of change in 3. Respiratory failure requiring chronic ventilatory
neurological status is: support may occur.
1. level of consciousness. 4. Motor function deficit will occur, but sensation
2. pupil reaction. will remain.
3. vital signs. 6. The client’s wife asks the nurse what she thinks
4. motor function. of memory training and reality orientation for a
2. Assessment of intellectual function requires that the client with Stage 2 Alzheimer’s disease. The nurse
nurse: responds that those interventions should be used
1. have knowledge of the client’s previous ability to with caution because:
function. 1. reality is painful.
2. administer a written test to determine the client’s 2. they are very costly.
IQ level. 3. they can accelerate the disease process.
3. utilize auscultation, percussion, and palpation 4. they might trigger anger and agitation.
skills. 7. A nurse is caring for a client with amyotrophic
4. observe the client’s behavior, posture, and facial lateral sclerosis (ALS) who has the following symp-
expression. toms. What symptom requires a prompt nursing
3. Contusion of the brain is a (an): intervention?
1. shaking of the brain. 1. Loss of bowel and urine control.
2. bleeding into the brain tissue. 2. Confusion.
3. open head injury. 3. Tonic-clonic seizures.
4. bruising of the brain. 4. Shallow respirations.
4. Benign brain tumors can be: 8. What client response indicates he understands
1. more anxiety producing than are malignant the nurse’s instructions about taking carbidopa-
tumors. levodopa (Sinemet)?
2. more life threatening than are malignant tumors. 1. “I will slowly rise from a sitting position to
3. treated with radiation therapy. standing position.”
4. the cause of increased intracranial pressure. 2. “I will limit my fluids to 1000 milliliters a day.”
5. A nurse is teaching A.W., a 24-year-old client with 3. “I will reduce my medication dosage by half when
Guillain-Barré syndrome, about her condition. What my symptoms improve.”
statement does the nurse include in her teaching? 4. “I will have a diet high in protein and vitamin B6
1. The nerve degeneration continues to slowly since I am taking Sinemet.”
progress in this chronic degenerative nerve 9. A nurse completes an assessment on her client. She
disease. finds that the client opens his eyes when she enters
2. The disease is an acute inflammatory process the room; answers questions but has incorrect
with most clients regaining complete function. answers about time, place, and events; and raises

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356 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

right hand when requested. According to the 1. Eye moves smoothly upward and outward.
Glasgow Coma Scale, what score does the nurse give 2. Eye blinks rapidly when cotton ball sweeps across
the client? cornea.
1. 3 3. Client tastes sweet sensation when given a piece
2. 6 of candy.
3. 12 4. Jaw moves symmetrical and overcomes resistance.
4. 14 5. Gag reflect is intact.
10. What are expected findings when the nurse assesses 6. Client feels cotton ball when swiped across
the client’s trigeminal nerve? (Select all that apply.) cheek.

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Retrieved from http://www.alz.org/Resource Center/FactSheets/ .associatedcontent.com/article/202499/simple_sniff_test_could
FSAlzheimerdisease.pdf _daignose_alzheimer?cat=5
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Mower-Wade, D., Cavanaugh, M., & Bush, D. (2001). Protecting a Parkinson’s Disease Foundation (PDF). (2002). Parkinson’s disease.
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Alzheimer’s Association, http://www.alz.org Epilepsy Foundation of America,
American Academy of Neurology, http://www.aan.com http://www.epilepsyfoundation.org/
American Association of Spinal Cord Injury Profes- Guillain-Barré Syndrome/Chronic Inflammatory
sionals, http://nurses.ascipro.org Demyelinating Polyneuropathy Foundation
American Headache Society, http://www.achenet.org/ International, http://www.gbs-cidp.org/
American Spinal Injury Association, Huntington’s Disease Society of America,
http://www.asia-spinal injury.org http://www.hdsa.org/
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Inc., http://www.comarecovery.org Stroke, http://www.ninds.nih.gov

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358 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

National Multiple Sclerosis Society, National Stroke Association, http://www.stroke.org

http://www.nationalmssociety.org/index.aspx Parkinson’s Disease Foundation, http://www.pdf.org
National Parkinson’s Foundation, Inc., Tourette Syndrome Association, Inc.,
http://www.parkinson.org http://www.tsa-usa.org
National Spinal Cord Injury Association,
http://www.spinalcord.org

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 CHAPTER 11
Sensory System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the sensory system:
Adult Health Nursing • Neurological System
• Surgery • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Compare and differentiate common disorders of the special senses.
• Identify the structure and function of the major parts of the eye and ear.
• Explain the purpose of the common diagnostic tests for sensory problems.
• List the nursing assessments and common nursing diagnoses related to
sensory impairment.
• Assist in planning nursing care for clients with sensory disorders.
• List some of the common sensory aids for the visual and hearing impaired.

KEY TERMS
affect efferent nerve pathway sensation
afferent nerve pathway hallucination sensorineural hearing loss
arousal hyperopia sensory deficit
astigmatism illusion sensory deprivation
awareness judgment sensory overload
cerumen keratitis sensory perception
chalazion myopia strabismus
cognition nystagmus stye
conductive hearing loss orientation tinnitus
conjunctivitis perception vertigo
consciousness presbycusis
disorientation presbyopia

359

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360 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

INTRODUCTION PROFESSIONALTIP
From the moment we wake in the morning until we fall asleep
at night, we are inundated with information from the outside
world through our senses. We depend on visual and auditory CNS Deficits and Illness
alarms to keep us from harm. This chapter reviews the struc- Specific conditions, such as diabetes mellitus and
ture and function, identifies appropriate nursing diagnoses, atherosclerosis, can impair neurosensory pathways
and presents the medical and nursing management for hearing and result in deficits in sensation, perception, and
and vision with some discussion of taste, smell, and touch.
cognition. Diseases of the CNS can result in loss of
sensory function and paralysis.

SENSATION, PERCEPTION,
AND COGNITION
Components of Sensation and
Sensation is the ability to receive and process stimuli through
the sensory organs. There are two types of stimuli: external Perception
and internal. External stimuli are received and processed The sensory system is a complex network that consists of
through the senses of sight (visual), hearing (auditory), smell afferent nerve pathways (ascending pathways that transmit
(olfactory), taste (gustatory), and touch (tactile). Internal sensory impulses to the brain), efferent nerve pathways
stimuli are received and processed through kinesthetic (an (descending pathways that send sensory impulses from the
awareness of the position of the body) and visceral (feelings brain), the spinal cord, the brainstem, and the cerebrum.
originating from large organs within the body) modes.
Perception is the ability to experience, recognize, orga-
nize, and interpret sensory stimuli. Sensory perception is
Components of Cognition
the ability to receive sensory impressions and, through corti- Cognition includes the cerebral functions of memory, affect,
cal association, relate the stimuli to past experiences and form judgment, perception, and language. In order for these higher
an impression of the nature of the stimulus. functions to occur, consciousness must be present.
Perception is closely associated with cognition, the
intellectual ability to think. The processes of organizing and Consciousness
interpreting stimuli depend on a person’s level of intellectual Consciousness is a state of awareness of self, others, and the
functioning. Cognition includes the elements of memory, surrounding environment. It affects both cognitive (intellec-
judgment, and orientation. The well-being of an individual tual) and affective (emotional) functions. An alert individual
depends on the functions of sensation, perception, and cogni- (one who is aware of self and stimuli) is able to perceive real-
tion because the person fully experiences and interacts with ity accurately and to base behavior on those perceptions.
the environment through these mechanisms. The components of consciousness provide a foundation for
Sensory, perceptual, and cognitive alterations are either behavior and emotional expression, thereby contributing to
temporary or progressive in their manifestations and result the uniqueness of each individual’s personality. Consciousness
from disease or trauma. Whatever the status or cause of the may be altered by various metabolic, traumatic, or other fac-
alterations, these conditions usually lead to social isolation tors, such as the pharmacological actions of drugs that affect
and increased dependence on others. In addition, impairment mental status. The primary components of consciousness are
in sensory, perceptual, and cognitive functions place the indi- arousal and awareness, both of which must be present before
vidual at risk for injury to self or others. higher cognitive functioning occurs.
Arousal The degree of arousal (state of wakefulness and
ANATOMY AND PHYSIOLOGY alertness) is indicated by a person’s general response and reac-
tion to the environment. People exhibit arousal by behaving
REVIEW in an alert and aware manner and by experiencing periods of
Sensation, perception, and cognition are neurological func- wakefulness. The degree of an individual’s arousal is indicated
tions. The nervous system is composed of two major subsys- by the general response and reaction to the environment.
tems: the central nervous system (CNS) and the peripheral Impaired arousal can exist when a sleep pattern deficit is
nervous system (PNS), which consists of the somatic and
autonomic nervous systems. The CNS and PNS act in uni-
son to accomplish three purposes: (1) collection of stimuli PROFESSIONALTIP
from the receptors at the end of the peripheral nerves; (2)
transportation of the stimuli to the brain for integration and
cognition processing; and (3) conduction of responses to Effects of Medications on Sensation
the stimuli from the brain to responsive motor centers in the Certain medications have the potential to alter
body.
or depress the neurosensory system. For example,
Sensory perception involves the function of both the
sedatives and narcotics alter the perception of
cranial and peripheral nerves. The cranial nerves arise from
the brain and govern the movement and function of various sensory stimuli. Medications such as analgesics alter
muscles and nerves throughout the body. The peripheral the level of consciousness.
nerves connect the CNS to other parts of the body.

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 CHAPTER 11 Sensory System 361

For example, a postoperative client, after receiving analgesic

PROFESSIONALTIP medication for pain, may see the belt from his bathrobe lying
on the floor and become terrified because he thinks there is a
snake in the room. Once the nurse determines that the client
Remote Memory is experiencing an illusion, appropriate reassurance and reality
orientation is implemented to reduce the client’s anxiety.
Remote memory is accurately assessed only when
client responses about past events can be validated,
either by others or by written account. Language
Language is one of the most complex of cognitive functions,
involving not only the spoken word but also reading, writing,
and comprehension. Characteristics of speech are fluency
experienced. There may be an inability to take advantage of (ability to talk in a steady manner), prosody (melody of
opportunities for activity because of inadequate periods of speech that conveys meaning through changes in the tempo,
rest. rhythm, and intonation), and content.
Awareness Awareness is the capacity to perceive sensory
impressions and react appropriately through thoughts and
actions. An essential element in awareness is orientation
(perception of self in relation to the surrounding environ- ASSESSMENT
ment). When awareness is impaired, orientation to time is When caring for clients with sensory, perceptual, and cognitive
frequently the first area affected. The degree of disorientation alterations, the nurse obtains a health history and performs a
is worse when the individual loses awareness of place, self physical examination to identify existing or potential problems
(person), and purpose/situation. in this area of functioning. The physical examination focuses
specifically on the client’s ability to hear, see, taste, smell, and
Memory touch. For hearing (auditory): Ask about hearing problems,
There are three types of memory: immediate, recent, and ability to distinguish sounds, buzzing or ringing noises, recent
remote. Immediate memory is the retention of information changes in hearing ability, and use of a hearing aid. For seeing
for a specified and usually short period of time. The recall of (visual): Ask about blurred vision, double vision, blind spots,
a telephone number long enough to dial it is an example of photosensitivity, rainbows or halos around objects, difficulty
immediate memory. Recent memory is the ability to recall seeing far or near, family history of visual problems, use of
events that have occurred over the past 24 hours, such as glasses or contact lenses, and date of last eye examination. For
remembering the foods eaten for dinner the previous night. tasting (gustatory): Ask about changes in tasting ability or
Remote memory is the retention of experiences that occurred appetite and ability to differentiate sweet, sour, salty, and bitter
during earlier periods of life, such as an adult’s memories of tastes. For smelling (olfactory): Ask about changes in the abil-
childhood or school days. The ability to learn depends on ity to smell and the ability to distinguish common smells. For
remote memory. touch (tactile): Ask about ability to feel temperature changes
and pain perception in extremities and the presence of unusual
sensations in extremities (tingling or numbness). Refer to the
Affect neurologic system chapter for assessment of cranial nerves.
Affect (expression of mood or feeling) is an important com- When assessing clients for sensory, perceptual, and cogni-
ponent of cognition in that variations of mood can affect one’s tive alterations, the level of consciousness (LOC) also is evalu-
thinking ability. For example, a client with a flat affect caused ated. Refer to the neurologic system chapter for the Glasgow
by depression may have difficulty sustaining concentration or Coma Scale, developed to assess LOC objectively.
attention.

Judgment SAFETY
Judgment is the ability to compare or evaluate alternatives
to arrive at a conclusion based on sound reasoning and sup- Sensory Impairments
ported by evidence. Judgment is closely related to reality test-
ing and depends on effective cognitive functioning. Behaviors Vision—Risk of tripping, falling
indicating impaired judgment include impulsiveness, unrealis- Hearing—Lack of awareness of warning sounds
tic decision making, and inadequate problem-solving ability.
such as automobile horns, sirens, smoke alarms
Perception Olfactory—Inability to perceive warning odors such
Perceptions are considered in the context of the individual’s as burning food, escaping gas
awareness of reality. Misperceptions of reality can occur in Gustatory—Inability to recognize spoiled or con-
the form of an illusion (an inaccurate perception or misinter-
taminated food or beverages
pretation of sensory stimuli) or a hallucination (a sensory
perception that occurs in the absence of external stimuli and Tactile—Lack of awareness of excessive pressure
is not based on reality). on a body part; at risk for exposure to extreme
Clients who are anxious and fearful or who are on temperatures (frostbite, burns)
therapeutic regimens involving the use of certain medications
may experience misperceptions of environmental stimuli.

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362 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

The Ear LIFE SPAN CONSIDERATIONS

The human ear is divided into three main anatomical compo-
nents: the outer ear, middle ear, and inner ear (Figure 11-1). Sensory Changes in the Elderly
Each part plays a major role in hearing. Similar to other paired
organs in the body, dysfunction of part or all of one ear does • When the eye lens yellows and becomes cloudy,
not affect the function of the other. the ability to discern colors, especially greens
and blues, is impaired.
Outer Ear • The elderly need more light to see because the
The outer ear is composed of the auricle (pinna), a cartilagi- pupils become smaller, letting in less light.
nous flap on the temporal sides of the head, and the external • It takes the elderly longer to accommodate
ear canal, or external auditory meatus. The outer ear is respon- (adjust) to darkness and glare.
sible for collecting, conducting, and amplifying sound waves.
The auricle directs sounds through the external ear canal to • Tear production decreases with age, predispos-
the tympanic membrane (eardrum). This canal is lined with ing to dry eye syndrome and corneal irritation.
ceruminous glands that secrete cerumen (ear wax), a yel- • The most common hearing loss is sensorineural,
lowish brown protective substance that guards against certain which can be helped by a hearing aid.
bacteria and small insects, and traps dust and debris that may • Taste sensation may be dulled with age.
damage the inner ear. Normally, the cerumen works its way
out of the ear as we eat, chew, or speak; however, cerumen
can build up and actually cause significant hearing loss in the
affected ear.
The tympanic membrane (TM) serves as a boundary of the malleus connects with the incus, which then joins the
between the outer and middle ear. As sound waves vibrate stapes. The flat oval bone of the stapes, called the footplate,
against the membrane, the motion is transmitted to the bones rests on the oval window (part of the inner ear). The vibration
of the inner ear. In an acute ear infection, fluid fills the middle created by sound waves passes through the outer ear canal to
ear, creating significant pressure on the tympanic membrane. the tympanic membrane and then to these three bones.
The eustachian tube opens into the pharynx from the
middle ear. It is approximately 3 to 4 cm long, and its primary
Middle Ear function is to equalize pressure on both sides of the eardrum
The three bones of the middle ear are collectively referred by providing a path (via the nasal passages) to relieve the
to as the ossicles and include the malleus (hammer), incus pressure. In addition to pressure equalization, the functions
(anvil), and stapes (stirrup), so named because they resemble of the middle ear include amplification of the sound waves
the tools of a blacksmith’s trade. The malleus is attached to the and stimulation of the oval window to move the fluids of the
upper, inner portion of the tympanic membrane. The head inner ear.

Malleus

Semicircular
canals
Vestibule
Incus
Branches of
vestibulocochlear
Auricle nerve

Cochlea

External Oval window

auditory canal
COURTESY OF DELMAR CENGAGE LEARNING

Round window

Eustachian tube

Outer ear Middle Inner ear

ear
Tympanic membrane
Stapes

Figure 11-1 Structures of the Ear

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 CHAPTER 11 Sensory System 363

structure containing smooth muscle. A thin diaphragm of

PROFESSIONALTIP mostly connective tissue and smooth muscle fibers with an
opening in the center is attached around the anterior margin
of the ciliary body. The muscles of the ciliary body serve to
Tympanic Membrane change the shape of the lens, allowing changes in the focal
distance of the eye. The third portion of the vascular tunic
The tympanic membrane is normally concave on
is known as the iris and contains the pigment responsible for
otoscopic exam, so a convex or bulging tympanic the color of the eye. The hole in the iris is the pupil, which
membrane is an important sign of an acute permits light to enter the eye. Some of the smooth muscle
infectious process. fibers in the iris encircle the pupil and others radiate from it.
Contraction of the radial muscle dilates the pupil and con-
traction of the circular muscle constricts the pupil. By their
control of pupil diameter, these muscles regulate the amount
Inner Ear of light entering the eye.
The inner ear has two main functions: hearing and equi-
librium. It consists of a complex series of interconnected,
fluid-filled chambers and tubes called the labyrinth. It is Nervous Tunic
divided into three main parts: the semicircular canals, the The third and innermost tunic of the eye, the retina, translates
vestibule, and the cochlea, all located in the temporal bone. light waves into neural impulses. An extremely complex struc-
The semicircular canals, which function in providing the ture, the retina contains several layers of nerve cells and their
sense of balance, open into the vestibule. The vestibule is processes, including two types of receptors, the rods for vision
the central chamber of the inner ear. The cochlea is a snail- in dim light, and the cones for daytime or color vision. Cones
shaped structure that contains the auditory organ for the are most densely concentrated in the central fovea, a small
sense of hearing. depression in the center of the macula lutea. The macula lutea,
Vibration of the stapes creates pressure and causes the or yellow spot, is in the central part of the retina. The fovea is
nerves to respond to different sounds and initiate neural the area of sharpest vision because the highest concentration
responses that are sent along the auditory nerve (cranial nerve of cones is located there. Rods are absent from the fovea and
VIII) to the brain. Thus mechanical information is translated macula, but they increase in density toward the periphery of
into nerve impulses and sent to the brain, which translates the the retina. The optic disk, where the optic nerve exits the
sound into meaningful impressions and language. eye, is a weak spot in the fundus (posterior wall) of the eye
because it is not reinforced by the sclera. The optic disk is also
The Eye called the blind spot because it lacks photoreceptors and light
focused on it is not detected.
The eyes are a pair of spherical organs located in bony orbital The interior of the eyeball contains an anterior and
cavities in the front of the skull. They are the sensory recep- posterior chamber separated by the lens. The anterior cham-
tor organs of the visual system that transduce light from the ber is filled with a watery fluid, called the aqueous humor,
environment into electrical impulses, which the optic nerve that maintains intraocular pressure, provides nourishment,
(cranial nerve II) then transmits to the brain, where they are and helps maintain the shape of the eyeball. The posterior
interpreted as the sensation of vision. The adult eyeball mea- chamber is filled with a jelly-like substance, called the vitre-
sures about 1 inch in diameter. Of its total surface area, only ous humor, that maintains the spherical shape of the eye and
the anterior one-sixth is exposed. The remainder is recessed supports the inner structures. Both substances are transpar-
and protected by the bony orbit into which it fits. Anatomi- ent, thus allowing light to pass through the eye to the retina
cally, the eye is divided into three separate coats, or “tunics”: (Figure 11-2).
the outer fibrous tunic, the middle vascular tunic, and the The lens, located in the anterior chamber of the eye, is a
inner nervous tunic. transparent biconvex crystalline body enclosed in an elastic
capsule held by suspensory ligaments. The shape of the lens
Fibrous Tunic changes to focus the image.
The fibrous tunic is the outer coat of the eyeball and is com-
posed posteriorly of the sclera and anteriorly of the transpar- External Structures
ent cornea. The sclera, or “white of the eye,” is leathery, white, The eyeball is protected from the external world by the eyelid,
and relatively thick and is composed of connective tissue. The which contains a thin protective layer of epithelium, the con-
cornea, or “window of the eye,” is a continuation of the sclera junctiva (Figure 11-3). The conjunctiva covers the anterior
and forms a transparent rounded bulge through which light portion of the eyeball and lines the eyelid. Projecting from the
passes. border of each eyelid is a row of eyelashes that protect the eye
from foreign particles. The lacrimal gland produces a secretion
Vascular Tunic called tears that contains a lysozyme, muramidase, to destroy
The vascular tunic is the eye’s middle layer and is composed pathogens.
of three portions: the posterior choroid, the anterior ciliary
body, and the iris. Collectively, these three structures are
called the uveal tract. The choroid carries the blood vessels
for the eyeball and contains a large amount of pigment, thus
COMMON DIAGNOSTIC TESTS
preventing internal reflection of light. Around the edge of Commonly used diagnostic tests for clients with problems in
the cornea the choroid forms the ciliary body, a thickened hearing and vision are listed in Table 11-1.

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364 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Ciliary body
and muscle
Suspensory
ligament
Conjunctiva Retina
Iris
Retinal arteries
Pupil and veins
Fovea
Path of light
centralis
Anterior chamber (center of the macula)

COURTESY OF DELMAR CENGAGE LEARNING

(aqueous humor) Optic disk

Cornea Optic
Lens nerve

Posterior chamber (vitreous humor) Choroid coat

Sclera

Figure 11-2 Lateral View of the Interior Eyeball

Table 11-1 Common Diagnostic Tests

Temporal side Nasal side for Sensory Alterations
Lacrimal gland Upper lid
(under eyelid) • Weber test (tuning fork)
• Rinne test (tuning fork)

Pupil • Audiometric testing (audiogram)

• Speech audiometry (Spondee threshold)
Eyelashes • Caloric test

Outer Inner canthus • Brainstem auditory evoked response (ErA and BAER)
COURTESY OF DELMAR CENGAGE LEARNING

canthus • Tympanometry
Palpebral
fissure • Computed tomography (CT)
Caruncle
Lower lid • Magnetic resonance imaging (MRI)
Iris • Romberg test
Conjunctiva Limbus Sclera
• Otoscopic exam
• Past-point testing
Figure 11-3 External View of the Right Eye
• Color vision tests
• Tonometry
• Slit lamp examination
SENSORY, PERCEPTUAL, AND • Perimetry
COGNITIVE ALTERATIONS • Visual acuity

A
COURTESY OF DELMAR CENGAGE LEARNING

n individual usually experiences discomfort and/or • Electroretinogram (ERG)

anxiety when subjected to a change in the type or • Ocular ultrasonography
amount of incoming stimuli. A person can become confused • Ophthalmoscopic examination
as a result of either overstimulation or understimulation.
According to the individual’s ability to process the stimuli, • Orbital computerized tomography
confusion (or disorientation) may occur. Disorientation is • Fluoresce in angiography
a mentally confused state in which the person’s awareness of
time, place, self, and/or situation is impaired. When aware-
ness of these four factors is accurate, a person is said to be perceive and interpret sensory input. As a result, the treatment
“oriented × 4.” setting becomes a stressor that negatively affects sensory, per-
A person admitted to a health-care agency experiences ceptual, and cognitive functions. If one or more of the factors
stimuli that are different from those usually encountered. just discussed causes an alteration in sensation, perception,
A change in environment can overwhelm one’s ability to or cognition, the client experiences problems with perceiving

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 CHAPTER 11 Sensory System 365

and interpreting stimuli. These problems are manifested by

three types of alterations: sensory deficit, sensory deprivation, ■ SENSORY OVERLOAD

S
and sensory overload.
ensory overload is a state of excessive and sustained
multisensory stimulation manifested by behavior change
■ SENSORY DEFICIT and perceptual distortion. The individual experiencing this
alteration is unable to process the amount or intensity of

A sensory deficit is a change in the perception of sensory

stimuli. This deficit affects all five senses. Examples of
sensory deficit are vision and hearing losses such as those
stimuli received. Factors contributing to sensory overload
are:
• Pain originating from a heightened quality or quantity of
caused by cataracts, glaucoma, and presbycusis (steady loss of internal stimuli
hearing acuity that occurs with aging). • Invasive procedures that result in an increased amount of
The client’s response to these losses usually depends on external stimuli
the time of onset and the severity of the condition. If the prob- • Activity-filled, busy environment that contributes to the
lem occurs suddenly and without warning, the client has diffi- amount of stimuli perceived
culty adjusting to the loss of sensory and perceptual function.
If these alterations occur gradually, the client may be able to • Medications that stimulate the CNS and prohibit the client
accommodate the change and actually compensate for it by from ignoring selective stimuli
strengthening one or more of the other senses. • Presence of strangers (both health care professionals and
The effects of hospitalization or intensive medical treat- others) who contribute to the quantity of stimuli
ments exacerbate the problems related to sensory deficit. • Diseases that affect the CNS and maximize the perception
For example, a client with acute hearing loss can feel alone of stimuli
and vulnerable. Clients with sensory deficit are at serious
risk of experiencing either sensory deprivation or sensory
overload.
DISORDERS OF THE EAR
■ SENSORY DEPRIVATION D isorders of the ear include impaired hearing, Ménière’s
disease, otosclerosis, acoustic neuroma, otitis media,

S ensory deprivation is a state of reduced sensory input

from the internal or external environment, manifested by
alterations in sensory perception. Individuals experience sensory
otitis externa, and mastoiditis.

deprivation as a result of illness, trauma, or isolation. A person

experiencing sensory deprivation misinterprets the limited stim- ■ IMPAIRED HEARING

A
uli with a resultant impairment of thoughts and feelings. Factors
that contribute to sensory deprivation include: ccording to a study by Agrawal, Platz, and Niparko (2008),
an estimated 55 million Americans have high-frequency
• Visual or auditory impairments that limit or prohibit hearing loss. Men were 5.5 times more likely to have hearing
perception of stimuli loss than women (Crosta, 2008). It can be seriously debilitat-
• Drugs that produce a sedative effect on the CNS and ing by limiting the ability to socialize and work, or respond
interfere with the interpretation of stimuli to the telephone or alarms, yet relatively few individuals who
• Trauma that results in brain damage and decreased experience impaired hearing actually seek help. Some may
cognitive function deny the problem and others may feel that a hearing aid is a
• Isolation (either physical or social) that results in a sign of old age. Family members are often the first to be aware
nonstimulating environment of a hearing deficit.
Some contributing factors (such as brain damage or
blindness) result in chronic sensory deprivation. Other factors
lead to acute, transient states of deprivation (such as receiving Types of Hearing Loss
analgesic medications). Hearing loss is generally categorized in two ways: conductive
Individuals who are sensory-deprived may exhibit any of and sensorineural. Mixed hearing loss, both conductive and
the following characteristics:
• Inability to concentrate
• Poor memory LIFE SPAN CONSIDERATIONS
• Impaired problem-solving ability
• Confusion Effects of Aging
• Irritability Sensory, perceptual, and cognitive function begin
• Emotional lability (mood swings) to diminish with aging. Decreased visual or auditory
• Hallucinations senses or impairments in memory are experienced.
• Depression These changes can have a profound effect on a
• Boredom and apathy client’s self-esteem and response to life.
• Drowsiness

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366 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Hearing Aids/Assistive
Devices
CULTURAL CONSIDERATIONS Hearing aids today come in a variety of designs and sizes.
Some are quite small and tinted to a person’s skin color so
Hearing Loss as to be virtually unnoticeable. Some are worn in the ear,
behind the ear, or are part of eyeglasses frames. Persons with
Caucasian and Mexican-American men had bilateral hearing loss may need binaural (worn in both ears)
the greatest incidence of both high-frequency hearing aids.
hearing loss and hearing loss in both ears. African- A hearing aid converts environmental sound and speech
American clients were 70% less likely to have into electronic signals that are amplified and converted to
hearing loss than Caucasian clients. Hearing loss acoustic signals. It makes speech and sound louder but not
is preventable by reducing risk factors and by necessarily clearer. Depending on the extent of hearing
screening for hearing loss in young adulthood, impairment and preference, the client may need to experi-
ment with several different types of hearing aids. In addition,
especially in Caucasian and Mexican-American men
speech therapy, lip reading, and auditory training may be
(Agrawal, Platz, & Niparko, 2008).
necessary to help discriminate speech and develop better
listening skills.
Many other assistive hearing devices are available for
sensorineural, is possible but far less likely. Either may occur the hearing impaired. Numerous television programs are
at birth (congenital), develop later in life, be genetic, or be closed-caption. Advanced technology allows telecommu-
caused by injury or trauma. nication through a device called the Telecommunication
Conductive hearing loss indicates an inability of the Device for the Deaf (TDD), also called TTY Typewriter,
sound waves to reach the inner ear. This is caused by cerumen which sends a printed message onto a small screen. Both
buildup or blockage, perforated tympanic membrane, or fixa- sender and receiver must have the typewriter/telephone
tion of one or all of the ossicles. device. Many hospitals have these to comply with ADA
In sensorineural hearing loss, the inner ear or cochlear requirements.
portion of cranial nerve VIII is abnormal or diseased. A tumor, Alarm clocks offer strobe lights or vibrators to awaken
infection, trauma, or exposure to loud noises may cause clients. State-of-the-art receivers give instant access to radio,
destruction of the nerve and result in sensorineural hearing television, computer, and stereos to enhance receiving and
loss. listening systems. For travelers, complete kits are available to
Sensorineural hearing loss associated with aging is termed provide ready access for smoke alarm, clock, TDD, and door-
presbycusis. Higher frequency sounds such as women’s knock alert in hotels or inns.
voices become especially difficult to hear, and distinguishing Hearing guide dogs are also available. The animals are
words may be a problem. People with sensorineural hear- specially trained to meet the needs of the hearing impaired.
ing loss can be helped by hearing aids or cochlear implants At home, the dog responds to alarms, knocking on doors,
(Ruben, 2007). and babies crying. In public, the dog takes a position
between owner and a potential threat. Special identifiers,
such as a collar for the dog and ID card for the owner, are
Behaviors Indicating Hearing available. The dogs are trained to go wherever their master
Loss goes, including restaurants, grocery stores, and on public
transportation.
A hearing impairment is a serious disorder that is often debili-
tating and embarrassing to the client. Hearing is part of the
communication process, so the inability to hear may cause the
person to do or say the wrong thing in response to a question
or command. Persons with hearing impairment may withdraw
from conversation or seem indifferent to their surroundings or
to those around them. PROFESSIONALTIP
Alterations in hearing are often manifested by changes in
speech habits and patterns. Individuals with hearing impair- Hearing Specialists
ments may not notice the changes in their own speech pattern
until someone constantly asks them to repeat themselves or An audiologist evaluates hearing and determines
to speak clearly. Indifference and withdrawal are common the extent and type of hearing loss, and provides
behaviors in response to hearing loss. If left undiagnosed and nonmedical treatment such as fitting hearing
untreated, the person may truly regress, become unhappy, aids, advice about assistive listening devices, and
lonely, and possibly even paranoid. Some individuals over- communication/aural rehabilitative training. An
compensate for the hearing loss by becoming very loud and otolaryngologist (ear, nose, and throat physician)
aggressive. provides medical evaluation of hearing disorders
Research on hearing impairment has created many
and medical and surgical interventions. A hearing
devices to aid speech and sound discrimination. Early diag-
nosis, treatment, and rehabilitation are essential to help aid specialist is licensed to dispense hearing aids but
hearing-impaired persons enjoy and appreciate the world in is not a medical doctor.
which they live.

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 CHAPTER 11 Sensory System 367

Medical–Surgical NURSING PROCESS

Management
Medical
Assessment
The type of hearing loss and underlying etiology determines Subjective Data
the best medical or surgical management. The client under- Ask the client to describe the initial onset of symptoms and
goes a complete physical examination as well as thorough possible familial traits, recent infections of the ears, nose,
diagnostic hearing tests to determine the etiology. The client or upper respiratory system. Determine recent trauma and
and doctor together decide on the best course of therapy. past surgery as well as medical history such as diabetes, heart
disease, or cancer. Ask about allergies to food, drugs, or envi-
ronmental factors, associated symptoms such as tinnitus
Surgical (ringing sound in the ear), vertigo (dizziness), nausea, and
The cochlear implant is a possible treatment for persons with vomiting. The client’s work history may reveal exposure to
profound deafness. In this procedure, a receiver/stimulator is loud noises.
implanted in the skull and a group of electrodes are planted in
front of the round window in the inner ear. The client wears
a microphone near the ear that picks up and translates sound
into electrical signals. These signals are then transmitted to the Objective Data
brain via the cochlear implant and cranial nerve VIII. Listen closely to the client and note any deterioration of
speech, slurring, or dropping of word endings. Document cur-
Nursing Management rent and recent medications used.
Inspect the outer ear for abnormalities, lesions, or
If the client uses a sign language interpreter, arrange for one to cerumen. Palpate the mastoid process, neck, jaw, and
assist with communication. Writing notes, using a TDD, or a temporal regions of the head for swelling or tenderness
computer may be helpful. Approach the client and elicit the cli- to touch. Note the degree of hearing loss as reported by
ent’s attention by waving. Make sure all personnel know the cli- the client and compare it to the diagnostic tests such as
ent is hearing impaired as well as the client’s preferred method of the speech audiogram. The client’s perception of hearing
communication. The publication Pictograms for Hospital Com- loss may be significantly different from the diagnostic
munication is available from the U.S. Department of Justice. findings.

A nursing diagnosis for a client with impaired hearing is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Social Isolation related to The client will participate Take time to engage client in conversation. Make sure you have
hearing impairment in conversations and other the client’s attention and be at eye level.
social situations. Speak slowly and distinctly.
Give the client time to respond.
Provide the client and family members written information re-
garding the availability, variety, and quality of assistive hearing
devices.
Encourage client to participate in social situations.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

endolymph and could be responsible for the symptoms asso-

■ MÉNIÈRE’S DISEASE ciated with Ménière’s disease.

M
The major symptoms are the classic triad of vertigo, tin-
énière’s disease, also known as endolymphatic hydrops, nitus, and unilateral fluctuating hearing loss. The vertigo is
is a state of hearing loss characterized by tinnitus and often associated with nausea and vomiting. Tinnitus may either
vertigo. Although the exact etiology is unknown, it is thought be a preceding aura or occur simultaneously with the vertigo.
to be an excessive accumulation of endolymph in the cochlear Initially, tinnitus is intermittent, but as the disease progresses,
duct and possible leakage of endolymph into the perilymph it may be a constant, low-pitched roaring sound. The fluctuat-
caused by increased capillary permeability. Mixing of the two ing, unilateral hearing loss becomes more profound with each
fluids chemically alters the homeostasis of the perilymph and attack.

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368 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

The symptoms are frequently at their worst during the neurectomy, the vestibular portion of cranial nerve VIII is
first attack, which may last from a few minutes to six hours. severed; hearing is preserved in 90% of clients having this
Nystagmus, repetitive and involuntary movement of the procedure. In surgical destruction of the labyrinth, hear-
eyeballs, and diaphoresis may occur during an attack. Sub- ing is destroyed but the incapacitating vertigo is completely
sequent attacks are less severe, but over time may involve relieved.
both ears and cause permanent bilateral hearing loss. Clients
report many different precipitating events, such as stress,
weather changes, menstruation, or pregnancy, and various Pharmacological
dietary influences, including caffeine, alcohol, and salt. Several medications are useful to help control the symp-
Smoking has also been implicated. toms, such as antihistamines, antiemetics, benzodiazepines,
diuretics, tranquilizers, vasoactive agents, and oral niacin.
Medical–Surgical The medications are prescribed for long-term use or at the
onset of symptoms. Because the cause of Ménière’s disease is
Management unknown, there is no cure.
Medical
Medical management is the preferred treatment and most Diet
helpful to 80% to 85% of persons with this disease. Diag- Dietary interventions include strict salt restriction and avoid-
nosis is not difficult and is usually made based on the cli- ance of those foods or beverages that precipitate or aggravate
ent’s report of symptoms. Diagnosis may also be confirmed an attack. Examples are beer, wine, soda, salty food or snacks,
with caloric stimulation (although this test is primarily chocolate, and caffeinated coffee and tea.
conducted on comatose clients) and magnetic resonance
imaging to rule out a tumor. Medical management is symp-
tomatic. Activity
Activity is not limited except during or after an attack,
Surgical when clients require prolonged bed rest and restriction of
activities that are unsafe, such as driving or operating heavy
Surgical intervention is needed only when the attacks are equipment.
frequent and debilitating, or when the disease severely affects
the quality of life and the ability for self-care. Surgical treat-
ment includes endolymphatic, subarachnoid shunt placement
to drain excessive endolymph. With this procedure, hearing
Nursing Management
is preserved in 60% to 70% of the clients. With a vestibular Advise client against reading and use of glaring lights. Instruct
client to avoid sudden position changes and have assistance
when getting out of bed or ambulating. Keep side rails up and
the call light within the client’s reach.

PROFESSIONALTIP
NURSING PROCESS
Assisting the Hearing-Impaired Client
• Speak slowly and distinctly after getting the
Assessment
client’s attention. Subjective Data
• Face the client and sit or stand to be at eye level The history begins with identifying significant contributory
with the client. data. Ask the client to describe the initial onset of symptoms
• Use short, simple sentences and give the client including, but not limited to, the classic triad of tinnitus, ver-
time to respond. Repeat or rephrase if tigo, and fluctuating unilateral hearing loss.
necessary. Relate questions to recent viral illness; upper respiratory
infections; past medical, surgical, and dental history; and any
• Use written materials when possible to commu-
problems related to the neck and face. Document food, drug,
nicate information. or environmental allergies. Record current or recent long-term
• Keep a notepad and pen or pencil available medications. Identify the client’s occupation and hobbies that
to write down new or unfamiliar words and contribute to hearing loss.
concepts.
• If sign language is the client’s preferred method Objective Data
of communication, locate a person who under- A thorough physical examination includes looking at the
stands sign language. ear for abnormalities, lesions and cerumen blockage, or
• If the client wears a hearing aid, make sure that unusual drainage. Palpate the neck, jaw, and mastoid pro-
the battery is functional, it is turned on, and is
cess for possible lymph node enlargement and tenderness.
The nurse assists with the otologic examination as needed.
adjusted to a comfortable level.
Audiologic testing determines unilateral or bilateral hear-
ing loss.

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 CHAPTER 11 Sensory System 369

Nursing diagnoses for a client with Ménière’s disease include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Activity Intolerance re- The client will be able to Provide adequate periods of bed rest. Provide assistance with
lated to severe vertigo tolerate activities of daily ambulation and encourage increased activity as tolerated.
living. Keep the room dim and quiet when possible. Avoid jarring the
bed and caution client to avoid sudden movements.
Administer antiemetic before symptoms become too severe.

Deficient Knowledge The client will verbalize Assess the client’s current knowledge of the disease
related to abrupt onset understanding of the dis- process.
and unknown progression ease process and potential Review the disease process and underlying etiology of
of the disease precipitating factors and Ménière’s disease with the client. Ask the client to identify pos-
how to manage or control sible precipitating factors such as stress or dietary habits.
the symptoms.
Discuss health promotion programs for stress management
and healthy cooking classes. Suggest consultations with di-
etary and social services.
Review follow-up appointments, medications, dietary manage-
ment, activity, and rest parameters.
Evaluate client’s readiness to discuss progressive hearing loss
and current assistive hearing devices available.

Risk for Injury related to The client will not fall or be Keep side rails up. Teach client to move or turn slowly. Instruct
vertigo injured because of vertigo. client to sit or lie down when vertigo occurs.
Reiterate need to call for assistance when ambulating. Keep
call bell within client’s reach.
Administer medications for vertigo prior to worsening of symp-
toms.
Avoid glaring, bright lights.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

CRITICAL THINKING Otosclerosis is more common in adults, more often in

women, and it is familial in some cases. The primary clinical
Hearing Impaired manifestations are subtle changes in hearing and low-pitched
tinnitus. It becomes more difficult to distinguish a whisper,
How can nurses assist the hearing impaired during or to hear in crowded places or understand conversation.
a hospitalization? Individuals affected by otosclerosis often blame others for
speaking too softly or mumbling. Frequently, rather than ask-
ing others to speak up or to repeat themselves, the person will
be irritable and withdrawn.
Diagnostic testing begins with the Weber and Rinne
tuning fork tests. In addition, audiometric testing should be
■ OTOSCLEROSIS performed. Schwartz’s sign, a pink blush, is seen on otoscopic

O
examination. Tympanometry shows stiffness in the sound
tosclerosis, the most common conductive hearing loss, conduction system.
is secondary to a pathologic change of the bones in the
middle ear. The exact cause is unknown. The ossicles are
normally hard, but over time and without warning, the bone Medical–Surgical
becomes softened, spongy, highly vascular, and partially or Management
totally fixed. This fixation reduces or prevents transmission of
source waves to inner ear fluids. Although all three bones may Medical
be affected, the stapes, which must vibrate on the oval window Treatment for otosclerosis is limited to three options. The
in order to transmit sound waves, is most commonly afflicted. individual may choose to do nothing and obtain periodic

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370 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

audiometry to evaluate progression of the disease. The second

choice is to use a hearing aid, and the third choice is surgical NURSING PROCESS
management with an outpatient procedure known as a stape-
dectomy. Assessment
Subjective Data
Surgical A careful history discovers possible hereditary traits or
A stapedectomy is the preferred surgical technique for acquired disease. Ask about recent infections of the ears,
improving hearing loss caused by otosclerosis. A stape- nose, or upper respiratory system, and also about past surgery,
dectomy is done under local or general anesthesia and trauma, or other illnesses such as diabetes, heart disease, or
routinely requires a surgical incision in the posterior ear cancer. Identify associated symptoms, such as dizziness, tin-
canal, removal of the stapes, and implantation of a plastic nitus, vertigo, and nausea.
prosthesis. Laser stapedectomy is performed through the Note allergies to foods, drugs, or any environmental
ear canal without an incision. The stapes tendon is vapor- factors, such as exposure to loud noises. Record current
ized, chards are removed with delicate micro instruments, and recent medications, especially those known to be
and an opening is made allowing the surgeon to implant ototoxic.
a prosthetic piston. This restores normal vibration against
the inner ear.

Objective Data
Nursing Management Objective data include a thorough physical examina-
Postoperatively, instruct the client to turn or move slowly, tion. Inspect the outer ear for abnormalities, lesions, or
not to blow the nose for 10 days, to avoid lifting for 1 month, impacted ear wax and palpate the mastoid process, neck,
and if sneezing occurs, to keep the mouth open. Adminis- jaw, and temporal regions of the head for pain or swelling.
ter antibiotics as ordered. Advise the client that hearing is Assess the degree of hearing loss. The client may experi-
decreased for 3 to 4 weeks until gel-foam packing dissolves. ence vomiting.

Nursing diagnoses for the client with otosclerosis include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to de- The client will show evi- Encourage the client to explore feelings of anxiety and to ask
crease or loss in hearing dence of reduced anxiety questions to clarify concerns. Provide honest and realistic
and verbalize understanding feedback.
of the disease process and Collaborate with the physician to provide thorough and clear
treatment regimen. explanations of the disease process, treatment options, and
anticipated results.

Risk for Injury related to The client will not fall or be Keep side rails up. Reiterate need to call for
vertigo injured because of vertigo. assistance when ambulating and keep call bell within
client’s reach.
Instruct the client to move or turn slowly.
Administer medications for vertigo prior to worsening of symp-
toms.
Keep room well lit when client is ambulating.

Deficient Knowledge The client will demonstrate Teach client how and when to perform dressing change and
related to activities after the ability to change dress- have client demonstrate the procedure.
surgery ing correctly and verbalize Instruct client to avoid pressure changes (such as flying in an
knowledge of self-care and unpressurized aircraft), avoid heavy lifting (60 lbs) for 1 month,
follow-up. avoid nose blowing for 10 days, and if sneezing occurs, keep
mouth open.
Advise client to keep water out of the ear and keep the ear exposed
to air as much as possible for one month. There will be some drain-
age which is initially red, then pink, and then brownish.
Tell client to report any greenish, yellowish, or foul-smelling
drainage.

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 CHAPTER 11 Sensory System 371

Nursing diagnoses for the client with otosclerosis include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Instruct client to take all antibiotics as prescribed and com-
plete the full course of treatment.
Advise client there should be very little pain or discomfort but
if there is, take prescribed analgesics and notify doctor if pain
is prolonged or intense.
Warn client that hearing is decreased for 3 to 4 weeks after
surgery until gel-foam packing dissolves.
Inform client that audiometric testing will be conducted
1 month after surgery.
Instruct client to schedule an appointment with the physi-
cian in 1 month but call physician if uncontrolled pain is
experienced or a malodorous, greenish discharge comes
from the ear.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

pharmacologic treatment is only temporary until diagnostic

■ ACOUSTIC NEUROMA tests are completed and surgery is planned.

A coustic neuroma is a slow-growing and usually benign

tumor of the vestibular portion of the inner ear (cranial
nerve VIII). Detection at the onset of symptoms is essential
Nursing Management
Assist client to express feelings about progressive hearing loss
and is accomplished with magnetic resonance imaging. Pre- and the changes in activities of daily living, employment, and
senting symptoms of dizziness, tinnitus, and hearing loss are quality of life issues. Note the family’s feelings and ability to
common to many dysfunctions of the ear, and the possibility cope. Perform postoperative care as ordered.
of acoustic neuroma must not be overlooked.
Clients who present with dizziness, tinnitus, and hearing
loss have a complete workup for auditory and vestibular (bal- NURSING PROCESS
ance) function. Facial weakness is caused by compression of
the tumor on cranial nerve VII. Cranial nerve V may also be Assessment
affected as the tumor grows, causing paresthesia of the face
and loss of the corneal reflex. Large neuromas cause increased Subjective Data
intracranial pressure, papilledema, vomiting, and headache. Obtain through the client history signs and symptoms and all
contributing data.
Medical–Surgical Objective Data
Management Obtain with the physical examination a complete cranial
Treatment is almost always surgical excision of the tumor. nerve evaluation performed by the physician or audiologist to
Although antihistamines may reduce the dizziness, determine the extent of cranial nerve involvement.

A nursing diagnosis for a client with acoustic neuroma is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anticipatory Grieving The client will express Assist the client to express feelings about progressive hearing
related to diminished feelings of grief and dem- loss and changes in activities of daily living, employment, and
quality of life, loss of onstrate adaptive coping quality of life issues.
ability for self-care, or mechanisms. Collaborate with physician and other members of the health
possible loss of life care team to provide thorough and clear explanations of the
disease process, treatment options, and anticipated results.

(Continues)
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372 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

A nursing diagnosis for a client with acoustic neuroma is: (Continued)

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Observe the client’s coping styles. Support those that the cli-
ent finds helpful and explore other coping mechanisms that
may prove useful in time (e.g., hobbies and other diversional
activities, prayer, reading, and so on).
Include the family in all interventions that the client desires.
Examine the family’s feelings and ability to cope.
Consult social services, pastoral care, or other hospital and
community resources when appropriate.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ OTITIS MEDIA upper respiratory infection, allergies, or acute bacterial infec-

O
tion. On physical examination, the tympanic membrane is
titis media is an inflammation of the middle ear and a retracted, normal, or bulging. A pneumatic otoscope allows
common cause of conductive hearing loss, although the practitioner to blow soft puffs of air against the tympanic
usually temporary. Symptoms include ear pain, fever, redness membrane to assess movement. A stiff, nonmoving, or bulg-
of auricle and ear canal, and sometimes enlarged lymph nodes ing tympanic membrane indicates inflammation or fluid
over the mastoid process, parotids, and upper neck. Otitis accumulation in the middle ear (Figure 11-4A-C). Visualiza-
media occurs more frequently in children than in adults. tion of the normal landmarks may be obscured. The Rinne
Fluid accumulates behind the eardrum because of tuning fork test and audiometry confirm a conductive hear-
blockage of the eustachian tube. This is secondary to an ing loss.

Image not available due to copyright restrictions

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 CHAPTER 11 Sensory System 373

CRITICAL THINKING Pharmacological

Hearing Impairment Medications used include decongestants, such as pseu-
doephedrine hydrochloride (Sudafed); antihistamines, such
What modifications would need to be made in the as diphenhydramine hydrochloride (Benadryl); and systemic
life of a person who could suddenly no longer hear? antibiotics, such as ampicillin (Omnipen).

Activity
Activity is not restricted unless surgical management is
Medical–Surgical indicated.

Management Nursing Management

Medical After myringotomy, maintain drainage flow. Sterile cotton
Topical heat and systemic analgesics may be used to control may be loosely placed in the external ear to absorb drainage.
pain. The client should lie on the affected side to facilitate Change cotton whenever it is damp. Perform hand hygiene
drainage. before and after ear care. Monitor vital signs. Warn client
against blowing nose or getting ear wet when bathing. Encour-
Surgical age client to complete prescribed antibiotics.
Surgical management may be necessary for diagnostic or ther-
apeutic reasons. A myringotomy may be performed, in which
an incision is made in the eardrum and fluid is aspirated. A NURSING PROCESS
polyethylene tube may be placed in the eardrum to equalize
pressure and allow drainage of fluid. Assessment
A tympanoplasty may be needed if the tympanic Subjective Data
membrane is ruptured. If there is a large tympanic mem-
brane perforation, the malleus, which is connected to the Ask about the onset, duration, and severity of pain and what
tympanic membrane, or other ossicles may be damaged. home remedies have been used. Hearing loss and/or tinnitus
Ossicular chain reconstruction typically refers to the and a deep throbbing pain in the ear may be reported.
removal of the actual bones and replacement with a plastic
prosthesis. The prosthesis and the tympanic membrane Objective Data
reconstruction often result in a significant improvement A watery or yellow discharge may be seen. It may have a foul
in hearing. odor. The client may have a fever.

A nursing diagnosis for a client with otitis media is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will experience Administer antibiotics and analgesics as ordered.
inflammation in the pain relief. Teach client and family the importance of administering medi-
middle ear cations as ordered and to complete full course of prescription.
Apply heating pad, set on low, for 20 minutes every 2 hours.
Do not use on small children.
Teach client if pain is unrelieved in 48 hours, to contact
physician.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

the canal size is constricted, a mild conductive hearing loss

■ OTITIS EXTERNA results.

O titis externa, or “swimmer’s ear,” typically involves a

bacterial infection of the external ear canal skin. The ■ MASTOIDITIS

M
canal skin becomes red and edematous. If the swelling is
severe enough, it will block the ear passage and cause a astoiditis (inflammation of the mastoid) is most often
mild conductive hearing loss (Figure 11-4D). Also, in most the direct result of chronic or recurrent bacterial oti-
cases, there is a discharge. If the discharge is copious and tis media. The recurrent infection may find its way into the

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374 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

bone and structures surrounding the middle ear and, if left

untreated, causes severe damage, sensorineural deafness, PROFESSIONALTIP
facial weakness, brain abscess, and meningitis. Symptoms
include earache, fever, headache, and malaise. Antibiotics are
given for a trial period. If symptoms do not resolve, surgical Eye Specialists
intervention such as mastoidectomy or meatoplasty may be
An ophthalmologist is a medical doctor who
necessary.
specializes in the diagnosis and treatment, medical
and surgical, of diseases of the eye, visual disorders,
and eye injuries. An optometrist is a doctor of
DISORDERS OF THE EYE optometry and is licensed to examine, diagnose,

D
manage and treat vision problems, diseases,
isorders of the eye include cataracts, glaucoma, reti- and other abnormalities of the eyes and related
nal detachment, infections, refractive errors, injuries, structures.
impaired vision, and macular degeneration.

Extracapsular cataract extraction is the procedure most com-

■ CATARACTS monly used (Figure 11-6). The ophthalmologist removes the

A cataract is a disorder that causes the lens or its cap-

sule to lose its transparency and/or become opaque
(Figure 11-5). The lens is normally clear and transparent
anterior portion of the capsule and then expresses, or removes,
the lens. An intraocular lens (IOL) is generally implanted.
Glasses or special contact lenses also are used.
and allows light to pass through to the retina. As clouding Most eye surgery is done on an outpatient basis under
develops, visual impairment occurs. Cataracts usually affect local anesthesia. General anesthesia is used at the client’s
both eyes; however, the degree of visual impairment is often request and for clients who are extremely anxious, deaf, or
different in each eye. mentally retarded. A tranquilizer such as diazepam (Valium)
Cataracts are typically associated with aging; however, or midazolam (Versed) is often given to reduce anxiety when
they may be congenital, caused by severe eye injury, or sec- receiving injections on the face and around the eye.
ondary to certain systemic diseases, such as metabolic prob- Preoperatively, the client can receive several types of
lems (diabetes mellitus) and chronic eye disease (uveitis). eye medications to prepare the eye for surgery: mydriatic
Ophthalmoscopic examination is the primary method of (makes pupil dilate) and cycloplegic (paralyzes ciliary
evaluation. muscle) eyedrops, antibiotic eyedrops as a prophylaxis
against infection, and an intravenous infusion of an agent

Medical–Surgical
Management Lens Implant Surgery for Cataracts

Surgical
The only treatment for a cataract is surgical removal of the lens;
however, the mere finding of a cataract is not an indication for
surgery. Surgery is indicated when significant vision loss has Cataract-
occurred. The lens are removed by the intracapsular or ext- clouded lens
racapsular approach. During the intracapsular cataract extrac- Posterior
tion, the ophthalmologist removes the lens within its capsule. capsule

Cataract Plastic lens

implant

Posterior
COURTESY OF DELMAR CENGAGE LEARNING

capsule

Following surgery

Figure 11-5 A cataract results in the loss of transparency Figure 11-6 To correct cataracts with an extracapsular
of the lens of the eye. (Courtesy of the National Eye Institute, extraction, the lens is removed, the posterior lens capsule is left
Bethesda, MD.) intact, and a plastic IOL is placed.

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 CHAPTER 11 Sensory System 375

to lower intraocular pressure (mannitol or a carbonic anhy-

drase inhibitor). NURSING PROCESS
After the anesthesia wears off, the client is discharged.
The client is instructed to have a driver available for the trip Assessment
home. Driving is restricted for a few days. Subjective Data
Postoperatively, the client has a patch over the eye. The
patch is removed and reapplied on the first postoperative day, A general medical history as well as a history of symptoms
when miotic (makes pupil contract) eye drops are begun. Mild is obtained. Symptoms may include haziness, cloudiness,
discomfort and scratchiness are expected. Atropine sulfate blurred vision, double vision, altered color perception, and
eyedrops and cold compresses are ordered to relieve these glare when looking at lights, especially with night driving.
discomforts. Fear of losing one’s eyesight is very devastating. There is
often a great deal of anxiety when the client seeks an eye
Nursing Management examination.
Assist with ambulation because depth perception has changed.
Maintain eye patch on affected eye. Advise client to sleep with
eye patch on as ordered. Teach client or family to administer Objective Data
eyedrops and ointments. Client should avoid heavy lift- Upon inspection of the eye, the usual black pupil appears
ing, straining during defecation, and vigorous coughing and clouded, progressing to a milky white appearance, which is a
sneezing. Dark glasses will relieve glare. Encourage client to characteristic finding of a mature cataract and indicates signifi-
keep all follow-up appointments. cant vision loss.

Nursing diagnoses for a client with cataracts include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Sensory Percep- The client will demonstrate Assess and document baseline visual acuity.
tion (Visual) related to improved ability to process Elicit functional description of what the client can and cannot
ocular lens opacity visual stimuli and communi- see.
cate visual limitations.

Risk for Injury related to The client will avoid activities Teach the client to change position slowly.
difficulty in processing associated with increased Teach the client to avoid reaching for objects to maintain
visual images and altered potential for injury. stability when ambulating, as depth perception is altered.
depth perception

Impaired Home Main- The client will perform Discuss the client’s ability to meet self-care needs and ac-
tenance related to age, self-care activities in home tivities of daily living.
limited vision or activity environment. Evaluate how the client’s current functional abilities are af-
restrictions imposed by fected by activity restrictions and postoperative care needs.
surgery
Help the client decide on a realistic site for postoperative
care needs.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

slowly progressive loss of peripheral vision, and, if not con-

■ GLAUCOMA trolled, a late loss of central vision and ultimate blindness. This

G
is the most prevalent form of glaucoma and is usually bilateral.
laucoma is a disorder characterized by an abnormally Closed-angle glaucoma (acute glaucoma) is characterized by
high pressure of fluid inside the eyeball (intraocular attacks of suddenly increased IOP, exhibited clinically by a
pressure, IOP). The aqueous humor does not return into bulging iris, which is an emergency situation. Closed-angle
the bloodstream through the canal of Schlemm as quickly as glaucoma is usually unilateral with severe pain and loss of
it is formed. The fluid accumulates and, by compressing the vision caused by acute obstruction of aqueous humor drainage
lens into the vitreous humor, puts pressure on the neurons within the eye.
of the retina. If the pressure continues over a long period, it Secondary glaucoma results from ocular or systemic dis-
destroys the neurons and brings about blindness. orders that elevate the IOP. These disorders indirectly disrupt
There are two primary forms of glaucoma: open-angle the activity of the structures involved in circulation and/or
glaucoma and closed-angle glaucoma. In open-angle glaucoma reabsorption of aqueous humor. This can happen suddenly
(chronic simple glaucoma) there is a gradual rise in IOP, a and without warning.

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376 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

(Carbacel), and demecarium bromide (Humorsol) are fre-

quently used.
CLIENTTEACHING Beta-adrenergics such as timolol maleate (Timoptic Solu-
Glaucoma Care tion) are the drugs of choice for decreasing IOP. When used as
eyedrops, beta-adrenergics reduce aqueous humor production
• Continue the use of eye medications as ordered. without pupil constriction.
• Continue to receive medical supervision for Carbonic anhydrase inhibitors, such as acetazolamide
observation of intraocular pressure to ensure (Diamox), reduce production of aqueous humor to help
control of the disorder. maintain a lowered IOP. Side effects reported are numbness,
weakness, tingling of extremities, and rashes. Adrenergics
• Avoid exertion, stooping, heavy lifting, or wear-
such as epinephrine bitartrate (Epitrate) also reduce aque-
ing constrictive clothing because these actions
ous humor production. Osmotic agents such as mannitol and
increase intra-ocular pressure. glycerin (Osmoglyn) are administered systemically to the cli-
ent with closed-angle glaucoma in an emergency as an effort
to decrease IOP. The high osmolarity of these agents draws
Medical–Surgical fluid into the intravascular space, which lowers the IOP.
Management
Medical Nursing Management
Administer medications as ordered. Stress client compliance
Medical management for glaucoma is focused on drug ther- with prescribed medication therapy. Encourage glaucoma
apy, and the main objective is to reduce intraocular pressure. screening for all persons older than age 35, especially if there
Two mechanisms for reducing this pressure are (1) physically is a family history of glaucoma.
constricting the pupil so that the ciliary muscle is contracted,
which allows better circulation of the aqueous humor to the
site of absorption, and (2) inhibiting the production of aque-
ous humor.
NURSING PROCESS
Surgical Assessment
Surgical intervention to facilitate drainage of the aqueous Subjective Data
humor is called an iridectomy. A surgical incision is made Obtain a history, noting the presence of risk factors: posi-
through the cornea to remove a portion of the iris to facilitate tive family history (believed to be linked in open-angle
aqueous drainage. glaucoma), eye tumor, intraocular hemorrhage, intraocular
A laser also is used to treat various eye disorders. In open- inflammation, or contusion of the eye from trauma during
angle glaucoma, a laser is used to create multiple scars around cataract surgery.
the trabecular meshwork (a supporting or anchoring strand Symptoms of open-angle glaucoma include gradual loss
that allows increased outflow of aqueous humor), thereby of peripheral vision, eye pain, difficulty adjusting to darkness,
reducing intraocular pressure. In closed-angle glaucoma, laser halos around lights, and an inability to detect color. For closed-
energy is used to create a hole in the periphery of the iris, cre- angle glaucoma, symptoms include sudden onset of severe pain
ating an opening between the anterior and posterior chambers in the eye often accompanied by headache, nausea, vomiting,
for aqueous drainage. malaise, rainbow halos around lights, and blurred vision.

Pharmacological Objective Data

Drugs that enhance pupillary constriction are commonly used Assessment reveals acute increased intraocular pressure (21
to treat glaucoma. Miotics and cholinesterase inhibitors such to 32 mm Hg) as measured with a tonometer (normal range
as pilocarpine hydrochloride (Isopto Carpine), carbachol is 12 to 22 mm Hg).

A nursing diagnosis for a client with glaucoma is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will verbalize relief Administer prescribed ophthalmic agent for glaucoma.
closed-angle glaucoma from discomfort. Notify physician of the following: hypotension, urinary output
less than 240 mL for 8 hours, no relief in eye pain within
30 minutes of drug therapy, and continual diminishing visual
acuity.
Monitor blood pressure, pulse, and respiration every 4 hours if
not receiving osmotic agent intravenously and every 2 hours if
receiving intravenous osmotic agent.

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 CHAPTER 11 Sensory System 377

A nursing diagnosis for a client with glaucoma is: (Continued)

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Monitor degree of eye pain every 30 minutes.
Monitor intake and output every 8 hours while receiving intra-
venous osmotic agent.
Monitor visual acuity before each instillation of prescribed
ophthalmic agent by asking if objects are clear or blurred and
if the client can read printed material held at arm’s length.
Remind the client that miotics may cause blurred vision for 1
to 2 hours after use and that adaptation to dark environments
is difficult because of the pupillary constriction.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Pneumatic retinopexy is used for an uncomplicated

■ RETINAL DETACHMENT detachment. A small amount of fluid is withdrawn from the

I
anterior chamber and an expandable gas is injected into the
n retinal detachment, the retina separates from the chor- posterior chamber. The gas pushes against the retinal tear
oid (Figure 11-7). Partial separation becomes complete, if and seals it off. The fluid under the retinal tear is absorbed
untreated, with the subsequent total loss of vision. A tear or hole and the gas is released from the eye over several weeks (Mayo
in the retina can extend the separation as vitreous humor seeps Clinic, 2008).
through the opening and separates the retina from the choroid. Sometimes when the surgeon cannot see the retinal tear
The cause of retinal detachment is from severe trauma to the eye because of vitreous cloudiness or retinal scarring that prevents
or from intraocular disorders such as cataract extraction, perfo- a pneumatic retinopexy or scleral buckling, sections of the
rating injuries, or severe myopia (nearsightedness). This condi- vitreous are removed (vitrectomy). Delicate instruments are
tion is painless because there are no pain receptors in the retina. inserted into the eye through incisions in the sclera. The surgeon
removes scar tissue from the vitreous and infuses a salt solution
Medical–Surgical Management into the eye to maintain the normal pressure and shape. A scleral
buckling may be performed after the vitrectomy, and the pos-
Medical terior chamber is filled with air, gas, or silicone oil to hold the
Early corrective intervention to reattach the retina uses one retina against the inside of the eye (Mayo Clinic, 2008).
of several techniques. Two procedures are used to create an
inflammatory reaction that, once healing and scarring occur, Pharmacological
results in the retina reattaching to the choroid. Freezing (cryo- Cycloplegic-mydriatic and antiinfective eyedrops are often
plexy) is an intensely cold probe applied to the scleral surface ordered following the attachment procedure.
directly over the hole in the retina. Laser photocoagulation
also seals tears or holes in the retina.
Activity
Surgical Bed rest and a patch on one or both eyes restricts activity. If air
A surgical procedure called scleral buckling is sometimes used. is injected into the vitreous humor, the client either lies prone
This operation reduces the scleral surface and allows contact or sits forward with the unaffected eye upward.
between the choroid and retina.

Torn retina Sclera Nursing Management

Choroid Explain surgery routines. Preoperative: Level of activity—
ocular rest, which includes bilateral eye patching and bed
rest to facilitate settling of the retina and prevent detach-
ment from worsening. The affected eye is maximally dilated
COURTESY OF DELMAR CENGAGE LEARNING

before surgery to permit adequate visualization of the

fundus. Intraoperative: Client must lie still during surgery
or give surgeon warning if needs to cough or change posi-
tion. Face covered with drapes. Air and oxygen provided.
Monitoring, including frequent blood pressure measure-
ments. Postoperative: Positioning (supine with a small pillow
under the head), bilateral eye patches, activity restrictions,
and need to call for assistance with ambulation until stable
Figure 11-7 Retinal Detachment and vision is adequate.

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378 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

vitreous cavity), blurred vision that becomes progressively

NURSING PROCESS worse, or complaints of a sensation of a veil in the line of
Assessment sight.

Subjective Data
Obtain a medical history for presence of causative factors: Objective Data
trauma, recent cataract surgery, eye tumor, severe myopia, Ophthalmoscopic examination visualizes the detachment.
uveitis. The client may describe sudden flashes of light An ultrasound is ordered if blood restricts ophthalmoscopic
(photopsia), floating spots (caused by bleeding into the vision of the retina.

Nursing diagnoses for a client with retinal detachment include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to sensory The client will demonstrate Assess degree and duration of visual impairment.
visual impairment and lack reduction of emotional Encourage conversation to determine client’s concerns,
of understanding about stress, fear, and depres- feelings, and level of understanding. Answer questions, offer
treatment sion; and an acceptance of support, and assist client to devise methods for coping.
surgery
Orient client to new surroundings. Explain interventions clearly.
Announce yourself with each interaction; interpret unfamiliar
sounds; use touch to assist with verbal communication.
Encourage to carry out ADLs as ability allows.
Order finger foods for those who cannot see well enough or
do not have the coping skills to use implements.
Encourage participation of family or significant others in client
care. Encourage participation in social and diversional activities
as allowed (visitor, radio, audio tapes, television, crafts, games).

Risk for Injury related The client will not have injury Assist client when able to ambulate postoperatively until
to visual impairment or caused by visual impairment. stable and has adequate vision or coping skills (remember
knowledge deficit that clients with bilateral eye patches are unable to see).
Assist client in arranging environment and do not rearrange
furnishings without reorienting client.
Discuss importance of wearing metal shield or glasses as
ordered.
Apply no pressure to the affected eye. Use proper procedure
to administer eye medications.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ INFECTIONS Stye

I
A stye is also referred to as a hordeolum. It is a pustular
nfections of the eye include keratitis, stye, chalazion, and inflammation of an eyelash follicle or sebaceous gland on the
conjunctivitis. lid margin commonly caused by staphylococcal organisms.
Symptoms include pain, redness, and swelling of a specific
Keratitis area of the eyelid. Treatment consists of warm compresses and
topical antibiotic ointments. More severe cases may require
Keratitis is inflammation of the cornea that may be caused by incision and drainage. Once the pus drains, the pain is relieved
infection, irritation, injury, or allergies. Symptoms associated and healing begins.
with keratitis include severe eye pain, red watering eye, photo-
phobia, sometimes reduced vision, and sometimes rash (e.g.,
herpes simplex, herpes zoster, or rosacea). Chalazion
Treatment of keratitis includes optical anesthetics to A chalazion is a cyst of the meibomian glands, which are
relieve pain and mydriatics to dilate the pupil. Dark glasses sebaceous glands located at the junction of the conjunctiva
should be worn to relieve the photophobia. Antibiotic solu- and inner eyelid margins (Figure 11-8A). The hard cyst is
tions are prescribed for the specific type of infection. filled with fatty material from the chronically obstructed

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 CHAPTER 11 Sensory System 379

With hyperopia, parallel light rays come to focus behind

the retina because the refractive system is too weak or the
eyeball is flattened. Vision beyond 20 feet is normal, but near
vision is poor. Figure 11-10 illustrates where light rays focus
for myopia and hyperopia.
Astigmatism is a visual defect caused by unequal curvatures
of the refractive surfaces of the eye. Light rays from a point do
not come to focus on the retina, resulting in visual distortion.
Presbyopia is the loss of elasticity of the lens of the eye
A caused by aging that causes the near point of vision to recede.

COURTESY OF DELMAR CENGAGE LEARNING

B

Figure 11-8 A, Chalazion; B, Bacterial Conjunctivitis

meibomian glands. The inherent feature of a chalazion is pain-

less localized swelling that develops over a period of weeks.
Treatment usually involves surgical excision if the cyst is large,
becomes infected, or interferes with vision or closure of the
eyelids. The cyst remains when the inflammation subsides.
Figure 11-9 Strabismus (Courtesy of the Armed Forces
Conjunctivitis (Pink Eye) Institute of Pathology)

Conjunctivitis is an inflammation of the conjunctiva (a

membrane that lines the inside of the eyelids and covers the
cornea) that results from invasion by bacterial, viral, or rickett-
sial organisms, allergens, or irritants (Figure 11-8B). Symptoms A
include burning and itching of eyes, discharge, swelling, pain,
and redness. Treatment consists of applying warm compresses
using saline or boric acid solution and instilling antibiotic
or antiviral ointments. When caused by allergens, treatment Normal eye
includes avoiding the allergen, taking antihistamines, or being Light rays focus on the retina
desensitized.
Conjunctivitis is contagious. Proper hand hygiene is
essential for the nurse and client. Gloves are worn when apply-
ing compresses or instilling ointment. The client’s linen is
disinfected to prevent spread of the infection.
B

■ REFRACTIVE ERRORS

R efraction is the deflection or bending of light rays when

they pass from a medium of one density to a medium
of another density. In the case of the eye, light waves pass
Myopia (nearsightedness)
Light rays focus in front
of the retina

through the air (less dense) into the fluids of the eye (more
dense) and are brought to focus on the retina.
Refractive errors result in changes in visual acuity or
COURTESY OF DELMAR CENGAGE LEARNING

vision that is not 20/20. Refractive errors include myopia

(nearsightedness), hyperopia (farsightedness), astigmatism C
(asymmetric focus of light rays on the retina), presbyopia
(inability of the lens to change curvature in order to focus on
near objects), and strabismus (inability of the eyes to focus
Hyperopia (farsightedness)
in the same direction) (Figure 11-9). Light rays focus beyond
With myopia, parallel light rays come to focus in front of the retina
the retina because the refractive system is too strong or the
eyeball is elongated. Near vision is normal, but distant vision Figure 11-10 Refraction; A, Normal Eye; B, Myopia;
is poor. C, Hyperopia

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380 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

The eye loses the ability to accommodate to near objects but

remains accommodated for far objects.
Nursing Management
Strabismus occurs when one eye is constantly deviated Reassure client that refraction testing is painless and that
to the side. dilating eyedrops are instilled. Advise client that it takes time
to adjust to new glasses and not to wear old glasses after get-
ting new ones.
Medical–Surgical Management
Medical NURSING PROCESS
Assessment
Refractory errors are corrected by prescription glasses or
contact lenses. The corrective lenses bend light rays to com-
pensate for a client’s refractive error. Subjective Data
Surgical Obtain a general medical history as well as a history of symptoms.
Symptoms include blurred vision, headache, or eye fatigue.
Radial keratotomy is a surgical procedure used to correct myo-
pia and astigmatism. Under local anesthesia, incisions that
resemble the spokes of a wheel are made in the cornea. After Objective Data
the cuts are made, pressure in the anterior chamber of the eye The client is asked to view an eye chart while lenses of different
reshapes the cornea to a normal or near-normal curvature. strengths are systematically placed in front of the eye. The cli-
Both LASIK (laser-assisted in-situ keratomileusis) and PRK ent is asked if the lenses sharpen or blur vision. The power or
(photo-refractive keratectomy) use laser to correct nearsight- strength of the lens necessary to permit focusing of the image
edness and astigmatism. on the retina is expressed in measurements called diopters.

A nursing diagnosis for a client with refractive errors is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to impaired The client will accept wearing Allow client to discuss impact of wearing glasses or contact
vision and having to wear glasses or contact lenses. lenses.
glasses or contact lenses Encourage client to wear the glasses or contact lenses as
prescribed.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ INJURY SAFETY
I njury to the eye or periorbital area results from a variety of
things, such as chemical sprays, tree branches, slingshots, BB
guns, flying debris from lawn mowers, and fireworks. Both chil-
Avoiding Eye Injury
The eyes are easily protected from injury by wear-
dren and adults are susceptible to eye injuries, and the importance ing protective goggles when performing tasks that
of protecting the eyes cannot be overemphasized. Injuries to the are potentially hazardous to the eyes. Those who
eyes require immediate attention by an ophthalmologist. Even a wear contact lenses should follow the manufac-
few hours’ delay in treatment may lead to permanent damage. turer’s recommendations for wearing them dur-
Corneal abrasion is the disruption of cells and the loss ing certain activities, such as swimming or when
of the superficial epithelium. The outer surface is easily sepa- sleeping.
rated from the underlying layers and is injured or destroyed by
exposure (lack of moisture), chemical irritants that dissolve in
the protective tear film, and abrasion from foreign bodies.

Foreign Bodies Chemical Burns

Foreign bodies in the conjunctiva or on the cornea cause exces- Emergency treatment of chemical burns to the conjunctiva
sive tearing and redness. The safest way to remove a foreign or cornea includes immediate lavage of the eye with tap water
object from the conjunctiva or cornea is to flush sterile saline and referral to an emergency room or ophthalmologist. In
starting from the sclera across the cornea (Primary Care Oph- the emergency room, a specially made lid speculum is placed
thalmology, 2004). Foreign bodies often become embedded in directly on the eyeball and connected to a minimum of 1 liter
the conjunctiva under the upper eyelid. The lid must be everted of isotonic saline solution for irrigation. A topical anesthetic
and the client instructed to look up to facilitate inspection and may be instilled to minimize pain during irrigation. No
removal. If the particle is not located and removed, sterile fluo- attempt is made to neutralize the chemical because the heat
rescein drops or strips are instilled to visualize minute foreign generated by the chemical reaction may cause further injury.
bodies that are not readily visible with the naked eye. Both eyes are then patched to allow more comfort.

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 CHAPTER 11 Sensory System 381

CRITICAL THINKING
■ IMPAIRED VISION

T
Visual Impairment
he term blindness evokes an image of total darkness and
is used for many legal purposes when central visual acu- What modifications have to be made in the life of a
ity is 20/200 or less with corrective lenses, in the better eye. person who can no longer see?
Those who have visual acuity between 20/70 and 20/200 in
the better eye, with the use of glasses, are often referred to as
partially sighted.
The aids that follow are designed to make the most of the vision. The loss of central vision interferes with the client’s
available vision (those in italics can also be used by persons ability to read, write, recognize safety hazards, and drive.
who are blind): magnifying glasses; hand and stand magnifiers; Management of clients with exudative macular degen-
telescopes; large-print books, newspapers, magazines; talking eration is geared toward halting the initiating process and
books; Braille books; closed-circuit television, which produces identifying further changes in visual perception. Fluid and
highly magnified images; tactually marked watches and clocks; blood may resorb in a small percentage of clients with exu-
tactually modified tabletop games; enlarged telephone dials, dative degeneration. Laser therapy to seal the leaking blood
kitchen implements, tools, medication devices; talking clocks, vessels in or near the macula may also limit the extent of the
timers, scales, calculators, computers; text scanner, which con- damage.
verts text to audio mode or Braille; speech synthesizer; flashlight
eye sonar devices; canes, laser canes, and seeing eye dogs. Nursing Management
Provide a safe environment. Announce your presence when
entering the client’s room and let the client know when you
■ MACULAR DEGENERATION are leaving. Make sure all personnel know of the client’s

M
decreased vision. Respond to the client’s call light quickly.
acular degeneration is atrophy or deterioration of the
macula, the point on the retina where light rays meet as
they are focused by the cornea and lens of the eye. The person NURSING PROCESS
loses central vision but still has peripheral vision.
The most common form of macular degeneration is asso- Assessment
ciated with the aging process and is called age-related macular
degeneration. Other forms of this disorder include exudative Subjective Data
(wet) macular degeneration (sudden growth of new blood Obtain a general medical history and a history of symptoms.
vessels in the area of the macula) and injury, infection, or Symptoms include blurred vision, disturbance in color vision
inflammation that damages the macula. (colors become dim), difficulty in reading or doing close
work, distortion of objects (especially those with lines), and
Medical–Surgical Management an empty area within the central field of vision.

Medical Objective Data

The treatment of age-related macular degeneration is geared Note coping mechanisms such as turning the head to use
toward assisting the client to maximize the use of the remaining peripheral vision.

A nursing diagnosis for the client with macular degeneration is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Sensory Percep- The client will discuss the im- Allow client to express feelings about vision loss such as its
tion (Visual) related to pact of vision loss on lifestyle impact on lifestyle. Convey a willingness to listen, but do not
macular degeneration and use adaptive measures. pressure client to talk.
Provide a safe environment by removing excess furniture or
equipment from client’s surroundings.
Orient client to surroundings and show how to use call light.
Provide reality orientation if client is confused or disoriented.
Always introduce yourself or announce your presence upon
entering the client’s room; let client know when you are leaving.
Provide sensory stimulation by using tactile, auditory, and
gustatory stimuli to help compensate for vision loss.
Suggest large-print books, talking books, audiotapes, or
radio as preferred by client.
Give clear, concise explanations of treatments and proce-
dures but avoid information overload.
(Continues)
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382 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

A nursing diagnosis for the client with macular degeneration is: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Make sure that health care personnel are aware of client’s vision
loss. Record information on the client’s chart or post in room.
Respond to call light quickly.
Provide continuity by assigning same staff members to care
for client when possible.
Refer to appropriate community resources.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Macular Degeneration
J.R. is a 60-year-old high school Latin teacher. He describes having blurred vision in both eyes with a
gradual loss of vision in only the right eye. He has trouble reading and is afraid to drive because he can
no longer recognize safety hazards. He denies having pain. He also relates having fallen several times
recently at home while going up and down the stairs. The family practitioner referred him to an ophthal-
mologist, who diagnosed J.R. as having macular degeneration in the right eye.
NURSING DIAGNOSIS 1 Disturbed Sensory Perception (Visual) related to macular degeneration as
evidenced by his inability to recognize safety hazards when driving
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Vision Compensation Behavior Environmental Management
Communication Enhancement: Visual Deficit

PLANNING/OUTCOMES INTERVENTION RATIONALE

J.R. will discuss impact of vision Encourage J.R. to express feelings Aids in the acceptance of vision loss.
loss on lifestyle. about vision loss.
Convey a willingness to listen, Determines J.R.’s awareness of his
and discuss J.R.’s current abil- limitations.
ity to meet self-care needs and
activities of daily living.
Educate J.R. in alternative ways Client will be better able to cope
of coping with vision loss; care with vision loss.
of such adaptive devices as eye-
glasses, magnifying glass, and
contact lenses.
Refer to appropriate community Helps J.R. and his family cope
resources. better with his vision loss.

EVALUATION
J.R. discussed the effects of vision loss on his lifestyle and contacted a local agency that provides assistance
to the visually impaired.
NURSING DIAGNOSIS 2 Risk for Injury related to difficulty in processing visual images and altered
depth perception as evidenced by recent falls
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Risk Control: Visual Impairment Teaching: Disease Process
Fall Prevention

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 CHAPTER 11 Sensory System 383

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
J.R. will not experience injury or Advise J.R. that depth perception Information promotes under-
visual compromise resulting from is changed with macular degen- standing.
a fall. eration.
Teach J.R. to avoid reaching for Objects may not be where they
objects for stability when ambu- are perceived. Excessive reaching
lating. alters the center of gravity which
can precipitate a fall.
Advise J.R. to go up and down Enhances the sense of balance.
steps one at a time.

EVALUATION
J.R. has not fallen in 2 weeks.

NURSING DIAGNOSIS

Impaired Home Maintenance related to limited vision, as evidenced by recent falls at home.

NOC: Family Functioning

NIC: Home Maintenance Assistance, Environmental Management: Safety

CLIENT GOAL
J.R. will develop a plan for self-care in the desired living environment.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Inform J.R. about required self-care 1. Knowing what self-care activities are
activities: personal care, eyedrop needed helps J.R. plan for his care at home.
instillation, activities permitted,
activity restrictions, medications,
and how to monitor for complications.

2. Assist J.R. to determine which activities 2. Helps J.R. to plan for his care at home.
will require assistance.

3. Evaluate sources of assistance: 3. Determines availability of assistance.

friends/family, home health care
(skilled nursing care), or home-care aids.

4. Critique the safety of J.R.’s home: 4. Changes are made to make J. R.’s home
location of telephone, emergency plan, safer.
presence of loose rugs or carpets.

EVALUATION
Has J.R. developed a plan to care for himself at home?

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384 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Pills Circumvallate
OTHER SENSES papillae

O ther senses include taste, smell, and touch. Bitter

■ TASTE

T he sense of taste (gustation) serves as a protector from

rotten or putrid food and provides delightful sensations
of creamy chocolate, crunchy carrots, chewy taffy, and fruitful
pies. Taste sensors are most efficient at room temperature and

COURTESY OF DELMAR CENGAGE LEARNING

respond only to substances in solution. The taste buds are Sour
located in four areas of the tongue that sense sweet, salt, bitter,
and sour (as shown in Figure 11-11).
Taste sensations are altered secondary to neurological
disorders or trauma. Assess clients who complain of food not Salt Sweet
“tasting good” for possible causes, including dietary habits,
medication use, smoking and caffeine use, as well as olfactory
disturbances. The sense of taste works very closely with the
sense of smell for identification of the taste sensations. Figure 11-11 Taste Regions of the Tongue

■ SMELL pressure, vibration, cold, heat, and pain are examples. Clients

T
who are unable to sense temperature variations are taught
he sense of smell (olfaction) also serves as a guardian cautionary measures when applying heat or cold therapies,
from danger. An individual’s nose warns of impending preparing bath water, cooking, or exposing self to hot or cold
danger from gas leaks, smoke, fires, rancid meat or fish, and climates and environmental temperatures.
sour dairy products. Body odors and halitosis are clues for Clients with reduced or loss of tactile sensation risk injury
personal hygiene and dental care. when their condition confines them to bed. They are unable
Disorders of the olfactory sense often go unnoticed. Tests to sense pressure on bony prominences or the need to change
such as the University of Pennsylvania Smell Identification Test position. The nurse’s role in reducing or preventing impair-
(UPSIT) allow self-testing of smelling deficiencies. Early identi- ment of skin integrity is crucial. Timely positioning, securing
fication of the loss of the sense of smell offers clues to alterations tubes or devices away from the client’s body, and using prod-
in dietary habits, weight loss or gain, anorexia, malnourishment, ucts to minimize skin breakdown are a few of the interventions
and changes in daily habits, such as bathing and brushing teeth. vital to excellent client care.
The receptors for the sense of smell are located in the roof of
the nasal cavity. If these cells are damaged, the sense of smell is
impaired. The body cannot regenerate the olfactory cells.
LIFE SPAN CONSIDERATIONS
■ TOUCH Aging and Taste Sensation

T he sense of touch (tactile) includes sensations pertaining

to the skin. The tactile receptors are located throughout
the integumentary system. Cutaneous sensations of touch,
The ability to taste sweetness remains as one ages,
but the ability to taste bitterness declines.

CASE STUDY
K.R. is a 34-year-old nurse who was diagnosed with a right ear hearing impairment during a routine physical
examination. She admitted to her doctor that she noticed she would only use her left ear to talk on the phone
and that she had particular difficulty hearing her family or friends in a crowded restaurant or other public set-
tings. She also noted that her husband asked her why she played the television so loud, yet if he turned it down
to his normal hearing level, she could not hear it clearly. Her physician ordered an audiogram, which showed a
conductive hearing loss of 40% secondary to otosclerosis. Hearing in her left ear was normal.
K.R.’s doctor gave her three medical treatment options:
1. Do nothing and monitor her hearing impairment by audiogram every 6 months. If it were to worsen, other
options would be considered.
2. Be fitted with a hearing aid.
3. Have a surgical procedure to correct the hearing loss.

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 CHAPTER 11 Sensory System 385

CASE STUDY (Continued)

K.R. agreed to have surgery. She thought she would be too self-conscious to wear a hearing aid, after all she was
only 34, but she simply could not ignore the problem by doing nothing. K.R. was scheduled for same-day surgery.
The following questions will guide your development of a nursing care plan for the case study.
1. How is a conductive hearing loss differentiated from a sensorineural hearing loss?
2. What does an audiogram reveal? What special things should K.R. know before she has the audiogram?
3. Describe the surgical procedure that will most likely be used to correct the conductive hearing loss.
4. What will the nurse teach K.R. before her surgery about the procedure and expected postoperative course?
5. List four individualized nursing diagnoses and expected outcomes for K.R., and nursing interventions for each
diagnosis.
6. Describe the expected discharge instructions that K.R. must know related to diet, medications, activity restric-
tions, and follow-up care.

SUMMARY
• Hearing loss is conductive, sensorineural, or a combination • Cataract surgery is indicated when significant vision loss
of the two. It may also be congenital. has occurred.
• Ménière’s disease is a result of excessive accumulation of • Untreated retinal detachment results in total loss of vision.
endolymph, causing severe vertigo, dizziness, and hearing • Many resources are available for the hearing impaired
loss. Treatment is primarily symptomatic. through community and national agencies.
• Otosclerosis is a conductive hearing loss that is treated • The senses of taste, smell, and touch are essential to our
medically with the use of a hearing aid or surgically with a enjoyment of life and serve to protect us from danger or
stapedectomy. harm.
• Otitis media is inflammation of the middle ear. Treatment
usually includes antibiotics, decongestants, and possibly a
myringotomy.

REVIEW QUESTIONS
1. In a conductive hearing loss: 4. A clinical symptom of a detached retina is:
1. the endolymph may cross the capillary membrane 1. an increase in tearing.
and mix with the perilymph, resulting in severe 2. an area of vague vision.
vertigo. 3. momentary flashes of light.
2. the ossicles of the middle ear fracture, resulting in 4. pain in the eye.
a tear of the eighth cranial nerve. 5. Macular degeneration is characterized by:
3. sound waves are not transmitted through the ear 1. purulent periorbital drainage.
canal to inner ear fluid. 2. pupil dilation.
4. a tumor in the inner ear blocks the flow of fluid 3. loss of central vision.
through the bony and membranous labyrinths. 4. ptosis (droopy lid).
2. A possible nursing diagnosis for a client with 6. A client presents to the emergency room with
Ménière’s disease is: symptoms of seeing several floaters with flashes of
1. activity intolerance related to impaired hearing. light in the affected eye and having blurred vision.
2. knowledge deficit related to surgical shunt The nurse recognizes these as symptoms of:
placement to drain excessive endolymph. 1. macular degeneration, and it is not an emergency.
3. communication, impaired, verbal, related to 2. glaucoma, and it is not an emergency.
tinnitus. 3. a cataract, and it is not an emergency.
4. risk for injury related to vertigo. 4. a retinal detachment, and it is an emergency.
3. Chemical burns of the eye are initially treated with: 7. A teenager arrives at the clinic with an inflamed
1. local anesthetics and antibacterial drops for 24 to conjunctiva of the right eye that burns and itches,
36 hours. is swollen and reddened, and has a discharge. The
2. hot compresses applied at 15-minute intervals. nursing interventions include: (Select all that apply.)
3. flushing of the lids, conjunctiva, and cornea with 1. washing his hands after examining the client’s eye.
water. 2. teaching the client to wash her hands frequently
4. cleansing of the conjunctiva with a small, cotton- and especially after touching her eye.
tipped applicator. 3. teaching the client that conjunctivitis is contagious.

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386 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

4. instilling an antibiotic in the eye without wearing 9. The nurse completed teaching postoperative
gloves because he is going to wash his hands after stapedectomy care to a client. The nurse knows the
the instillation. client needs some reteaching when he states:
5. teaching the client to wash linens to prevent 1. “I will turn and move slowly.”
spreading the conjunctivitis to others. 2. “I will sneeze with my mouth closed.”
6. teaching the client to apply ice to the affected eye. 3. “I will report any greenish, yellowish, or foul-
8. Nursing interventions for a client with glaucoma smelling drainage.”
include: (Select all that apply.) 4. “I will keep water out of my ear and keep it
1. applying warm compresses and topical antibiotic exposed to air as much as possible.”
ointment. 10. Which of the following is an appropriate nursing
2. administering prescribed ophthalmic agent. diagnosis for a gradual hearing impaired client who
3. teaching the client to avoid reaching for objects is 80- years-old?
to maintain stability when ambulating, as depth 1. Activity Intolerance related to severe vertigo.
perception is altered. 2. Deficit Knowledge related to abrupt onset and
4. monitoring blood pressure, pulse, and respiration unknown progression of the disease.
every 4 hours if not receiving osmotic agent 3. Social Isolation related to hearing impairment.
intravenously. 4. Acute Pain related to inflammation in the middle ear.
5. reminding the client that miotics may cause
blurred vision for 1 to 2 hours after use.
6. immediately lavaging the eye with saline solution.

REFERENCES/SUGGESTED READINGS
Agrawal, Y., Platz, E., & Niparko, J. (2008). Prevalence of hearing loss Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
and differences by demographic characteristics among US adults: Outcomes Classification (NOC) (4th ed). St. Louis, MO: Elsevier -
Data from the national health and nutrition examination survey, Health Sciences Division.
1999−2004. Archives of Internal Medicine, 168(14), pp. 1522−1530. National Institute on Deafness and Other Communication Disorders.
American Speech-Language-Hearing Association. (2002). Types of (2002). Cochlear implants. Retrieved October 4, 2004 from www.
hearing loss. Retrieved December 27, 2004 from www.asha.org/ nidcd.nih.gov/health/pubs_hb/coch.htm
hearing/disorders/types/cfm North American Nursing Diagnosis Association International. (2010).
Barnie, D. (2002). Restoring vision in older patients. RN, 65(1), 30–35. NANDA-I nursing diagnoses: Definitions and classification 2009–2011.
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. Ames, IA: Wiley-Blackwell.
(2008). Nursing Interventions Classification (NIC) (5th ed.). St. Primary Care Ophthalmology. (2004). Foreign body removal.
Louis, MO: Mosby/Elsevier. Retrieved August 3, 2009 from http://www.med.uottawa.ca/
Crosta, P. (2008). Hearing loss affects millions of US adults. procedures/slamp/body_removal.htm
Medical News Today. Retrieved August 3, 2008 from http:www/ Ralph, S. & Taylor, C. (2007). Sparks and Taylor’s nursing diagnosis reference
medicalnewstoday.com/printerfriendlynews.php?newsid=116360 manual (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Cavendish, R. (1998). Clinical snapshot: Hearing loss. AJN, 98(8), Ramponi, D. (2000). Go with the flow during an eye emergency.
50–51. Nursing2000, 30(8), 54–56.
Dana, R. (1998, January 27). Dry eye syndrome. Health News 1, 3. Ramponi, D. (2001). Contact lens removal. Nursing2001, 31(8), 56–57.
Daniels, R. (2009). Delmar’s guide to laboratory and diagnostic tests Ruben, R. (2007). Hearing loss and deafness. Retrieved August 3, 2009
(2nd ed). Clifton Park, NY: Delmar Cengage Learning. from http://www.merck.com/mmhe/sec19/ch218/ch218a.html
Estes, M. (2010). Health assessment & physical examination (4th ed.). Shelp, S. (1997). Your patient is deaf, now what? RN, 60(2), 37–40.
Clifton Park, NY: Delmar Cengage Learning. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner
Kearney, K. (1997). Retinal detachment. AJN, 97(8), 50. and Suddarth’s textbook of medical surgical nursing (11th ed.).
Lucas, L., & Matthews-Flint, L. (2001). Sound advice about hearing Philadelphia: Lippincott Williams & Wilkins.
aids. Nursing2001, 31(2), 59–61. Sommer, S., & Sommer, N. (2002). When your patient is hearing
McConnell, E. (2001a). Instilling ear drops. Nursing2001, 31(4), 17. impaired. RN, 65(12), 28–32.
McConnell, E. (2001b). Myths & Facts . . . about macular degeneration. Spencer, J. (1998, February 17). Coping with hearing loss. Health News
Nursing2001, 31(8), 30. 2, 1–2.
McConnell, E. (2002). How to converse with a hearing-impaired Spratto, G., & Woods, A. (2008). 2009 Delmar’s (nurses drug handbook).
patient. Nursing2002, 32(8), 20. Clifton Park, NY: Delmar Cengage Learning.
Mayo Clinic. (2008). Retinal detachment. Retrieved August 3, 2009 Tupper, S. (1999). When the inner ear is out of balance. RN, 62(11),
from http://mayoclinic.com/health/retinal-detachment/DS00254/ 36–40.
METHOD=print&DSECTION=all Walbecker, J. (1997). Knowing the signs. RN, 60(2), 40–41.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 11 Sensory System 387

RESOURCES
Alexander Graham Bell Association for the Deaf, Hearing Loss Association of America,
http://www.agbell.org http://www.hearingloss.org/
American Academy of Ophthalmology Head and Neck International Hearing Dog Inc.,
Surgery, http://www.aao.org http://www.hearinglossweb.com
American Academy of Otolaryngology, Leader Dogs for the Blind, http://www.leaderdog.org/
http://www.entnet.org Lion’s Club International, http://www.lionsclubs.org
American Council of the Blind, http://acb.org Prevent Blindness America,
American Foundation for the Blind, Inc., http://www.preventblindness.org
http://www.afb.org National Association for the Deaf, http://www.nad.org
American Speech-Language-Hearing Association, National Association for Visually Handicapped,
http://www.asha.org http://www.navh.org
American Tinnitus Association, Recording for the Blind & Dyslexic, Inc.,
http://www.ata.org http://www.rfbd.org
Better Hearing Institute, http://www.betterhearing.org/ Self Help for the Hard of Hearing, http://www.shhh.org
Guide Dogs for the Blind, http://www.guidedogs.com The Vision Council/The Better Vision Institute,
Guide Dog Users, Inc., http://www.gdui.org http://www.thevisioncouncil.org/bvi/
Guiding Eyes for the Blind, University of Ottawa – Canada’s University,
http://www.guidingeyes.org http://www.med.uottawa.ca

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 CHAPTER 12
Endocrine System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the endocrine system:
Adult Health Nursing • Neurological System
• Oncology • Sensory System
• Cardiovascular System • Reproductive System
• Hematologic and Lymphatic Systems • Integumentary System
• Urinary System • Immune System
• Musculoskeletal System • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Identify and locate the endocrine glands and list function(s) and hormone(s)
secreted by each.
• Differentiate between type 1 and type 2 diabetes in terms of pathophysiology,
presenting symptoms and treatment.
• Discuss the roles of diet and exercise in the management of diabetes
mellitus.
• Identify signs, causes, and treatment of acute complications of
hypoglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic
nonketotic syndrome.
• Discuss the major long-term complications of diabetes.
• Discuss rationale for the pituitary gland being traditionally called the
“master” gland.
• Compare symptoms of the disease process resulting from a hyper- or
hyposecretion of an endocrine gland.
• Discuss assessment techniques for a client suspected of having an
endocrine disorder.
• Formulate a nursing care plan for the client with an endocrine disorder.

388

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 CHAPTER 12 Endocrine System 389

KEY TERMS
agranulocytosis gynecomastia myxedema
autosomal hirsutism paroxysmal
Chvostek’s sign hormone polydipsia
cretinism hyperglycemia polyphagia
dawn phenomenon hypoglycemia polyuria
endocrine hypovolemia Somogyi phenomenon
exophthalmos iatrogenic tetany
glucagon insulin Trousseau’s sign
glycosuria ketonuria
goiter lipodystrophy

The pancreas lies horizontally behind the stomach at the

INTRODUCTION level of the first and second lumbar vertebrae. The head of the
The endocrine system provides the same general functions as pancreas is attached to the duodenum with the tail reaching to
the nervous system: communication and control; however, the spleen. It has both exocrine and endocrine functions.
the endocrine system is generally slower and has longer- The pituitary gland consists of an anterior and a poste-
lasting control over the various body activities and functions. rior lobe. It has traditionally been called the “master” gland
It exerts this control through the secretion of hormones that because so many of its secretions influence other endocrine
circulate through the blood. A malfunction of any part of the glands and body systems. It is attached to the hypothalamus
endocrine system can result in a shift of homeostasis with far- by a stalk called the infundibulum. The hypothalamus is located
reaching systemic reactions. in the lower portion of the brain and produces secretions
Assessment of the endocrine system is difficult. Not only influencing the production and release of the anterior pitu-
are the components not in direct contact, but only the thyroid itary hormones as well as the posterior pituitary hormones.
gland is close enough to the body surface for direct physical Both the pituitary and hypothalamus are located in the head.
assessment. Still, the nurse needs to be familiar with the normal The pituitary, about the size of a pea, is located in the sella
functioning of the endocrine system. In assessing the client for turcica, a small depression in the sphenoid bone. Refer to
endocrine dysfunction, the nurse must note negative findings Table 12-1 for specific endocrine hormones and functions.
as well as positive ones. Assessment includes results of diagnos- The thyroid gland is butterfly-shaped and lies in the neck.
tic tests as well as any precipitating or aggravating factors. It consists of two lobes—one on each side of the trachea
connected by an isthmus. The gland sits saddle-like starting
on the anterior surface of the trachea just below the larynx and
ANATOMY AND PHYSIOLOGY surrounds it partway. The thyroid gland stores iodine. The
thyroid gland produces thyroid hormones including thyroxine,
REVIEW
The endocrine system is unique in that it is composed of a group
of various glands scattered throughout the body. The glands of Pituitary gland
Pineal gland
the body have either exocrine or endocrine functions. Exocrine
glands, including sweat glands and lacrimal glands, are respon-
sible for secreting substances directly into ducts that lead to the
target area. The term endocrine (endo—within, crin—secrete)
Hypothalamus
indicates that the secretions formed by these glands directly Thyroid
enter the blood or lymph circulation, rather than being trans-
ported via tubes or ducts. These secretions, called hormones, Parathyroids Thymus
are chemical substances that initiate or regulate activity of an-
other organ, system, or gland in another part of the body. The Adrenal gland
level of hormone in the blood is regulated by the homeostasis (suprarenal gland)
Pancreas
mechanism called negative feedback. If the blood level for a specific
COURTESY OF DELMAR CENGAGE LEARNING

(islets of Langerhans)
hormone falls below normal, negative feedback causes the spe-
cific endocrine gland to produce more of the hormone, which
when increased to the normal level causes a decrease in production.
The glands discussed in this chapter that make up the Testis (male)
2
Ovary (female)
2
endocrine system are the pancreas, pituitary, hypothalamus,
thyroid, parathyroid, and adrenals (Figure 12-1). Several endo-
crine glands such as the pineal, thymus, ovaries, and testes are of
great importance; however, they are discussed in other chapters
in connection with the organ system in which they function. Figure 12-1 Structures of the Endocrine System

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390 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

which is the most abundant, and triiodothyronine. It regulates The adrenal, or suprarenal, glands are located on top of
the metabolic rate for carbohydrates, protein, and fats. each kidney. The adrenal cortex secretes mineralocorticoids
There are usually four parathyroid glands. Two glands including aldosterone, glucocorticoids including cortisol, and
are embedded in the posterior portion of each thyroid lobe. androgens, which are sex hormones. The adrenal medulla
They produce parathyroid hormone, parathormone, which secretes epinephrine or adrenalin and norepinephrine or nor-
regulates the concentration of blood calcium and phosphorus. adrenalin, which help the body function under stress.

Table 12-1 Endocrine Glands and Hormones

HORMONE FUNCTION
Pancreas
Glucagon Released by alpha cells to increase the blood glucose level
Insulin Released by beta cells to decrease blood sugar
Somatostatin Inhibits secretion of insulin, glucagon, and growth hormone (GH) from the anterior pituitary
and gastrin from the stomach

Anterior Pituitary
Thyroid-stimulating Stimulates thyroid growth and secretion of the thyroid hormone
hormone (TSH)
Adrenocorticotropic Stimulates the growth and secretion of glucocorticoids from the adrenal cortex
hormone (ACTH)
Follicle-stimulating Stimulates ovarian follicle to mature and produce estrogen; in the male, stimulates sperm
hormone (FSH) production
Luteinizing hormone (LH) Acts with FSH to stimulate estrogen production; causes ovulation; stimulates progesterone
production by corpus luteum; in male, stimulates testes to produce testosterone
Melanocyte-stimulating Causes increase in synthesis and spread of melanin (pigment) in skin
hormone (MSH)
Growth hormone (GH) Stimulates growth by stimulating the epiphyseal plates of long bones and by increasing
protein production
Prolactin or lactogenic Stimulates breast development during pregnancy and milk secretion after delivery of baby
hormone

Posterior Pituitary
Antidiuretic hormone (ADH) Stimulates water retention by kidneys to decrease urine secretion
Oxytocin Stimulates uterine contractions; causes breast to release milk into ducts

Thyroid Gland
Thyroid hormone (thyroxine T4 Controls metabolic rate of all cells; aids in carbohydrate, fat, and protein metabolism
and triiodothyronine T3) Both released in response to TSH
Calcitonin When stimulated, decreases blood calcium (Ca) by promoting excretion of Ca and phosphorus
by the kidneys; also decreases bone resorption by maintaining adequate Ca levels

Parathyroid Gland
Parathyroid hormone When stimulated, increases blood calcium concentration by promoting resorption of Ca and
phosphorus from the bones; by increasing blood calcium levels, bone formation is decreased

Adrenal Cortex
Glucocorticoids (cortisol, Stimulates gluconeogenesis and increases blood glucose; antiinflammatory; antiimmunity;
hydrocortisone) antiallergy; aids in the metabolism of carbohydrates, fats, and proteins
Mineralocorticoids Regulates electrolyte and fluid homeostasis by increasing sodium and water reabsorption;
stimulates K excretion in the kidneys
Sex hormones (androgen) Stimulates sexual drive in females; in males, negligible effect

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 CHAPTER 12 Endocrine System 391

Table 12-1 Endocrine Glands and Hormones (Continued)

HORMONE FUNCTION

COURTESY OF DELMAR CENGAGE LEARNING

Adrenal Medulla
Epinephrine (adrenalin) Prolongs and intensifies sympathetic nervous response to stress, resulting in increased
heart rate, constriction of blood vessels, dilation of bronchioles, and hyperglycemia
Norepinephrine Prolongs and intensifies sympathetic nervous response to stress, resulting in increased
heart rate, constriction of blood vessels, dilation of bronchioles, and hyperglycemia

It is important to understand the normal function of the the 23.6 million people, almost 1 in 4 cases are undiagnosed
endocrine glands and hormones. Most endocrine disorders are (CDC, 2007). Diabetes mellitus (DM) is a disorder of metab-
a result of either overactivity or underactivity of these glands. olism. When we eat, most of the food we eat is broken down
by digestive juices. Of the food we eat, 100% of carbohydrate
and approximately 58% of protein and 10% of fat is broken
COMMON DIAGNOSTIC TESTS down to glucose. For the glucose to get into the cells, insulin
must be present (Figure 12-2).
Commonly used diagnostic tests for clients with symptoms of Insulin is a hormone produced and secreted by the beta
endocrine system disorders are listed in Table 12-2. cells of the islets of Langerhans in the pancreas. Insulin stimu-
lates the active transport of glucose into muscle and adipose
tissue cells, making it available for cell use. For glucose to cross
■ DIABETES MELLITUS the cell membrane, insulin must connect with a receptor on

N
the cell membrane. Some clients with diabetes mellitus have
early 23.6 million Americans or approximately 7.8% enough insulin but too few functioning receptor sites. Others
of the American population have diabetes mellitus. Of have inadequate or no insulin production. Blood glucose can

Table 12-2 Common Diagnostic Tests for Endocrine System Disorders

Pancreas Diagnostic Tests Thyroid Gland Diagnostic Tests
Blood glucose, Fasting blood sugar (FBS) Antithyroid microsomal antibody, Antimicrosomal
2-hour postprandial glucose (2hPPG) or 2-hour antibody, Microsomal antibody, Thyroid
postprandial blood sugar (2hPPBS) autoantibody, Thyroid antimicrosomal
antibody
Glucose tolerance test (GTT)
Calcitonin, HCT, Thyrocalcitonin
Pituitary Gland Diagnostic Tests Serum-free triiodothyronine (T3)
Adrenocorticotropic hormone (ACTH), Corticotropin Thyroid-stimulating hormone (TSH), Thyrotropin
Antidiuretic hormone (ADH), Vasopressin Thyroid-stimulating hormone (TSH) stimulation test
Follicle-stimulating hormone (FSH) Thyroxine index free, FTI, FT4 Index
Growth hormone (GH), Human GH (HGH), Somatotropin Thyroxine, T4, Thyroxine screen
hormone (SH)
Triiodothyronine, T3 radioimmunoassay, T3 by RIA
Growth hormone (GH) stimulation test, GH provocation
Radioactive iodine uptake (RAIU), Iodine uptake test,
test, Insulin tolerance test (ITT), Arginine test 131
I uptake
Luteinizing hormone (LH) assay
Thyroid scan, Thyroid scintiscan
Prolactin level (PRL)
Thyroid ultrasound, Thyroid echogram,
Thyrotropin-releasing hormone (TRH) test, Thyrotropin- Thyroid sonogram
releasing factor (TRF) test
Thyroid biopsy
Urine specific gravity
Long bone x-rays Parathyroid Gland Diagnostic Tests

Sella turcica x-ray Parathyroid hormone (PTH), Parathormone

Computed tomography of head (CT scan of head), Calcium, total/ionized Ca++

Computerized axial transverse tomography (CATT) Phosphorus

(Continues)
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392 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Table 12-2 Common Diagnostic Tests for Endocrine System

Disorders (Continued)
Adrenal Glands Diagnostic Tests 17-Hydroxycorticosteroids (17-OHCS)
Adrenocorticotropic hormone (ACTH) stimulation test, 17-Ketosteroids (17-KS)
Cortisol stimulation test, Cosyntropin test Urine cortisol, Hydrocortisone
Cortisol, Hydrocortisone Vanillylmandelic acid (VMA) and catecholamines,

COURTESY OF DELMAR CENGAGE LEARNING

Dexamethasone suppression test (DST), Prolonged/rapid VMA and epinephrine, Norepinephrine, Metanephrine,
DST, Cortisol suppression test, ACTH suppression test Normetanephrine, Dopamine
Plasma renin assay, Plasma renin activity (PRA) Adrenal angiography, Adrenal arteriogram
Progesterone assay Adrenal venography
Aldosterone assay Computed tomography of adrenals (CT scan of adrenals)

always be used by the brain and kidneys. Insulin is not needed • Promoting conversion of fatty acids into fat that can be
for glucose to enter brain cells or cells of the glomeruli. stored as adipose tissue and preventing breakdown of
The amount of glucose in the blood regulates the rate adipose tissue and conversion of fat to ketone bodies
of insulin secretion. When a meal is eaten, the blood glucose • Stimulating protein synthesis within tissues and inhibiting
elevates and the beta cells of the islets of Langerhans release the breakdown of protein into amino acids
insulin. As the blood glucose level drops, insulin secretion In summary, insulin actively promotes those processes that
diminishes. It is important to note that during times of fasting lower the blood glucose level and inhibits those processes that
(overnight or between meals), a low level of insulin continues raise the blood glucose level. A deficiency of insulin results in
to be secreted along with glucagon. Glucagon secreted by hyperglycemia, or elevated blood glucose. Excess insulin results
the alpha cells of the pancreas stimulates release of glucose by in hypoglycemia (low blood glucose). Diabetes mellitus is actu-
the liver. The balance and interactions of insulin and glucagon ally a group of disorders characterized by chronic hyperglycemia.
maintain a constant serum glucose level.
Other functions of insulin include:
• Promoting conversion of glucose to glycogen for storage in
the liver and inhibiting conversion of glycogen to glucose DIAGNOSIS AND CLASSIFICATION
The Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus (1997) presented to the American Diabetes
Association (ADA) new criteria for diagnosis and new clas-
sifications for diabetes, which the ADA approved.

Diagnosis
The Committee identified two precursors to diabetes, screen-
Pancreas ing criteria, and diagnostic criteria.
The two precursors identified are:
When we eat, food is broken Insulin 1. Impaired glucose tolerance (IGT)—a glucose level of
down into chemicals and 140 to 199 mg/dL 2 hours after a glucose load
glucose enters bloodstream. In response to elevated 2. Impaired fasting glucose (IFG)—a fasting glucose of
serum glucose, beta cells
of pancreas secrete insulin
110 to 125 mg/dL
into bloodstream. The criteria for who should be screened for diabetes include:
1. Anyone age 45 and older
2. Anyone, regardless of age, with one of the following risk
factors:
• Obesity (body mass index of 27 or greater)
• Immediate family member with diabetes
• Member of high-risk ethnic group (African
COURTESY OF DELMAR CENGAGE LEARNING

Cell
Insulin combines with American, Hispanic American, some Native
insulin receptors on cell wall American groups)
(activating glucose transporters), • Having a baby weighing more than 9 pounds
allowing glucose to enter cell.
= Glucose
• History of gestational diabetes mellitus (GDM)
= Insulin • Hypertension
= Insulin receptors • High-density lipoprotein level of 35 mg/dL or less,
or a triglyceride level of 250 mg/dL or more
Figure 12-2 How Insulin Works • Have either of the two precursors of diabetes
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 CHAPTER 12 Endocrine System 393

The diagnostic criteria identify when a physician can • Immune-mediated—the body’s immune system destroys
make a diagnosis of diabetes. The situations are: the beta cells. These beta cells are the body’s only
• A random blood glucose of 200 mg/dL or greater with the mechanism to produce insulin to help control blood
classic symptoms of polyuria, polydipsia, and unexplained glucose levels. The rate of this destruction is usually higher
weight loss in children than in adults. Children and adolescents may
or rapidly develop ketoacidosis. Adults seldom develop
ketoacidosis unless they have an infection or other stressor.
• A fasting blood sugar of 126 mg/dL or greater This is what used to be called insulin-dependent diabetes
or mellitus (IDDM), or juvenile-onset diabetes.
• The 2-hour sample of the oral glucose tolerance test is • Idiopathic—no evidence of autoimmunity; the individual
200 mg/dL or greater using a load of 75 grams of just does not produce insulin and is prone to ketoacidosis.
anhydrous glucose In the absence of insulin, glucose from food eaten cannot
• In the absence of a definitive diagnosis, the testing should be used or stored and remains in the bloodstream, resulting in
be repeated on an alternative date. hyperglycemia. In addition, glucose production from the liver
The committee also recommended not using glycosylated goes unchecked, further elevating the blood glucose level.
hemoglobin (HA1C) to diagnose diabetes since terminology As the blood glucose rises, the kidney begins to excrete excess
is confusing, and many methods of measuring glycosylated glucose in the urine (glycosuria). Glucose eliminated in the urine
hemoglobin are used. Glycosylated hemoglobin (HA1C) pulls excessive amounts of water with it (osmotic diuresis), result-
is primarily used to evaluate the effectiveness of the client’s ing in fluid volume deficit and producing symptoms of excessive
adherence to the treatment regimen. thirst (polydipsia) and increased urination (polyuria).
Insulin deficiency also results in impaired metabolism
Classification of fats and proteins. Because of the impaired glucose, fat,
and protein metabolism and the inability to store glucose,
Etiology, not insulin use, is used to classify diabetes into four clients frequently experience protein wasting, weight loss, and
categories: type 1 diabetes, type 2 diabetes, other specific increased hunger (polyphagia).
types, and gestational diabetes mellitus. Metabolism of fat stores for energy leads to production
of acid by-products called ketones, which can be detected in
Type 1 Diabetes the urine (ketonuria). As ketones accumulate, the associ-
There are two forms of diabetes resulting from pancreatic ated decrease in pH leads to metabolic acidosis, or more spe-
beta-cell destruction or a primary defect in beta-cell function, cifically a condition known as diabetic ketoacidosis, discussed
resulting in no release of insulin and ineffective glucose trans- later in this chapter.
port. There is usually an absolute insulin deficiency so the
clients are insulin-dependent. The two subdivisions of type 1 Type 2 Diabetes
diabetes are: Type 2 diabetes mellitus initially begins with insulin resistance,
where the cells are not able to use the insulin properly. Then,
as the disease progresses, the pancreas gradually loses its ability
to produce adequate quantities of insulin. Most of these clients
PROFESSIONALTIP are obese. When weight is lost, insulin resistance diminishes but
reappears if the client regains weight. A strong family history of
diabetes is often evident. Many clients do not require insulin, but
Diabetes eventually one-third will need insulin to maintain a normal glu-
According to the Centers for Disease Control and cose level. This is what used to be called noninsulin-dependent
Prevention (CDC, 2007), 17.9 million Americans are diabetes mellitus (NIDDM), or adult-onset diabetes.
diagnosed as having diabetes mellitus. Another
Hyperglycemia results when the pancreas cannot match
the body’s need for insulin and/or when the number of insulin
5.7 million are estimated to be undiagnosed. Diabetes
receptor sites are decreased or altered. Although available insu-
was the seventh-leading cause of death in the United lin may be insufficient to meet the body’s metabolic needs and
States in 2006 and is associated with many serious prevent hyperglycemia, there is a sufficient amount of insulin to
complications (CDC, 2007). Diabetes is the leading prevent fat breakdown for energy and the resulting ketoacidosis.
cause of new blindness among adults and accounts Extremely elevated glucose in the type 2 diabetic will result in
for 44% of new cases of renal failure. The risk of development of hyperosmolar hyperglycemic nonketotic syn-
heart disease and stroke is 2-4 times greater in clients drome (HHNS), discussed later in this chapter. Table 12-3 com-
with diabetes mellitus. pares the clinical manifestations of type 1 and type 2 diabetes.
Diabetes is seen in all age groups and races. About
33% of clients with diabetes are older than age
Other Specific Types
This section includes conditions such as beta-cell genetic
60. African American, Hispanic, and some Native
defects, endocrinopathies, and drug- or chemical-induced
American populations have a higher incidence of
diabetes. These are in a separate category because there are
diabetes than the white population (CDC, 2002a). different disease etiologies.
Direct and indirect medical costs (disability, lost
work, health care costs) have risen to $174 billion Gestational Diabetes Mellitus
annually (CDC, 2007). Occurring during pregnancy, this may be controlled either with
or without insulin. Generally, the client’s glucose tolerance
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394 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Table 12-3 Comparison of the Clinical Manifestations of Type 1 Diabetes

and Type 2 Diabetes
TYPE 1 DIABETES TYPE 2 DIABETES
Etiology Autoimmune Genetic susceptibility associated; usually associated with obesity.

Age of onset Rare before age 1 Incidence increases with age

Percent of diabetics 5%–10% 90%–95%

Onset Abrupt, rapid Gradual, over years

Body weight at onset Normal or thin 80% are overweight

Insulin production None Less than normal, normal, or greater than normal

COURTESY OF DELMAR CENGAGE LEARNING

Insulin injection Always Necessary for approximately 30%

Ketosis Occurs mainly in children and Unlikely

adolescents

Management Insulin, diet, exercise Diet and weight loss, exercise, possibly oral hypoglycemics or
insulin

returns to normal after the infant’s birth. The client should be Since the advent of home glucose monitoring devices,
rechecked 6 weeks after the birth to see if the diabetes persists. urine testing for glucose is rarely used. Testing urine for
ketone (product of fatty acid oxidation) production, however,
Contributing Factors continues to be recommended when the blood glucose level is
consistently higher than 240 mg/dL or when any symptoms of
Persons with a family history of diabetes are at greater risk for ketoacidosis are present.
developing diabetes. Other factors associated with diabetes The client with type 1 diabetes will always require admin-
include obesity, lack of exercise, aging, and ethnicity. The istration of insulin to lower the glucose level and prevent
most powerful risk factor for type 2 diabetes is obesity. For complications of diabetes. Diet and exercise regimens are also
persons with a family history of type 2 diabetes, maintenance important to control the glucose level and maintain health.
of an ideal body weight may delay or prevent the onset of dia- Dietary management is the cornerstone of treatment for
betes. Aging can also be considered a contributing factor. the person with type 2 diabetes. As the obese person loses
It is known that members of certain racial groups are weight, the body’s insulin requirements decrease, resulting in
more likely to develop diabetes. In the United States, there improved glucose tolerance. Exercise plays an important role in
is a greater chance of developing type 2 diabetes for Hispan- losing weight and lowering the blood glucose level. Type 2 dia-
ics, Latinos, certain Native American populations, African betes not controlled by diet and exercise may necessitate admin-
Americans, and Asian/Pacific Islanders. Other groups at risk istration of medications. Oral hypoglycemic agents or parenteral
for development of diabetes include those with a history of administration of insulin may be required for optimal control.
gestational diabetes or impaired glucose tolerance (IGT).
Surgical
Medical–Surgical Pancreas transplantations have been performed and have success-
Management fully eliminated the need for exogenous insulin in some clients.
At present, pancreas transplants are being performed primarily
Medical on clients with type 1 diabetes who also need kidney or other
There is no known cure for diabetes. The goal of therapeutic organ transplants because the serious side effects of the antirejec-
management is aimed at the control of blood sugar and the tion medications do not justify a pancreas transplant alone. Pan-
prevention and early detection of the complications associ- creatic islet cell transplants are also being done experimentally
ated with diabetes. Diabetes is considered under control if the with limited success but hold much promise for the future.
client maintains ideal body weight and enjoys good health,
preprandial glucose levels are less than 140 mg/dL, and post- Pharmacological
prandial glucose levels do not rise above 180 mg/dL. Various pharmacological treatments that are used in the man-
Treatment plans vary and are individualized for each agement of type 1 and type 2 diabetes are discussed in the
client. Control of blood glucose generally involves a balance following text.
of a dietary prescription, an exercise plan, and medications.
Ultimately, the client is the manager of the treatment plan Insulin Persons with type 1 diabetes always require insulin
and, therefore, must be very well informed about diabetes administration. Persons with type 2 diabetes may not initially
and involved in all aspects of care planning and decision require insulin, but it may become necessary as endogenous
making. insulin production decreases or during times of stress or illness.

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 CHAPTER 12 Endocrine System 395

Historically, insulin has been obtained from beef or pork

pancreas. Today, biosynthetic human insulin is used almost
exclusively, but some clients still use pork or beef insulin. Human
Glucose Monitoring insulin is purer, more effective, and has a much lower incidence
of causing insulin allergies and resistance. Insulin is available in
The availability and use of home glucose very short-, short-, fast-, intermediate-, and long-acting forms
monitoring equipment to evaluate serum (blood) that can be injected separately or mixed in the same syringe. Pre-
glucose has revolutionized self-care for the diabetic mixed insulins are also available. See Table 12-4 for descriptions
client. Also called “fingerstick blood glucose” of types of insulins and their actions. Insulin is routinely admin-
(FSBG), self-monitoring of blood glucose (SMBG) can istered subcutaneously. Regular insulin (short-acting) may be
be done quickly using capillary blood that provides
administered intravenously when immediate response is desired,
as in treatment of greatly elevated glucose levels occurring with
fairly accurate reading of the current blood glucose.
diabetic ketoacidosis (DKA) or HHNS. Regular insulin is the
Most often, the glucose level is checked before only insulin that can be given intravenously (IV).
meals and at bedtime so the client can adjust The strength of insulin correlates to the number of units
the treatment plan accordingly. Self-monitoring of insulin per cubic centimeter. The most common concentra-
of blood glucose is recommended for all clients tions of insulin used today are U-50 and U-100 insulin (50 and
requiring insulin or those with a widely fluctuating 100 units of insulin per 1 mL, respectively). U-500 insulin is
glucose level. Symptoms of hypoglycemia at any available for clients who require very high doses.
time warrant immediate evaluation of the blood Insulin should always be measured in an insulin syringe,
glucose level. which is marked in units (Figure 12-3). When mixing two
types of insulin in the same syringe, it is important that the
regular (clear, short-acting) insulin be drawn up first. The

10–16
Table 12-4 Types of Insulin and their Actions
ACTION IN HOURS
TYPES OF INSULIN APPEARANCE ONSET PEAK DURATION NURSING INTERVENTIONS
Very short-acting
Insulin lispro (Humalog) Clear ¼ 1–1½ 5 or less Eat meals 5 to 10 minutes after
Insulin aspart (Novolog) Clear ¼ 1–3 3–5 injection. Glulisine (Apidra) can
be taken 15 minutes before or
Glulisine (Apidra) Clear ⁄3
1
½–1½ 3–4 20 minutes after the start of a
meal. Medication can be mixed
with NPH insulin.

Short-acting
Humulin R Clear ½–1 2–4 6–8 Available in U-100 and U-500
strengths. Eat meal 15 minutes
following injection.

Intermediate-acting
Humulin N Cloudy 1–1½ 4–12 Up to 24 Roll insulin vial between palms of
Humulin L Cloudy 1–2½ 7–15 22 hands to equally distribute.

Long-acting
Humulin U Cloudy 4–8 10–30 36+ Usually given once a day. Cannot
Insulin glargine (Lantus) Clear 1 None up to 24 be mixed with any other insulin
preparations.
Detemir (Levimir) Clear 1 None 24
COURTESY OF DELMAR CENGAGE LEARNING

Premixed
Humulin N/Reg Cloudy ½–1 4–8 24 Roll insulin vial between palms of
Humulin 70/30 Cloudy ½–60 Varies 10–16 hands to equally distribute. Do not mix
with any other insulin preparations.
Humulin 50/50 Cloudy ½–1 Varies 10–16 With Humalog 75/25, eat meal within
Humalog mix 75/25 Cloudy ⁄4
1
Varies 10–16 5 to 10 minutes of injection.

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396 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

COURTESY OF DELMAR CENGAGE LEARNING

COURTESY OF DELMAR CENGAGE LEARNING
Figure 12-3 Insulin syringes are used to administer insulin Figure 12-4 Subcutaneous Injection Sites; A, Abdomen;
subcutaneously. B, Lateral and Anterior Aspects of the Upper Arm and Thigh;
C, Scapular Area of Back; D, Upper Ventrodorsal Gluteal Area
policy of many health care institutions requires that two
nurses check insulin dosages before administration. Even if
the facility does not have such a policy, checking the insulin in the subcutaneous fat). More recently, some authorities are
dosage with another nurse will help protect against an adverse recommending that the abdomen, which provides the most
reaction resulting from error. predictable absorption of insulin, be used exclusively for insulin
Insulin dosages are individually determined, usually administration.
requiring two or more injections per day and involving a com- If sites other than the abdomen are used, site rotation
bination of a short-acting and a longer-acting insulin. Various needs to be done systematically to prevent erratic absorp-
regimens of insulin administration can be used, each with tion. Failure to rotate injection sites may cause a complication
its own advantages and disadvantages. In general, the more known as lipodystrophy; a change in the subcutaneous fat that
complex the regimen, the more normal the blood glucose level decreases the absorption of the insulin. One system of rotation
throughout the day. Clients can be taught to use the results is to always use the same area of injection the same time each
of their self-monitoring blood glucose to adjust their insulin day (e.g., always using the abdomen in the morning and the
doses, allowing more flexibility in their meals and schedules. thigh in the afternoon). Another system of rotation is to use all
Recent studies strongly support the theory that intensive available injection sites in one area before moving to another.
insulin regimens that tightly control the blood glucose level Exercise will increase the rate of absorption, so diabetics
delay the onset and progression of complications of diabetic planning to exercise should not inject insulin into the areas to
retinopathy, nephropathy, and neuropathy. be exercised.
Vials of insulin not being used should be refrigerated
Sliding-Scale Insulin During times of surgery, illness, or to prevent loss of potency. Vials in use may be kept at room
stress, clients may have their glucose level managed with an temperature to decrease local irritation at the injection site,
insulin sliding scale in lieu of their regular regimen of insulin which can occur when cold insulin is used. When mixing a
or oral hypoglycemics. A sliding scale determines insulin dos- short-acting and a longer-acting insulin in the same syringe,
age based on fingerstick blood glucose level. Regular lispro the regular (clear) should always be drawn up into the
(Humalog) or aspart (Novolog) insulin may be used, and a dose syringe first, followed by the longer-acting (cloudy) insulin.
is administered every 4 or 6 hours based on the blood glucose Figure 12-5 illustrates mixing and administering insulin. It is
level. The sliding scale allows for much flexibility and ensures recommended that insulin syringes be used only once and
frequent monitoring of and response to changes in the client’s then discarded.
glucose level. An example sliding scale might be as follows: The visually and/or neurologically impaired diabetic
• 4 units of Humulin R Insulin for glucose 151–200 mg/dL client may benefit from assistive devices available to facili-
• 6 units of Humulin R Insulin for glucose 201–250 mg/dL tate drawing up the insulin and administering it. Clients
dependent on others for drawing up their insulin may benefit
• 8 units of Humulin R Insulin for glucose 251–300 mg/dL from prefilled syringes, which are considered stable for up to
• 10 units of Humulin R Insulin for glucose 301–350 mg/dL 3 weeks when stored in the refrigerator.
• Call physician for glucose >350 mg/dL The nurse should keep in mind that the most impor-
tant factor in the administration of insulin is consistency in
Insulin Injections Insulin injections are administered into the technique. Also, simplification of the procedure may have a
subcutaneous tissue. If an inch of skin can be pinched, the nee- major impact on a client’s ability to comply and to maintain
dle is injected at a 90-degree angle, otherwise, at a 45-degree independence. It is important that the nurse understand the
angle. The five main areas for injection are the abdomen, arms, basic principles of insulin administration and thereby remain
thighs, hips, and subscapular regions (Figure 12-4). Factors flexible when teaching new clients or assessing the skills of
affecting absorption should be considered when selecting an experienced clients.
injection site. Absorption occurs most quickly in the abdomen,
followed by the arms, thighs, hips, and subscapular regions. Insulin Pumps A portable insulin infusion pump delivers
Rotation of sites for injection has traditionally been recom- insulin continuously through a subcutaneous needle, usually
mended to prevent lipodystrophy (atrophy or hypertrophy anchored in the abdomen. A continuous, or basal, rate of regular

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 CHAPTER 12 Endocrine System 397

R N
3 3

2 2

1 1
1 1

2 2

3 3

N R

1. Cleanse the rubber 2. Inject the amount of air 3. Withdraw the correct 4. Withdraw the correct amount of
stopper on both vials with an equal to the dose of the amount of rapid-acting intermediate-acting insulin by

COURTESY OF DELMAR CENGAGE LEARNING

alcohol wipe, then inject the rapid-acting insulin into the insulin. pulling the plunger down to the unit
amount of air equal to the R vial. mark that equals the dose of rapid-
dose of the intermediate- acting insulin plus the dose of
acting insulin into the N vial. intermediate-acting insulin. The
insulins mix immediately in the
syringe. If too much intermediate-
acting insulin is withdrawn, the
entire contents of the syringe must
be discarded.

Figure 12-5 How to Mix Insulin

aspart (Novolog) or lispro (Humalog) insulin is programmed uptake of the glucose resulting in elevated morning glucose
and delivered to closely imitate the body’s natural insulin levels. Administering the evening insulin dose at a later time
secretion. Additional boluses can be manually administered to will coordinate the insulin peak with the hormone release.
coordinate with meal times. The injection site is changed every
48 to 72 hours. The use of the insulin pump prevents multiple Oral Hypoglycemic Agents Oral hypoglycemic agents are
injections and allows flexibility in meal size and time. Use of used to treat persons with type 2 diabetes who are not con-
the pump requires a motivated and educated client because trolled with exercise and diet. These agents are meant to
intensive self-monitoring of blood glucose is essential. supplement diet and exercise, not replace them. Oral hypogly-
cemics are not insulin and work by other mechanisms.
Complications of Insulin Therapy Complications of insulin Sulfonylurea is the original class of oral hypoglycemic
therapy include hypoglycemia (discussed later in this chap- medications used for diabetes therapy. The sulfonylureas work
ter), insulin resistance (requiring >200 units/day), lipodystro- primarily by increasing the ability of the islet cells of the pancreas
phy, Somogyi phenomenon, and the dawn phenomenon. to excrete insulin. To a lesser degree, they increase the cells’ sen-
Lipodystrophy can be minimized by using human insulin, sitivity to insulin and decrease glucose production by the liver.
using room temperature insulin, and by rotating sites of insulin Metformin (Glucophage), a biguanide, does not
injection. increase insulin release but works by making existing insu-
The Somogyi phenomenon occurs when a rapid lin more effective at the cellular level. Metformin decreases
decrease in blood glucose (hypoglycemia) causes the release of the amount of glucose produced by the liver. Muscle tis-
glucose-elevating hormones (epinephrine, cortisol, glucagon). sues become more sensitive to insulin and improve glucose
The hypoglycemia usually occurs during the night but mani- absorption. Metformin may be given alone or in combi-
fests as an elevated glucose in the morning and may be inadver- nation with other oral hypoglycemics. In some clients,
tently treated with an increase in insulin dosage. The Somogyi Glucophage works more effectively if given with some
phenomenon can be diagnosed by checking the blood glucose dose of Diabeta. Because it does not stimulate increased
during the night at about 3:00 a.m. Adjusting the insulin regi- insulin release, metformin is not associated with episodes
men to avoid the peaking of insulin during the night will correct of hypoglycemia. The major side effects of metformin are
this effect. gastrointestinal and include anorexia, nausea, abdominal
The dawn phenomenon is an early morning glucose discomfort, and diarrhea.
elevation produced by the release of growth hormone. The Oral hypoglycemics require some production of insulin
release of the growth hormone decreases the peripheral by the pancreas and, therefore, are not useful in the treatment

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398 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

of type 1 diabetes. See Table 12-5 for a description of oral

hypoglycemic agents used today. Table 12-5 Oral Hypoglycemics
ONSET
Diet GENERIC USUAL TIME DURATION
Medical nutrition therapy provides an individualized dietary (BRAND) DOSE (HOURS) (HOURS)
prescription to meet client and family needs. Consideration is First-Generation Sulfonylureas
given to usual eating habits and other lifestyle factors, such as
dietary likes and dislikes, cultural influences, who prepares the Tolbutamide (Orinase), tolazamide, (Tolinase), and
meals, and family finances. It is important that meals remain chlorpropamide (Diabinese) are seldom used because
a social experience, and the person with diabetes not feel iso- of their long action, higher incidence of adverse effects,
lated or different. and risk of drug interactions (Cincinnati & Veliko, 2001).
The goals of medical nutrition therapy are (1) maintain
as near-normal blood glucose level as possible, (2) achieve Second-Generation Sulfonylureas
optimal serum lipid levels, (3) provide adequate calories
to maintain or attain a reasonable weight, (4) prevent glipizide 2.5–40 mg 1–1½ 10–16
complications of diabetes, and (5) improve overall health. (Glucatrol) single or
Because of the complexity of individualizing medical nutri- divided
tion therapy, it is recommended that clients be referred early dose
to a registered dietician (RD) for nutritional assessment and glimepride 1–4 mg 1 24
education. (Amaryl) single dose
Diabetes is a strong risk factor for atherosclerosis and
cardiovascular disease. Therefore, reducing serum lipid levels glyburide 1.25–20 mg 2–4 24
is a goal of medical nutrition therapy. To reduce the risk of car- (Diabeta, single or
diovascular disease, the ADA recommendations incorporate a Micronase) divided dose
reduction in saturated fat and cholesterol consumption.
It is recommended that individuals taking insulin or oral Biguanides
hypoglycemic agents eat at consistent times synchronized
metformin 500– 24–48 6–12
with the actions of the medications used. Distribution of
calories over 24 hours, with regular meals and snacks, helps HCl 2,500 mg
prevent extreme highs and lows in blood glucose. (Glucophage) two or three
divided
doses
Consistent-Carbohydrate Meal Plan Current ADA nutri-
tion guidelines suggest using a “consistent-carbohydrate meal Alpha-Glucosidase Inhibitors
plan.” The client eats an individually prescribed amount of
carbohydrates at each meal or snack. Carbohydrates determine acarbose 25–100 mg 1 No data
premeal insulin requirements more than the amount of protein (Precose) with meals
or fat in the meal, and they have the greatest effect on the post- (tid)
prandial blood glucose level. Protein and fat intake must be
watched to avoid weight gain and increased serum lipid levels. miglitol 25–100 mg 2–3 4–6
Protein intake of both animal and vegetable sources (Glyset) with meals
should make up 15% to 20% of the daily calorie intake. Cho- (tid)
lesterol intake should not exceed 300 mg per day (Bartels,
2004). If nephropathy is present, protein should be 10% of the Thiazolidenediones
daily calorie intake. rosiglitazone 4 mg daily 1
Total fat intake depends on the goals set by the client maleate
and health care provider for desired levels of glucose, lipid, (Avandia)
and weight. If lipid level is normal, 30% or less of calories
should come from fat with less than 10% from saturated Combinations
fat. If weight loss is a primary issue, reduction in fat intake
is an efficient way to reduce calorie intake. When lipid glyburide and 1.25 mg/
level is a problem, a decrease of saturated fat intake to less metformin 250 mg
than 7% of the total calories, total fat to less than 30% of HCl 2.5 mg/
total calories, and cholesterol to less than 300 mg per day is (Glucovance) 500 mg
recommended. once or
The remainder of the calorie intake comes from carbo- twice a day
hydrates. The amount consumed is more important than the
COURTESY OF DELMAR CENGAGE LEARNING

source of the carbohydrate. rosiglitazone 1 mg/

Persons with diabetes should follow the same precau- maleate and 500 mg
tions regarding the use of alcohol as applied to the general metformin 2 mg/
public. Alcohol may increase the risk for hypoglycemia in HCl 500 mg
people treated with insulin or sulfonylureas, such as acetohex-
(Avandamet) 4 mg/
amide (Dymelor), chlorpropamide (Diabinese), or tolazamide
(Tolinase). 500 mg

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 CHAPTER 12 Endocrine System 399

Activity
The beneficial effects of regular exercise for the diabetic
are multiple. Exercise decreases the blood glucose by

COURTESY OF DELMAR CENGAGE LEARNING

increasing the uptake of glucose by muscles and improving
insulin usage. Exercise also increases circulation, improves
cardiovascular status, decreases stress, and assists with
weight loss.
Before starting an exercise program, the person with
diabetes should have a complete physical and review the exer-
cise plan with the physician or primary health care provider.
Regular daily exercise rather than sporadic exercise should be
encouraged. Figure 12-6 The nurse measures a client’s blood glucose
Persons with diabetes need to correlate exercise with their level.
blood glucose, taking care to avoid periods of hypoglycemia or
exercising when blood glucose is too high. Exercise potenti- Hypoglycemia (Insulin Reaction)
ates the action of insulin, resulting in lower insulin require- Hypoglycemia (low blood glucose) occurs when a client’s
ments and an increased risk of hypoglycemia during and after glucose level decreases to less than 70 mg/dL, with the most
exercise. On the other hand, in the person with diabetes who severe reactions occurring when it decreases to less than
is insulin-deficient, exercise may cause a further rise in blood 50 mg/dL. Hypoglycemia can occur any time of the day, but
glucose and rapid development of ketosis. Diabetics should most often will occur before meals or when insulin action is
not exercise at the peak of insulin activity, when their blood peaking. Factors that can contribute to the development of
glucose is greater than 250 mg/dL, or if they have ketones in a hypoglycemic reaction are skipping meals or eating late,
their urine. unplanned exercise, and administration of excess insulin.
Hypoglycemic symptoms can occur suddenly and unex-
pectedly and vary from client to client. The cardinal rule is:
Health Promotion Always believe clients who tell you they are having an insulin
The diabetic educator plays a pivotal role in assisting the dia- reaction. Most persons with diabetes have had hypoglycemic
betic client/family to understand diabetes and the necessary reactions before, so they know the symptoms that precede an
lifestyle changes. Some teaching is unique to an individual insulin reaction. Hypoglycemia unawareness occurs when the
client and is done one-to-one, whereas some teaching applies client experiences an inability to recognize the warning symp-
to all clients with diabetes and is often done in a class set- toms of hypoglycemia. It is usually a complication of type 1
ting. This also allows clients with diabetes to meet each other diabetes but can occur in type 2.
and share concerns, information, and ideas that have worked When a hypoglycemic reaction is suspected, the nurse
for them. must respond immediately according to the institution’s
The diabetic educator nurse is part of a team, including protocol. Treatment involves assessing the client, checking
the client/family, physician, dietician, and pharmacist, who all blood glucose level, and administering glucose in the most
work together to help the client understand and comply with appropriate form. Daniels (2007) recommends providing
the treatment plan.
Sick-Day Management It is important that persons with
diabetes have a plan for managing their diabetes in the event of LIFE SPAN CONSIDERATIONS
illness. It is important that they continue taking their insulin or
oral hypoglycemic medication when they are experiencing ill- Hybrid or Mixed Diabetes
ness because illness and fever can increase blood glucose and
the need for insulin. Some persons with diabetes who do not Usually a child or teenager develops either type 1
normally take short-acting insulin may require it during times or type 2 diabetes. Some teenagers have elements
of fever or illness. Blood glucose should be monitored 4 to 6 of both kinds of diabetes. This phenomenon is
times per day (Figure 12-6), and urine should be checked for referred to as “hybrid” or “mixed” diabetes.
ketones. Blood glucose greater than 300 mg/dL or ketones in Given the fact that more children and teenagers
the urine should be reported to the physician. are becoming overweight and obese, it is not
If the client cannot ingest the planned meal, carbohy- surprising that these age groups have elements
drates in the form of soft foods and liquids can be substituted. of both types of diabetes. Youth with “hybrid” or
Extreme nausea and vomiting or diarrhea should be reported “mixed” diabetes typically have:
to the physician because extreme fluid loss can be dangerous. • insulin resistance associated with obesity and
Clients with type 1 diabetes who are unable to retain fluids
type 2 diabetes, and
may need to be hospitalized to avoid ketoacidosis.
• antibodies against the pancreatic islet cells that

Acute Complications
are associated with autoimmunity and type 1
diabetes.
of Diabetes (National Diabetes Education Program, 2008;
There are three major acute complications of diabetes related Lorenz & Silverstein, 2005)
to blood glucose imbalance: hypoglycemia, diabetic ketoaci-
dosis (DKA), and HHNS (Table 12-6).

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400 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Table 12-6 Symptoms of Acute

CLIENTTEACHING Complications of Diabetes
Guidelines for Exercising
Symptoms of Hypoglycemia (Insulin Reaction)
• Try to exercise at the same time and in the same
Mild hypoglycemia
amount each day.
• Diaphoresis; cold, clammy skin
• Test blood glucose level before, during, and • Palpitations
after exercise. • Pallor
• Do not inject insulin into a limb that you will be • Tremors
exercising. • Excess hunger
• Do not exercise at the peak of insulin activity. • Anxious but alert
• Do not exercise before meals unless trying to Moderate hypoglycemia
lower blood glucose level. • Confusion, vertigo
• Do not exercise with a blood glucose level over • Behavior changes
250 mg/dL or with ketones in the urine. This • Slurred speech
indicates severe insulin deficiency and may • Irritability
predispose to hyperglycemia. • Paresthesia
• Eat a snack (15 g of carbohydrates) before or Severe hypoglycemia
during exercise if appropriate, based on blood • Seizures
glucose level. • Loss of consciousness
• Always carry a source of carbohydrates and • Shallow respirations
emergency cash, if away from home, in case • Nursing Alert: Severe hypoglycemia is a medical
hypoglycemia occurs while exercising. emergency. Administer some form of glucose
immediately.
• Always carry personal and medical alert
identification. Symptoms of Diabetic Ketoacidosis (DKA)
• Watch for post-exercise hypoglycemia. Individuals • Same as HHNS plus symptoms of acidosis:
who have more than usual exercise during the • “Fruity” odor to breath
day should increase their carbohydrate intake • Kussmaul’s respirations (deep, nonlabored)
and test their glucose during the night to detect
nocturnal hypoglycemia. (Hypoglycemia can Symptoms of Hyperosmolar Hyperglycemic
occur 8 to 15 hours after exercise.) Nonketotic Syndrome (HHNS)
• Polyuria

COURTESY OF DELMAR CENGAGE LEARNING

• Polydipsia
• Skin hot, dry, decreased turgor
• Dehydration—hypotension, increased pulse
CLIENTTEACHING • Blurred vision
Fingersticks • Weakness
• Mental status changes, confusion to coma
• Use shallow skin penetration, just to get enough
blood for the meter.
• Rotate sites; use sides of fingertips and thumb. have. Hypoglycemic reactions can be fatal, so leaving the client
• Use alcohol sparingly or wash hands with warm untreated is more dangerous than causing mild hyperglycemia
soapy water before fingerstick instead of using with overtreatment. Figure 12-7 provides a sample hypogly-
alcohol. The warm water brings more blood cemic protocol.
into the fingers. Persons with diabetes and their families must know the
symptoms and treatment for hypoglycemia. Hypoglycemic epi-
• Apply firm pressure directly over the puncture
sodes can be prevented by following a regular pattern of eating,
for 10 to 15 seconds; if area is still bleeding,
exercise, and insulin administration. Between-meal and bed-
apply pressure until it stops. time snacks can be used to cover times of peak insulin action.
Additional food should be eaten when engaging in greater than
usual exercise. Blood glucose level should be checked at the first
suspicion of hypoglycemia. All clients should wear an identifi-
the client with 10–15 grams of simple carbohydrates, for cation bracelet or tag indicating that they have diabetes because
example 8 oz of low-fat milk or 4 oz of fruit juice. The cli- hypoglycemic reactions can occur unexpectedly.
ent taking acarbose (Precose), which slows digestion and
absorption of most carbohydrates—including hard candies Diabetic Ketoacidosis
and many fruit juices—but not glucose, will not have the Diabetic ketoacidosis (DKA) is one of the most serious
rapid response to fruit juice or sugar that other clients will complications of hyperglycemia. Glucose is a hyperosmolar

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 CHAPTER 12 Endocrine System 401

glucose < 60 mg/dL glucose 60–100 mg/dL glucose > 100 mg/dL

Unconsciousness or change w/symptoms w/o symptoms

in LOC at any blood
glucose level

If IV line available, No IV available, > 1 hour < 1 hour > 1 hour < 1 hour
give 50 mL D50W give glucagon IM before before before before
(20 mL for a child) (1 mg adult, 0.5 mg meal/snack meal/snack meal/snack meal/snack
slowly over 5–10 if < 3 yrs) then start IV
minutes and call M.D. line, and follow with
food when client Do not treat.
15 gm of simple 15 gm CHO
able to swallow.
sugar, follow with
Position client on side
a protein source.
since glucagon may
cause nausea.

In all instances, repeat BG 15 minutes after treatment and repeat appropriate treatment if reaction continues.
Document each fingerstick result and treatment.
Report all severe hypoglycemic reactions to charge nurse and/or M.D.

Treatment
(All treatment in addition to meals)

15 gm CHO = 4 oz most juices Protein = For follow-up, treatment can be any

(Renal clients should NOT be given orange juice protein source.
or milk. Substitute with cranberry juice or ginger ale.) 1 tbsp peanut butter

COURTESY OF DELMAR CENGAGE LEARNING

OR 8 oz skim milk OR 1 oz cheese
OR 3 graham crackers OR 1 oz meat

Simple sugar = tablespoon sugar in H2O

OR most juices or 4 oz grape juice
OR 1 tbsp honey
OR 3 glucose tablets, 1/2 –1 tube glucose gel
1 tbls sugar = 3 packets of sugar = 12 gm CHO

Figure 12-7 Sample Hypoglycemic Protocol

substance drawing fluid out of the cell and into the circula- Treatment regimen must be initiated immediately
tion, where it is excreted by the kidneys. This oncotic diuresis with clients experiencing DKA. Fluid replacement consists
results in polyuria (increased urine output), dehydration, of NS intravenously to improve blood pressure. Regular
and electrolyte imbalances. Increased fat metabolism results insulin may be provided intravenously to assist in decreas-
in accumulation of ketones, resulting in metabolic acidosis. ing the blood glucose levels. Potassium replacement is also
Surgery, stress, or illness may trigger DKA, which usually necessary to prevent any additional complication associ-
develops in clients with immune-mediated type 1 diabetes, ated with fluid replacement (Daniels, 2007).
although it can occur in clients with type 2 diabetes. The client
with undiagnosed immune-mediated type 1 diabetes may also Hyperosmolar Hyperglycemic
present with DKA.
The onset of DKA may be gradual or sudden. Classic Nonketotic Syndrome
symptoms of hyperglycemia (polyuria, polyphagia, polydipsia) HHNS occurs when there is insufficient insulin to prevent
usually precede DKA. Other symptoms include nausea and hyperglycemia but enough insulin to prevent ketoacidosis.
vomiting, abdominal pain from acidosis, headache, weakness, HHNS occurs in persons with type 2 diabetes. Because symp-
fatigue, and blurred vision. Assessment may reveal hot, flushed toms of acidosis do not occur, no symptoms may be noticed
skin and signs of hypovolemia or shock. Acidosis will produce until the glucose level is dangerously high.
signs of hyperpnea (Kussmaul’s breathing), fruity odor to HHNS occurs most often in the elderly client with
breath from respiratory elimination of acetone, and decreased undiagnosed type 2 diabetes. HHNS can also occur in the
level of consciousness ranging from lethargy to coma. poorly controlled client and is usually precipitated by illness
Laboratory values will reveal blood glucose from 300 mg/ or another stressor. The onset of symptoms of HHNS is
dL to 800 mg/dL and metabolic acidosis. Urine will be posi- lower than DKA, often taking days to weeks to display clinical
tive for glucose and ketones. symptoms.

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402 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Clinical manifestations of HHNS reflect dehydration

and shock. Hyperosmolality eventually results in lethargy, sei-
zures, and coma (Table 12-6). Blood glucose level ranges from
CLIENTTEACHING
600 mg/dL to 2,000 mg/dL and serum osmolality greater Guidelines to Healthy Feet
than 350 mOsm/L.
Medical management of DKA and HHNS involves fluid • Wash feet daily and dry them carefully,
and electrolyte replacement (particularly potassium), insulin, especially between the toes.
and treatment of any precipitating factors. DKA and HHNS • Inspect feet and between toes for blisters, cuts,
are associated with significant mortality rates, and the client and infections. Use a mirror to see the bottoms
is usually acutely ill. Treatment will occur in the intensive care of the feet. If your vision is impaired, have a
setting until the client is stabilized. family member examine your feet. Remember,

Chronic Complications because of decreased feeling in your feet, you

of Diabetes
may have an infection and not know it.
• Avoid activities that restrict blood flow to the
Long-term complications of diabetes occur 5 to 10 years feet, especially smoking and sitting with legs
after diagnosis in both type 1 and type 2 diabetes. The exact crossed.
pathophysiology is not completely understood but is known
• Wear shoes that are comfortable, well-fitting,
to be related to the effects of elevated blood glucose level.
Recent studies have shown that intensive insulin therapy and and closed toed. Wear new shoes for short
tight glycemic control can reduce or delay the occurrence of intervals until broken in. Do not walk barefoot.
many long-term complications associated with diabetes. • Prevent cuts and irritations. Always wear
stockings. Look inside shoes for rough edges,
Infections nail points, foreign objects.
Diabetics, particularly clients who are poorly controlled, • Avoid temperature extremes. Test bath water
appear to be more prone to developing certain infections. with hands before getting in. Do not use water
Infections of particular concern to diabetics include diabetic bottles or heating pads on feet.
foot infections, boils, cellulitis, necrotizing fasciitis, urinary
tract infections, and yeast infections. Small cuts on the feet can • See your physician regularly and make sure that
become gangrenous (Figure 12-8) and require amputation. your feet are examined each visit.
Infections increase the need for insulin and can result in • When toenails are trimmed, cut them straight
ketoacidosis. Infections, once they occur, can often be difficult across. When corns or calluses are present, see a
to treat and heal slowly because of impaired circulation. physician or podiatrist. Do not cut them yourself.

Diabetic Neuropathy
Neuropathy is the most common chronic complication asso-
ciated with diabetes. The incidence of neuropathy increases peripheral circulation place the client at risk for undetected
with age and duration of disease and is related to elevated foot injury.
blood glucose level. Neuropathy can affect all types of nerves, Autonomic neuropathy can affect almost any organ system,
but the two most common types of diabetic neuropathy are including gastrointestinal (delayed gastric emptying, constipa-
peripheral neuropathy and autonomic neuropathy. tion, diarrhea), urinary (retention, neurogenic bladder), and
Peripheral neuropathy causes paresthesias and burning reproductive (male impotence).
sensations, primarily in the lower extremities. Decreased
sensations of pain and temperature coupled with decreased
Nephropathy (Chronic Renal Failure)
Diabetic nephropathy develops slowly over many years, pro-
gressing eventually to kidney failure. Elevated blood glucose
level causes a decrease in the glomerular filtration rate result-
ing in fluid retention. Prolonged injury to the nephron may
eventually lead to renal failure. Controlling hypertension and
blood glucose level is the key to delaying renal damage. Good
hydration before and diuresis following any dye study is valu-
able in preventing renal damage. Diligent monitoring of a
COURTESY OF DELMAR CENGAGE LEARNING

LIFE SPAN CONSIDERATIONS

Diabetic Neuropathy
Advancing age is the strongest risk factor regardless
of disease duration and blood sugar control.
Figure 12-8 Gangrene of the toes and foot as a result of an
infection often means eventual amputation.

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 CHAPTER 12 Endocrine System 403

client’s urinary output is essential. Clients may be required to

adhere to a low protein, low salt diet.

Retinopathy
Changes in the small vessels of the retina result in diabetic
retinopathy, which is a major cause of blindness among per-
sons with diabetes (Figure 12-9). Because of the insidious
onset of type 2 diabetes, retinopathy is often present at diag-
nosis. The severity and progression of retinopathy appear to be
closely related to glucose and blood pressure control. Persons Image not available due to copyright restrictions
with diabetes also develop cataracts at an earlier age. Although
most clients develop some degree of retinopathy, most do
not develop visual impairment. To facilitate early detection,
diabetics should have ophthalmologic evaluations every 6 to
12 months.

Vascular Changes
Diabetes is an independent risk factor for atherosclerotic
vessel disease. Atherosclerotic changes that occur in per-
sons with diabetes are similar to those that occur in nondia-
betics, but they occur at earlier ages and progress at a more
rapid rate.
Cardiovascular Hypertension is twice as common in per- Nursing Management
sons with diabetes and is an important factor in the progres- Monitor vital signs and serum electrolytes. Record I&O,
sion of retinopathy, nephropathy, and vascular (large vessel) administer fluids as ordered, and encourage oral fluid intake.
disease. The incidence of coronary artery disease, angina, Teach client about diabetes, use of insulin or oral hypoglyce-
and myocardial infarction is higher when compared to the mics, methods of insulin administration (syringe, pen injector
nondiabetic population. Cerebral vascular disease and cere- [Figure 12-10], and pump), relationship of exercise to diabe-
bral vascular accident are also more common in persons tes management, and how to perform SMBG. Provide a list of
with diabetes. Therapies aimed at lowering risk factors and symptoms and treatment for hypoglycemia.
effects of atherosclerosis include weight control, low-fat diet,
treatment of hypertension and hyperlipidemia, regular exer-
cise, and control of blood glucose level. NURSING PROCESS
Peripheral Vascular Disease Peripheral vascular disease Assessment
occurs most commonly in diabetics with hypertension or
hyperlipidemia and in diabetics who smoke. Diabetics have Subjective Data
two to three times the incidence of occlusive peripheral arte- This includes assessment of the health history, family
rial disease when compared to the nondiabetic population. history, diet, activity regimen, and the understanding of the
Diabetes is present in more than half of persons experiencing disease and medical therapies. The client may describe fatigue,
nontraumatic lower extremity amputations. weakness, weight changes, mental status changes, polyuria,
polyphagia, polydipsia, numbness or tingling of the extremi-
ties, blurred vision, and increased appetite.

Objective Data
Objective data should focus on the symptoms of diabetes, the
common acute and chronic complications, and the results of
diagnostic tests. There may be dependent redness or cyanosis
of the lower extremities as well as the absence of hair. A fasting

CLIENTTEACHING
Retinopathy Prevention
• Refrain from straining to have a bowel movement.
Figure 12-9 Microaneurysms in Diabetic Retinopathy • Use stool softener or laxative.
(Courtesy of Salim I. Butrus, M.D., Senior Attending, Department of • Avoid postures that lower the head.
Opthalmology, Washington Hospital Center, Washington, D.C., and • Avoid lifting weight above shoulders.
Associate Clinical Professor, Georgetown University Medical Center,
Washington, D.C.)

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404 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses, based on the assessment findings, may be varied and

extensive due to the multiple problems and complications caused by
diabetes mellitus. Nursing diagnoses include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will relate basic understanding of Teach client about diabetes and the use of
diabetes, medical pathophysiology of diabetes, and relationship insulin to prevent hyper-/hypoglycemia or
regimen, diet, exercise, between insulin and hyper-/hypoglycemia. assist client to enroll in a formal diabetic
self-care management education program.
skills (insulin injection, The client will verbalize how/when to take Teach client about oral hypoglycemics or
SMBG) related to new oral hypoglycemics and the side effects to insulin, whichever the client will be using.
diagnosis or changes in report or will correctly demonstrate how to
treatment administer insulin and rotate sites.
The client will relate importance of an Discuss how exercise is related to diabetes
exercise program. management.
The client will describe the relationship between Discuss how dietary management is related
dietary management and glycemic control; to the control of blood glucose and provide
choose foods that comply with diet prescription. an exchange list of foods.
The client will correctly demonstrate how to Teach client how to perform SMBG and have
use SMBG to determine blood glucose level. client return demonstration.
The client will verbalize symptoms and Provide client with a list of symptoms and
treatment of hypoglycemia. treatment for hypoglycemia.

Risk for Deficient Fluid The client will exhibit normal skin turgor, Measure client’s intake and output,
Volume related to moist mucous membranes, and maintain oral administer intravenous fluids as ordered,
hyperglycemia, polyuria, fluid intake of 2,500–3,000 mL/day. and encourage oral fluids.
and dehydration The client will have vital signs within normal Monitor vital signs and serum electrolytes.
limits.

Imbalanced Nutrition: The client will have weight within normal Refer client to dietician to adjust dietary
Less than Body range for height and age. intake in order to maintain weight in normal
Requirements related range.
to imbalance between
insulin, diet, and activity

Evaluation: Evaluate each outcome to determine how it has been met by the client.

glucose level greater than 126 mg/dL or a nonfasting (ran- Excess secretion of GH produces different changes
dom) level greater than 200 mg/dL on two separate occasions depending on the client’s age when it occurs. When the excess
is diagnostic of diabetes. secretion occurs in childhood before the epiphyses close,
gigantism is the result; in adults, acromegaly is the result.
Syndrome of inappropriate antidiuretic hormone and
pituitary tumors are also discussed.
PITUITARY DISORDERS

H yperpituitarism and hypopituitarism are discussed in

this section. GIGANTISM
Gigantism affects infants and children, causing propor-
tional overgrowth of all body tissues. By the time these
■ HYPERPITUITARISM children reach adulthood, they may be more than 8 feet

H
tall.
yperpituitarism is most commonly diagnosed between Hyperplasia of the anterior pituitary is usually the cause
the second and fourth decade of life but can appear in of GH oversecretion. The oversecretion of GH is often caused
infancy and childhood. Although other pituitary hormones by benign tumors of the pituitary gland. Clients with gigantism
may be affected, the most common are the GH and antidi- do not have the strength their size implies. Additional signs and
uretic hormone. symptoms often experienced by clients with gigantism include

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 CHAPTER 12 Endocrine System 405

delayed puberty, double vision, increased sweating, large hands in females), and sleep disturbance. The client may experience
and feet with thick fingers and toes, and weakness. decreased libido or impotence, oligomenorrhea (scanty or
infrequent menstruation), and infertility.
Medical–Surgical Management The client’s history and clinical manifestations along with
cranial x-rays and a CT scan make a diagnosis of acromegaly.
Medical Serum GH level is elevated.
Irradiation of the anterior pituitary may be the treatment chosen. Prognosis depends on the causative factor, hyperplasia
The child must then be observed for heart failure, hypertension, or a tumor; however, there is generally a reduced life span.
thickened bones, osteoporosis, and delayed sexual development. Diabetes mellitus, hypertension, and a higher risk of cardio-
vascular disease are the most serious health consequences
(NIDDK, 2009).
Surgical
If the cause is a tumor, surgery may be performed to remove Medical–Surgical
Management
the tumor (explained under the section “Acromegaly”). If
surgery cannot completely remove the tumor, medication
management including somatostatin analogs may be used.
Medical
Pharmacological Medical treatment consists of either medication that affects the
GH or irradiation of the pituitary gland. Proton beam therapy
When the pituitary is either destroyed by irradiation or removed uses a very low dose of radiation and is much less destructive
by surgery, pituitary hormone replacement is necessary. to nearby tissue than conventional radiation therapy.

Nursing Management Surgical

Monitor children’s growth for early identification of a prob- Surgical treatment for hyperpituitarism is to remove the
lem. Be understanding and emphasize the positive aspects of pituitary gland. Two surgical approaches to remove the pitu-
being tall. itary are transfrontal or transsphenoid hypophysectomy. The
transfrontal approach is rarely used because it has a high risk
of mortality as well as permanent loss of smell and taste and
NURSING PROCESS causes severe diabetes insipidus. The transsphenoid approach
(Figure 12-11) involves an incision in the superior maxillary
Assessment gingiva. Surgery may be the treatment of choice or used after
attempting medical treatment.
Subjective Data Postoperatively, nasal packing should be checked for clear,
Listening to the child’s description of the disease process may colorless drainage. If it occurs, the drainage must be docu-
provide insight into the child’s emotional responses. mented and reported to the physician. If this drainage is sus-
pected of being cerebrospinal fluid, it should be checked for
Objective Data glucose, which is found in cerebrospinal fluid. The nurse
Frequent measurements of growth indicate a more rapid rate should observe for meningitis infection, which includes ele-
of growth than expected. vated leukocytes, sudden temperature elevation, or complaint
of headache or nuchal rigidity. Analgesics are administered as
needed. The client should avoid activities such as coughing,
ACROMEGALY
Acromegaly affects nearly 60 of every 1 million Americans
(NIDDK, 2008a). Because acromegaly occurs after epiphy-
seal closure of bones, there is bone thickening with transverse
growth and tissue enlargement. This occurs between 30 and
50 years of age. Photographs over years will reveal a progres-
sive enlargement of the face and hands.
Acromegaly involves a gradual onset of clinical mani-
festations, including visual defects from pressure of the
pituitary tumor on the optic nerve, soft tissue swelling, or
hypertrophy of the face and extremities. The cartilaginous and
connective tissue overgrowths result in a characteristic hulking
COURTESY OF DELMAR CENGAGE LEARNING

appearance with thickened ears and nose, and marked projec-

tion of the jaw. The jaw can appear enlarged and the tongue
may also thicken. The paranasal sinuses can become enlarged.
Also laryngeal hypertrophy can occur. The client has thick
fingers with tips that appear “tufted” (shaped like arrowheads
on x-rays). The client exhibits a characteristic moist, weak,
doughy handshake. The heart, liver, and spleen may enlarge.
Some other characteristics are diaphoresis (profuse perspira-
tion), oily or leathery skin, fatigue, heat intolerance, weight gain, Figure 12-11 Transsphenoidal Approach to
headache, joint pain, hirsutism (excessive hairiness especially Hypophysectomy

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406 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

straining, vomiting, or sneezing. The client should be encour-

aged to use an incentive spirometer instead of coughing. The
Nursing Management
client should not brush teeth for 2 weeks to avoid problems Be supportive. Show respect and acceptance. Assess ability
with the incision. Mouthwash can be used. The client should to perform ADLs. Provide soft diet and encourage client to
be instructed to avoid lifting and bending at the waist for 2 to thoroughly chew food and drink fluids often.
3 months after surgery.
NURSING PROCESS
Pharmacological
Two drugs may be prescribed for acromegaly. Bromocriptine Assessment
mesylate (Parlodel) is a nonhormonal drug that activates dop- Subjective Data
amine receptors to inhibit the release of the GH and prolactin.
Bromocriptine mesylate (Parlodel) should be given with food Obtain a thorough nursing history, asking about vision impair-
to decrease gastric upset. Because this drug can cause drowsi- ment, headache, muscular weakness, menstrual irregularities,
ness or dizziness, the client should be instructed to avoid fatigue, sleep pattern changes, and sexual and psychological
activities that require mental alertness. If the client is on oral disturbances.
contraceptives, alternate contraceptive measures should also
be used because bromocriptine can stimulate ovulation. Objective Data
The other drug, octreotide acetate (Sandostatin), inhibits Objective data includes gait changes, vital sign changes (tachy-
the GH. Although octreotide is given by injection, it can still cardia or hypotension, which may indicate congestive heart
cause gastric distress. The injections should be given between failure), dyspnea, thick oily skin, and a deepening of the voice.
meals and at bedtime. Clients with diabetes mellitus should The jaw is enlarged and projected, so the client may have dif-
closely monitor their blood sugar level. ficulty in chewing.

Nursing diagnoses for a client with gigantism or acromegaly include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Disproportionate The client will comply with Assist client with activities of daily living and range-of-motion
Growth related to treatment to minimize hyper- exercises.
increased Ievel of GH pituitarism and stop exces- Administer medications as ordered.
sive growth with treatment.
Remind client to carry medications on person.

Disturbed Body Image The client will acknowledge Encourage client to verbalize feelings. Assist client in setting
related to irreversible physical changes, express achievable short-term goals.
physical changes positive feelings about self, Offer emotional support and help client to develop coping
and exhibit ability to cope strategies. Show respect and acceptance of the client as a person.
with altered body.
Provide a positive but realistic assessment of the situation. Refer to
professional counseling as needed.
Provide education to client and family members concerning disease
process.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

The client will have hyponatremia (<130 mEq/L), water

SYNDROME OF INAPPROPRIATE retention, weight gain, concentrated urine (urine osmolality
ANTIDIURETIC HORMONE >1,200 mOsm/L; specific gravity >1.020), muscle cramps,
and weakness. The low osmolality of the blood allows fluid
Syndrome of inappropriate antidiuretic hormone (SIADH) to leak out of vessels and causes brain swelling. If untreated,
results from an excess of ADH. The posterior pituitary gland lethargy, seizures, coma, and death will result.
continues to release ADH, causing the kidneys to reabsorb
excess water, which decreases urine output and increases
fluid volume. The most common cause is oat-cell lung cancer Medical–Surgical
(NIH, 2007). Other causes are lymphoid pancreatic, duo- Management
denal, thymus, and prostate cancer; central nervous system
trauma; infection; chronic obstructive pulmonary disease; Medical
acute respiratory failure; mechanical ventilation; and medica- The underlying disorder must be treated or medications
tions such as antineoplastic agents, tricyclic antidepressants, stopped that may be contributing to SIADH. Fluid restriction
anesthetics, thiazides, and opioids. will be implemented to prevent further hemodilution. Serious

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 12 Endocrine System 407

hyponatremia (<120 mEq/L) usually is treated with intra- record I&O. Auscultate lungs every 2 to 4 hours. Explain why
venous administration of 3% NaCl. The serum sodium level fluid intake is restricted. Weigh client daily. Provide frequent
should be increased by 12 mEq/L or less per day. If the Na mouth care and apply lubricant to lips.
level is increased too rapidly, the client may experience fluid
volume overload and congestive heart failure.
NURSING PROCESS
Pharmacological
Furosemide (Lasix) is given to increase urine output, while Assessment
demeclocycline hydrochloride (Declomycin) and fludrocorti-
sone (Florinef) are given to enhance sodium retention. Subjective Data
The client may describe muscle cramps, weakness, anorexia,
nausea, and headache.
Diet
Fluid restriction is determined by the serum sodium level.
Fluid restrictions of 1–1.5 liters/day are often implemented Objective Data
for the client with SIADH (Goh, 2004). The client will have weight gain and fluid intake greater than
output, may be irritable and disoriented, become progres-
Nursing Management sively lethargic, and have seizures and diminished or absent
deep tendon reflexes. Serum sodium and osmolality will
Assess client’s hydration and neurologic status every 3 to be decreased. Urine osmolality and specific gravity will be
4 hours. Provide a safe environment for the client. Accurately increased.

Nursing diagnoses for a client with SIADH include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Excess Fluid Volume The client will have Assess client’s weight daily on same scale at same time and
related to decreased increased urine output. vital signs.
urine output Accurately record I&O. Maintain fluid restrictions.
Monitor laboratory reports, including Na, serum osmolality,
urine Na, and urine osmolality.
Administer medications as ordered.

Impaired Oral Mucous The client will have Provide frequent oral care, avoiding alcohol-based mouth
Membrane related to moist, intact oral mucous washes and lemon-glycerine swabs. Allow client to rinse mouth
restriction of fluid intake membranes. with water, but not swallow any.
Provide lubricant for client’s lips.
Allow client to choose fluids and times to drink them.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Treatment is removal of the tumor. Complications of

PITUITARY TUMORS pituitary tumors are endocrine abnormalities if there is no
Pituitary tumors more often affect the anterior pituitary rather replacement therapy after removal of the tumor. If the hypo-
than the posterior portion. Adenomas of the pituitary, which thalamus is compressed, diabetes insipidus can result. If the
are rarely malignant, replace glandular tissue and enlarge the tumor has eroded the base of the skull, the client may have
sella turcica. The cause is unknown, but there may be a predis- rhinorrhea (thin watery nasal discharge). Prognosis depends
position toward tumor formation from an inherited autosomal on the extent of invasion. In most cases, the tumor causes
dominant trait, meaning it is a dominant characteristic carried excessive secretion of the anterior pituitary hormones. Diag-
on any chromosome other than the one determining sex. nostic testing includes dexamethasone suppression test, urine
Clinical manifestations frequently start with a headache cortisol, FSH, LH, free T4, TSH, and MRI of the head.
unrelated to stress or other factors. The next obvious manifesta-
tion is visual problems caused by the tumor putting pressure on Medical–Surgical
the optic nerve. Others include personality changes, dementia, Management
amenorrhea, impotence, lethargy, and weakness. The client
may complain of cold intolerance, increased fatigue, constipa- Medical
tion, and may have seizures. Although the tumor is not malig- Medical treatment of a pituitary tumor often includes radia-
nant, damage is done by tumor invasion of normal tissue. tion therapy. This can be used for small tumors or if the client

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
408 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

is a poor surgical risk. Radiation can also be used after surgery to After a transphenoid approach to removal of the tumor,
shrink tissue remaining after surgical excision. Another alterna- prohibit the client from sneezing, coughing or brushing the
tive to surgery is cryohypophysectomy. This involves freezing the teeth. Monitor dressing for clear leakage which may indicate
area with a probe inserted via the transsphenoidal approach. CSF leakage.

Surgical
Large tumors, especially those impinging on the optic nerve, are NURSING PROCESS
generally removed by using the transfrontal approach. Smaller
tumors can be resected via the transsphenoidal approach. Assessment
Pharmacological Subjective Data
Permanent hormone imbalances frequently result from surgi- Obtain a thorough client history and assess for manifestations
cal removal of the tumor. Consequently, long term hormone of a tumor, such as visual problems, headache, impotence,
replacement therapy is necessary. lethargy, cold intolerance, fatigue, or constipation. The family
may provide insight into any personality changes.
Nursing Management
Provide a safe, clutter-free environment. Keep a call light within Objective Data
the client’s reach. Provide periods of rest after activity. Adjust Assess the client for tilting of the head to compensate for
room temperature for client’s comfort or provide extra blankets. visual disturbances, axillary and pubic hair loss, a waxy appear-
The client will be in ICU for several days if surgery is performed. ance to the skin, and few wrinkles.

Nursing diagnoses for a client with a pituitary tumor include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fatigue related to decreased The client will verbalize Explain relationship between pituitary tumor, fatigue,
ACTH and TSH levels an understanding of the and activity level.
relationship between Suggest alternating periods of activity with
fatigue, the disease, and periods of rest.
activity level, and express
feeling of increasing energy Administer medications as ordered.
as treatment progresses. Encourage completion of all treatments.

Disturbed Sensory Perception The client will use adaptive Provide information about adaptive devices and
(Visual) related to altered devices and appropriate resources for visual changes.
sensory reception, transmission, resources to compensate Provide a safe clutter-free environment. Make certain
and/or integration due to for visual changes, and that the bed is in the low position and the call signal is
pressure on optic nerve by the regain normal vision with in reach of the client. Use side rails as needed.
pituitary tumor treatment.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Deficiency of the GH results in dwarfism, which becomes

■ HYPOPITUITARISM apparent by 6 months of age as the infant exhibits growth

H
retardation, with chubbiness in the lower trunk and a short
ypopituitarism is a complex syndrome marked by meta- stature. As it progresses, secondary tooth eruption is delayed,
bolic dysfunction, sexual immaturity, and growth retar- and later there is a delay in puberty. Growth continues at
dation when it occurs in childhood; Simmonds’ disease and about half the normal rate until the child reaches about
diabetes insipidus are examples of hypopituitarism. The most 4 feet in height. Body proportions are normal, as is mental
common cause of hypopituitarism is a tumor. Other causes are development. Frequently in adulthood, sex organs may not
congenital defects (hypoplasia or aplasia), pituitary infarction develop normally unless treated with hormones. Clients
(from postpartum hemorrhage), pituitary surgery or irradiation, experience an accelerated pattern of aging, resulting in the life
or chemical agents. Hypopituitarism can be primary (meaning span being shortened by as much as 20 years. If the deficiency
there is no known cause) or secondary. Secondary hypopitu- occurs in adults, manifestations are not as apparent. There are
itarism can be a result of a deficiency of hypothalamic-releasing subtle signs such as wrinkles near the mouth and eyes.
hormones. This deficiency can be idiopathic (without a known Deficiencies of follicle-stimulating hormone and LH
cause) or a result of infection, trauma, or tumor. cause differences in clinical manifestations between female
Clinical manifestations develop slowly and generally are and male clients. In the female, symptoms include amenor-
not apparent until 75% of the pituitary is destroyed. Specific rhea, dyspareunia, infertility, decreased libido, breast atrophy,
manifestations will vary with the specific hormone that is sparse or absent axillary and pubic hair, and dry skin. In the
deficient. male, symptoms include weakness, impotence, decreased
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 12 Endocrine System 409

libido, decreased muscle strength, testicular softening and Clinical manifestations have an abrupt onset. The client
shrinkage, and retarded secondary sexual hair growth. experiences extreme polyuria of 4−16 L of dilute urine daily.
In a child, a deficiency of TSH will result in severe growth In some cases, there can be up to 30 L of urine per day. Serum
retardation even with treatment. Other deficiency manifesta- osmolality is >295 mOsm/L and urine osmolality is <150
tions include cold intolerance; constipation; increased or mOsm/L. Urine specific gravity is <1.005 and serum sodium is
decreased menstrual flow; lethargy; dry, pale puffy skin, and 145−150 mEq/L. The client has extreme thirst, preferring cold
bradycardia. Thought processes may also be slowed. beverages. Even though there is an extraordinary volume of
A deficiency of adrenocorticotrophic hormone (ACTH) fluid intake, weight is lost. Other manifestations include dizzi-
results in fatigue, nausea, vomiting, anorexia, weight loss, and ness, weakness, bed wetting, constipation, nocturia, and fatigue
depigmentation of the skin and nipples. Vital signs taken dur- that may be a result of inadequate rest because of frequent
ing periods of stress would show fever and hypotension. nighttime voiding and excess thirst. Diagnostic tests used to
Prolactin deficiency results in absent postpartum lactation, diagnose DI include measurement of ADH, MRI (brain), a
amenorrhea, and sparse or absent axillary and pubic hair. There trail of DDAVP (synthetic ADH), and water deprivation test.
may also be manifestations of thyroid or adrenal cortex failure. Complications of untreated diabetes insipidus are hypo-
Findings of hypopituitarism depend on the specific hor- volemia (abnormally low circulatory blood volume), circula-
mone, client’s age, and severity of condition when detected. tory collapse, unconsciousness, and central nervous system
X-rays of the wrist determine bone age, and a skull series will damage. Prolonged urine flow can cause chronic urinary sys-
rule out a pituitary tumor. Total failure of the pituitary with- tem conditions such as bladder distension, enlarged calyces,
out treatment is fatal; however, prognosis is good with treat- and hydronephrosis.
ment by the appropriate hormone(s). Treatment is primarily Prognosis is generally good with fluid replacement in
replacement therapy for the deficient hormone(s). uncomplicated cases. Prognosis also depends on the underly-
ing cause of diabetes insipidus.

SIMMONDS’ DISEASE Medical–Surgical Management

Simmonds’ disease is defined as a total absence of all pituitary Pharmacological
secretions. This is also called panhypopituitarism. This disease In addition to intravenous fluids, several medications can be
results from surgery, infection, injury, or tumor. It may also used to treat diabetes insipidus. For neurogenic and gesta-
occur after a difficult labor in childbirth because of thrombo- tional diabetes insipidus, desmopressin acetate (DDAVP), a
sis formation during or after delivery. synthetic antidiuretic hormone that can be given parenterally
Clinical manifestations, which vary in intensity, include or nasally, is the drug of choice. Also, vasopressin (Pitressin
extreme weight loss, general debility, lethargy, pallor, dry Synthetic) may be given parenterally or nasally. Make certain
yellowish skin, loss of libido, amenorrhea, and intolerance to that the nasal passage is clear before administering the medica-
cold. The disease leads to loss of axillary and pubic hair and tion. Monitor intake and output and assess for hypovolemia
atrophy of genitalia and breasts. It progresses to bradycardia and electrolyte imbalance. The client should drink fluids or
(slow pulse), hypotension, premature wrinkling of the skin, water only when thirsty (NIDDK, 2008b).
and atrophy of the thyroid and adrenal glands. For nephrogenic diabetes insipidus, a diuretic such as
Treatment consists of administration of ACTH, TSH, or hydrochlorothiazide (HydroDiuril) may be given alone or
thyroid, adrenal, and sex hormones for a lifetime. with amiloride (NIDDK, 2008b).

DIABETES INSIPIDUS Nursing Management

Carefully and accurately monitor and record the client’s I&O.
Diabetes insipidus (DI) is a deficiency of ADH, causing a met- Assess skin turgor and condition of oral mucous membranes.
abolic disorder characterized by severe polyuria and polydipsia. Weigh client daily. Oral fluids are often restricted and provided
Diabetes insipidus generally starts in childhood or early adult- only in amounts equal to the client’s urine output. Assess skin
hood, with a median onset of 21 years. It affects males more on each shift. Apply moisturizing lotion to skin. Provide egg-
often than females. Although a deficiency of ADH is the most crate mattress or sheepskin.
common cause (central), diabetes insipidus can also be caused
by failure of the kidneys to respond to ADH (nephrogenic), a
defect in or damage to the thirst mechanism (dipsogenic), or NURSING PROCESS
during pregnancy (gestational) (NIDDK, 2008b).
Neurogenic diabetes insipidus may be caused by injury or Assessment
ischemia to the hypothalamus or pituitary gland, CNS infec-
tions, head injuries, neurosurgery, or sickle-cell disease. Neph- Subjective Data
rogenic diabetes insipidus may be caused by pyelonephritis, Obtain a thorough client history, including severity of thirst,
chronic renal failure, polycystic disease, or medications such weakness, fatigue, lethargy, bed wetting, dizziness, constipa-
as lithium carbonate (Carbolith), amphotericin B (Fungi- tion, and nocturia.
zone), furosemide (Lasix), or ethycrynic acid (Edecrin).
Dipsogenic diabetes insipidus results in an extreme increase in Objective Data
thirst and then fluid intake, which suppresses ADH secretion, Assess for weight loss, constipation, and signs of fluid volume
increasing urine output. Often dypsogenic DI is caused by deficit, such as dry skin and mucous membranes, fever, dysp-
damage to the hypothalamus. Gestational diabetes insipidus is nea, and poor skin turgor. Check urine for color, amount, and
caused by a placenta enzyme that destroys ADH in the mother specific gravity. Assess weight daily. Figure 12-12 illustrates the
(NIDDK, 2008b). comparison of assessment findings between SIADH and DI.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
410 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

W
a
t
e
r

Tachycardia
Bounding pulse
Hypertension
Hemoglobin

COURTESY OF DELMAR CENGAGE LEARNING

Weak pulses
Decrease urine output Sodium
Hypertension
Weight gain Dry mucus membranes
Hematocrit Hemoglobin Dry skin
Sodium Increased hematocrit
Irritability

SIADH DI

Figure 12-12 Comparison of Assessment Findings between SIADH and DI

Nursing diagnoses for a client with diabetes insipidus include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Imbalanced The client will have Provide easy access to bedpan/bathroom. Answer call signal
Fluid Volume related to sufficient fluid intake to promptly. Monitor the client for dizziness and weakness.
polyuria prevent dehydration. Record client intake and output. Teach client and family how to
record intake and output.
Provide fluids as ordered to cover output.
Monitor weight daily. Use same scale, same amount of
clothing, at the same time daily.
Provide oral care. Use a soft toothbrush, mild mouthwash, and
lubricant for the lips.
Assess condition of oral mucous membranes.
Administer medications via intranasal or subcutaneous routes.

Risk for Impaired Skin The client will maintain skin Assess skin, especially pressure points, 3 times a day. Apply
Integrity related to altered integrity. moisturizing lotion to skin.
hydration Prevent pressure on skin by turning or ambulating client. Use
egg-crate mattress or sheepskin.
Encourage adequate intake of fluids, protein, vitamin C, and
calories.
Monitor for incontinence and nocturia. Thoroughly clean and
dry area following episodes of incontinence.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 12 Endocrine System 411

distal nail separation from the nail bed (onycholysis). There

THYROID DISORDERS may be general or local muscle atrophy and acropachy (soft

W
tissue swelling with underlying bone changes where new
orldwide, a deficiency of iodine is the most likely cause bone forms). There is a tachycardia with bounding pulse up to
of thyroid disorders; however, in countries where 160 beats per minute and down to 80 beats per minute during
iodine in food is plentiful, autoimmune thyroid disease is the sleep. Pulse pressure is widened. There can be muscular weak-
most common thyroid disorder (Walpert, 1998). The thyroid ness and atrophy; osteoporosis; paralysis; vitiligo, milky-white
gland is a butterfly shaped gland located anteriorly to the tra- patches on the skin surrounded by areas of normal pigmenta-
chea. The purpose of the thyroid gland is to produce, store, tion; decreased libido; impaired fertility; and gynecomastia
and release hormones into the bloodstream. The hormones, (abnormal enlargement of one or both breasts in males).
T3 and T4, are responsible for the regulation of body metabo- Diagnostic tests generally include TSH, T3, T4, radioac-
lism (brain development, breathing, heart rate, temperature, tive iodine uptake, and a thyroid scan.
and the nervous system) (NIDDK, 2008c). The production One major complication is thyrotoxic crisis, also called
of T3 and T4 is regulated by the release of TSH from the ante- thyroid storm. This is a medical emergency that can lead to
rior pituitary gland. Thyroid disorders are classified as hyper- cardiac, hepatic, or renal failure. Undiagnosed or inadequately
thyroidism, hypothyroidism, tumors, cancer, or goiter. treated hyperthyroid clients often experience thyroid storm.
Thyroid storm can be precipitated by stressful situations such
as surgery, infection, or trauma. Less common causes are
■ HYPERTHYROIDISM cerebrovascular accident (CVA), myocardial infarction, sud-
den discontinuing of antithyroid medications, subtotal thy-

H yperthyroidism is a collective term for a condition marked

by increased thyroid activity and overproduction of
thyroid hormones thyroxine (T4) and triiodothyronine (T3).
roidectomy with excess intake of synthetic thyroid hormone,
toxemia, or diabetic ketoacidosis. Any of these events can lead
to overproduction of thyroid hormone, causing an increase in
The thyroid gland may be enlarged. Different forms of hyper- systemic adrenergic activity. This causes an overproduction
thyroidism are Graves’ disease, Basedow’s disease, Parry’s of epinephrine and severe hypermetabolism, leading to rapid
disease, or thyrotoxicosis. Graves’ disease is the most com- cardiac, gastrointestinal, and sympathetic nervous system
mon cause of hyperthyroidism and occurs more frequently in decompensation. The client will rapidly exhibit severe clinical
women over age 20 (NIH, 2009). manifestations of hyperthyroidism, including extreme high
In this autoimmune disorder, the immune system trig- fever, restlessness, agitation, coma, heart failure, and angina.
gers the formation of thyroid-stimulating immunoglobulins If the nurse suspects that the client is experiencing thy-
(TSIs). The TSIs bind with TSH receptors, causing an over- rotoxic crisis, inform the physician immediately. The client
production of thyroid hormone. will be transferred to intensive care for closer monitoring of
Clinical manifestations include two obvious physical vital signs, EKG pattern, and cardiopulmonary status. Priority
changes. The thyroid, palpated for asymmetry and size, may treatment includes respiratory support and hemodynamic sta-
be enlarged 3 to 4 times its normal size. The enlargement of bility. Antithyroid therapy is initiated immediately. Adrenergic
the thyroid gland is called goiter. This is generally a result blocking agents are administered to decrease the sympathetic
of overactivity of the thyroid gland. The accumulation of nervous system stimulation. The client’s temperature is moni-
orbital fluid behind the eyeball, forcing it to protrude, is called tored and cooling measures initiated as needed. Acetamino-
exophthalmos. This occurs in about half the cases of hyper- phen is administered to lower the temperature, but aspirin is
thyroidism. It produces a characteristic stare. not given because it can increase the free T4 level. Supportive
The increased thyroid hormone production causes an care is given until the client is out of the thyrotoxic crisis.
increased metabolic rate. This leads to weight loss despite
increased appetite, fatigue, poor tolerance to heat, and profuse
perspiration. The client is very nervous, restless, irritable, Medical–Surgical Management
has difficulty concentrating, is emotionally labile, has mood
swings, possible personality changes, and sleep disturbances. Medical
The client may have fine tremors of the fingers and tongue, The goal of managing hyperthyroidism is to decrease excessive
shaky handwriting, clumsiness, trouble climbing stairs, or thyroid hormone production. With treatment to decrease the thy-
dyspnea on exertion and possibly at rest. The skin is warm roid production of the thyroid’s hormone, the prognosis is good.
and moist with a velvety texture. The skin may be a charac- The client can live a normal life. There can be a combination of
teristic salmon color. The hair is fine and soft with premature treatment methods. The first method is to administer antithyroid
graying and increased hair loss. The nails appear fragile with medications. This is usually a temporary solution.
Radiation therapy of the thyroid gland could be external
radiation to the neck; however, the more accepted method
LIFE SPAN CONSIDERATIONS is the oral administration of radioactive iodine, either liquid
or capsule, that targets the thyroid tissue. Radioactive iodine
Hyperthyroid Complications acts on the thyroid tissue to destroy thyroid cells, potentially
leading to hypothyroidism (NIDDK, 2008c). It is most com-
The older client in particular develops cardiovascular monly used for women past the reproductive years or clients
problems such as arrhythmias (atrial fibrillation), not planning to have children. The client of reproductive age
cardiac insufficiency leading to cardiac decompensation, must sign an informed consent form because small amounts of
and resistance to the usual dose of digoxin. the radioactive iodine could lodge in the gonads.
Antithyroid medications are stopped 4 to 7 days before
treatment. The physician must know if the client is receiving

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412 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

amiodarone hydrochloride (Cordarone), an antiarrhythmic, Laryngeal spasms may occur following injury to the parathyroid
because it contains large amounts of iodine. The oral 131I should glands resulting in hypocalcemia and tetany. A tracheotomy tray
not be given to the client with severe vomiting or diarrhea. or endotracheal tubes and insertion tray are kept readily available at
A single dose of oral 131 I will destroy some iodine con- the client’s bedside in case of a respiratory emergency.
centrating cells that produce the thyroxine. Clinical manifesta- Because the thyroid is so vascular, the dressing must be
tions decrease in about 3 weeks, with the full effect in about checked frequently for drainage, especially at the back of the
3 months. Some clients require a second or third dose. neck. If there is a drain, approximately 50 mL of drainage is
The client usually resumes the thyroid hormone antagonist expected the first day. If there is no drainage, the drain must
3 to 5 days after 131I therapy until the physician determines the be checked for kinks or obstruction. Voice rest is encouraged
thyroid to be atrophic (decreased in size). The client may con- for 48 hours, with voice checks every 2 to 4 hours as ordered
tinue to take propranolol hydrochloride (Inderal) for tachycar- to make certain there is no laryngeal nerve damage.
dia, tremor, and diaphoresis. Continued monitoring of thyroid Because the parathyroid glands could be accidentally
hormone blood levels and physical condition is necessary. removed during the thyroidectomy, the client’s blood calcium
The most common complication is hypothyroidism, level is monitored. The client is checked for Chvostek’s sign
which occurs about 2 to 4 months after treatment. The client is or Trousseau’s sign. (These are discussed under hypoparathy-
then placed on thyroid replacement therapy, generally for life. roidism.) Analgesics are administered as needed.
Complications of thyroidectomy are respiratory distress
Surgical and hemorrhage. There can be damage to the laryngeal nerves,
Generally just a portion of the thyroid gland is removed, but affecting the voice. Manipulation of the thyroid gland dur-
a total thyroidectomy may be performed. This is the most ing surgery can cause a release of large amounts of thyroid
expensive option and has the most risks. A thyroidectomy hormone causing thyroid storm, which is rare but may occur.
may also be done for respiratory obstruction by a goiter or Thyroid crisis usually occurs within the first 12 hours postop-
thyroid cancer. If a partial thyroidectomy is done, the remain- erative. Hyperthyroid signs and symptoms are exaggerated,
ing thyroid tissue should provide adequate amounts of thyroid plus the client may vomit, have severe hypertension and tachy-
hormones. If a complete thyroidectomy is done, the client will cardia, and sometimes have hyperthermia up to 106°F (41°C).
require thyroid hormone replacement for life. The client may develop congestive heart failure and die. The
Clients usually take propylthiouracil (PTU) for 4 to 6 client must be advised that tetany can occur up to 10 days after
weeks before surgery and iodine preparations may be prescribed surgery. Tetany is sharp flexion of the wrist and ankle joints,
10 to 14 days before surgery to decrease thyroid vascularity and muscle twitchings, or cramps caused by decreased blood cal-
decrease bleeding. Depending on the symptoms, the client may cium level.
also be taking propranolol hydrochloride (Inderal). Thyroid
function tests and an EKG are performed before surgery to pro- Pharmacological
vide baseline information. Informed consent must be obtained. Antithyroid therapy is used for children, younger adults, preg-
Preoperatively, the client should be told about activities nant females, the client who refuses surgery, or clients after
after surgery. There will be a neck incision, generally with some surgery. The goal of pharmaceutical management includes the
type of drain. The client may experience a sore throat and client reaching a euthroid state (Daniels, 2007). Several drugs
hoarseness. The client is kept in high-Fowler’s position to pro- can be used for antithyroid therapy. PTU is used frequently,
mote venous drainage. The client should support the head with especially in cases of thyroid storm. It reduces the production
a hand when moving the head to prevent strain on the incision. of the thyroid hormones. It should be given with food. The
Respiratory problems may occur, such as tracheal collapse, tra- client must be instructed to avoid foods high in iodine such as
cheal mucous accumulation, or laryngeal or local tissue edema. shellfish and iodized salt. Over-the-counter preparations must
be checked to see if they contain iodine. This drug requires
several weeks to exert the full effect, and it may be adminis-
SAFETY tered up to 2 years. This drug may cause agranulocytosis
(a decreased number of granulocytes), so it is important to
Radioactive Iodine report signs and symptoms of infection immediately to the
physician.
No pregnant nurse should care for the client. The Methimazole (Tapazole) is another antithyroid prepara-
client should expectorate carefully for the first tion that interferes with thyroid hormone synthesis. It has
day because the saliva is radioactive. The client a more rapid onset than PTU; however, it does not have
should drink plenty of fluids for 2 days to help as much consistency in effect. It should be administered at
circulate and eliminate the radioactive iodine. The evenly spaced intervals with food to prevent gastric upset.
toilet should be flushed twice after each use for This drug can also cause agranulocytosis, particularly in the
client older than age 40.
at least 2 days or throughout the hospitalization.
Iodide preparations may be given to the client with hyper-
Disposable eating utensils should be used by the
thyroidism. Because iodides inhibit the release of thyroid
client. Close contact with children or pregnant hormones rather than the synthesis, they take effect in 2 days.
females should be avoided for a week after the Two common preparations are saturated solution potassium
administration. Females should avoid pregnancy iodide (SSKI) and a solution of iodine and potassium iodide
for 6 months after treatment. that is called Lugol’s solution. When iodide preparations are
administered orally, they should be mixed with milk, juice, or
water and given after meals to decrease gastric upset. Drinking

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 CHAPTER 12 Endocrine System 413

additional meals or snacks. Fluids should be encouraged,

PROFESSIONALTIP but caffeine should be avoided. Clients also may experience
extreme fatigue due to the increased metabolism.
Hypersensitivity to Iodides
The first signs of hypersensitivity reactions caused
Nursing Management
Provide a high-calorie diet and snacks throughout the day.
by iodides are irritation and swollen eyelids. Encourage fluids, but avoid caffeine. Keep client’s skin dry and
clean and change gown and linens as needed. Preoperatively,
teach the client how to support his head while turning or rising
to a sitting or standing position. Inform client that “voice rest”
the preparations through a straw will decrease discoloration of may be enforced for 48 hours and provide paper and pencil
the teeth. These drugs are contraindicated in the client with for writing notes.
acute bronchitis or a known hypersensitivity to iodine and Postoperatively, keep bed in semi-Fowler’s position
shellfish. with head and shoulders supported by pillows. Keep
Clients may be prescribed propranolol hydrochloride suction equipment and tracheotomy tray in the client’s room.
(Inderal) to counteract tachycardia and peripheral effects of Monitor vital signs. Inspect dressing, sides and back of neck,
hyperthyroidism. Clients should not smoke while taking this and shoulders frequently for bleeding. Watch for signs of
medication. Abrupt withdrawal of the drug can cause hyper- internal bleeding (apprehension, restlessness, increased pulse,
tension, myocardial ischemia, or cardiac arrhythmias. Clients decreased blood pressure, and fullness feeling in the neck).
should rise slowly from a sitting or lying position in order to Watch for signs of tetany and for signs of edema in the opera-
prevent orthostatic hypotension. tive area.
Topical medications such as isotonic eyedrops may be
ordered to protect the eyes of the client with exophthalmos.
Care must be taken that the eyes are not injured or infected,
including the use of tinted eye glasses, artificial tears, oint- NURSING PROCESS
ments and protective shields. Some physicians may order high
doses of corticosteroids to help reduce exophthalmos. Assessment
During a thyrotoxic crisis, antithyroid drugs are given.
Other medications that may be used are propranolol, corticos- Subjective Data
teroids, and iodine preparations. Individual client needs could Obtain a thorough client history and ask about the ability to
indicate a need for vitamins, nutrients, fluids, or sedation. concentrate, nervousness, insomnia, jitteriness, excitability,
emotional lability, dysphagia, weight loss, personality changes,
Diet or sleep disturbances.
Because the client has a greatly increased metabolic rate as
well as weight loss, diet is important. The client may require Objective Data
between 4,000 to 6,000 calories per day. There is a need Assess for rapid pulse, elevated blood pressure, warm skin,
for increased protein, vitamins (especially vitamins B and C), elevated temperature, diaphoresis, or hand tremors. Female
and minerals. In addition to 3 meals per day, the client needs clients may cease to menstruate. Hair is fine and soft.

Nursing diagnoses for a client with hyperthyroidism include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Preoperative
Imbalanced Nutrition: The client will eat a Monitor weight daily. Use same scale, same amount of
Less than Body nutritionally balanced diet clothing, at the same time daily.
Requirements related to with enough calories to Encourage 6 meals per day with adequate protein,
increased metabolism prevent weight loss. carbohydrate, and caloric intake.
Arrange a consultation with the dietitian to assist in determining
the client’s increased nutritional needs.
Encourage client to eat a well-balanced diet. Provide snacks
throughout the day.
Complete pre-albumin test to determine protein reserve.

Risk for Injury related to The client’s eyes will not be Administer isotonic solutions or eye lubricants to keep the eye moist.
exophthalmos injured from exophthalmos. At night, elevate head of the bed which may assist in keeping the
eyelids closed, or cover the eyes with eye guards to prevent drying.
(Continues)

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414 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for a client with hyperthyroidism include

the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Suggest to client that dark or tinted wraparound glasses may
protect the eyes from wind and airborne particles.

Postoperative
Impaired Swallowing The client will have Ensure gag, cough, and swallowing reflexes are present
related to mechanical diminished problems with before offering oral fluids. Maintain client in Fowler’s position
obstruction (edema) swallowing. when drinking or eating. Encourage client to drink slowly and
chew thoroughly.

Ineffective Airway The client will be able to Keep intubation and tracheostomy kits readily available.
Clearance related to clear airway. Keep suctioning equipment ready.
edema and pain
Administer analgesic as ordered.
Complete respiratory assessment frequently and monitor for
respiratory distress and laryngeal spasms.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Hyperthyroidism
A.J., 33 years old, has returned to her physician’s office to find out results of her tests for hyperthy-
roidism. She continues to have multiple complaints. “I have lost 15 pounds in the last month despite
eating all the time. I am restless and can’t sleep. I feel jittery and irritable. My family says my moods
change so rapidly they don’t know what to expect from me. I feel so hot most of the time and sweat
a lot.”
During assessment, the client appears flushed and her eyes protrude slightly. Her vital signs are
temperature 100.6°F orally, pulse 120 beats/min, respiration 26 breaths/min, and blood pressure
140/88 mm Hg, which are slightly elevated from her previous office visit. Test results confirm the presence
of hyperthyroidism.

NURSING DIAGNOSIS 1 Imbalanced Nutrition: Less than Body Requirements related to increased
metabolism as evidenced by weight loss despite eating
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Nutritional Status: Food & Fluid Intake Fluid Management
Nutritional Status: Nutrient Intake Nutrition Management

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

A.J. will eat a nutritionally bal- Monitor amount of food Provides data to determine if diet
anced diet with enough calories ingested and caloric intake. is adequate to prevent weight loss.
to prevent weight loss. Monitor weight daily. Determines weight gains or losses.
Provide a diet high in calories, Maintains or increases weight while
protein, and carbohydrates. preventing muscle mass breakdown.
Advise A.J. to avoid highly Prevents increased peristalsis
seasoned or fibrous foods or resulting in diarrhea.
foods causing flatulence.

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 CHAPTER 12 Endocrine System 415

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Provide small frequent meals Provides calories without
spread over waking hours, up to extremely large meals.
6 meals per day.
Obtain nutritional consult as Ensures nutritional status.
needed.

EVALUATION
A.J. gained or maintained weight.

NURSING DIAGNOSIS 2 Hyperthermia related to increased metabolic rate as evidenced by com-

plaints of feeling hot, flushing, and elevated temperature
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Hydration Fluid Management
Thermoregulation

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

A.J.’s body temperature will Assess for elevated temperature, Indicates increased heat production
be within normal range. heat intolerance, and diaphoresis. from increased metabolic rate.
Provide a well-ventilated room Promotes comfort if heat
with temperature control. intolerant.
Suggest wearing cool, loose- Provides comfort and prevents
fitting, lightweight clothing. overheating.
Provide frequent bathing and Promotes comfort if diaphoretic.
changes in linens or clothing.
Provide fluids up to 3 L per day. Replaces fluid if diaphoretic.

EVALUATION
A.J. maintained her temperature in a normal range.

NURSING DIAGNOSIS 3 Risk for Impaired Skin Integrity related to diaphoresis as evidenced by
excessive sweating
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Nutritional Status Fluid/Electrolyte Management
Tissue Integrity: Skin & Mucous Membranes Nutrition Management
PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
A.J.’s skin will remain Complete Braden Scale. Indentifies risk level of skin
intact and free of injury. breakdown.
Assess skin for flushing and moisture. Indicates heat intolerance.
Assess skin for redness, especially Indicates potential for
bony prominences. breakdown.
Keep skin clean and dry. Prevents skin breakdown.

EVALUATION
A.J. maintained intact skin without impairment.

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416 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Complications affect almost every system. Cardiovascular

■ HYPOTHYROIDISM complications include ischemic heart disease, poor peripheral

H
circulation, enlarged heart, or pleural or pericardial effu-
ypothyroidism is a condition in which the metabolic sion. Gastrointestinal complications include adynamic colon
processes are decreased because of a deficiency of (decreased functioning of the colon), megacolon (massive
thyroid hormones. It is termed primary if the problem arises and abnormal dilation of the colon), or intestinal obstruction.
from a dysfunction solely of the thyroid. It is secondary if the Other complications include conductive or sensorineural
thyroid gland is not stimulated to produce normally or if the deafness, psychiatric disorders, carpal tunnel syndrome, or
target cells fail to respond to normal thyroid functioning. This impotence or infertility. Prognosis depends on the organs
condition is more common in females than males. There is a involved, duration, and severity of condition.
significant increase in incidence between the ages of 30 to 60. Myxedema coma or hypothyroid crisis is a rare but serious
Hypothyroid conditions include cretinism, myxedema, and complication of extreme hypothyroidism. It is life threatening,
Hashimoto’s thyroiditis. with symptoms of unresponsiveness, hypothermia, decreased
respirations, low blood pressure, and low blood sugar. It has a
gradual onset but is triggered by severe stress such as infection,
CRETINISM exposure to cold, or trauma. Abrupt withdrawal of thyroid
medication or the use of narcotics, sedatives, or anesthetics can
A congenital condition with decreased thyroid hormone also cause myxedema coma. If myxedema coma occurs, it must
production causes defective physical development and men- be reported to the physician immediately. The client is moved
tal retardation. This is called cretinism and occurs in about to the ICU, where intubation and mechanical ventilation are
1 of 3,000 live births (NIH, 2007). Female clients are two instituted. The client is monitored closely for vital signs, EKG
times more likely to be affected than male clients. The child changes, and cardiopulmonary status. Wrapping the client in
generally has a large head, short limbs, puffy eyes, thick and blankets will warm the client, but a warming blanket should
protruding tongue, excessively dry skin, and a lack of coordi- not be used because it could cause peripheral vasodilation and
nation. If untreated, the child will be permanently dwarfed, shock. Thyroid medications and possibly corticosteroids are
mentally retarded, and sterile. This condition is rare in the administered. Supportive care is given until the client comes
United States and is diagnosed by the T4, serum TSH, x-ray of out of the myxedema coma. Myxedema coma is often fatal.
long bones, and thyroid scan.
Medical–Surgical
MYXEDEMA Management
Myxedema is the term for severe hypothyroidism in adults.
Pharmacological
A variety of abnormalities lead to decreased thyroid hormone Thyroid replacement therapy is lifelong. Thyroid (Armour
production. The obvious ones are thyroid gland surgery Thyroid) is a natural form, whereas levothyroxine sodium
such as thyroidectomy or irradiation of the thyroid gland. (Levothroid, Synthroid) is a synthetic. The physician orders
Some other causes are chronic autoimmune Hashimoto’s thyroid hormone to begin slowly and increases the dosage
thyroiditis, inflammatory conditions (sarcoidosis), pituitary every 2 to 3 weeks until the desired response is achieved.
failure to produce TSH, or hypothalamus failure to produce Medication should be administered 1 hour prior to or 2 hours
thyrotropin-releasing hormone. There may be an inability after meals to improve absorption. The medication should be
to synthesize thyroid hormones related to iodine deficiency given in the morning to prevent insomnia.
(rarely from general diet deficiency) or as a result of taking If the client has diabetes mellitus, insulin or oral hypogly-
antithyroid medications. cemic dosage might have to be adjusted. The blood sugar level
Clinical manifestations are vague and varied, develop- must be monitored closely. If the client is on anticoagulant
ing slowly over a period of time, but are primarily related to therapy, thyroid potentiates the anticoagulant action. The cli-
the reduced metabolic rate. These include an energy loss, ent should be taught to watch for excessive bleeding or bruis-
fatigue, forgetfulness, sensitivity to cold, unexplained weight ing. Digitalis preparations are also potentiated by thyroid.
gain, hypoventilation, and constipation. As the condition Because hypothyroidism impairs the metabolic rate, the
progresses, manifestations include reduced libido, menor- client may have difficulty metabolizing medications. The cli-
rhagia, paresthesias, joint stiffness, and muscle cramping. ent may have an increased sensitivity to hypnotics, sedatives,
There is a characteristic alteration in overall appearance and or opiates. Dosage may have to be adjusted appropriately.
behavior, including decreased mental stability and a thick Synthesis of the thyroid hormone can be impaired by drugs
and dry tongue, causing hoarseness and slow, slurred speech. such as lithium carbonate (Lithotabs) or aminoglutethimide
The skin is flaky and inelastic, and feels cool, dry, rough, and (Cytadren).
doughy. There is edema of the face, hands, and feet. The hair
is dry and sparse, with patchy hair loss including loss of the Diet
outer third of the eyebrow. The nails are thick and brittle with The client is instructed to avoid foods high in iodine and
visible transverse and longitudinal grooves. The pulse is weak foods that interfere with thyroid hormone replacement, such
and bradycardic because of the decreased pumping strength of as dried kelp, shellfish, iodized salt, saltwater fish, cabbage,
the heart. The thyroid gland may be so small that it may not be turnips, pears, and peaches. The diet is designed for weight
palpated unless there is a goiter. The blood pressure is gener- loss and to combat constipation. A high-fiber, high-protein,
ally lower than normal for the client. low-calorie diet is given. Sodium is decreased to prevent fluid
Diagnostic tests generally include TSH, T3, T4, radioac- retention. A dietary consultation for meal planning and a list of
tive iodine uptake, and a thyroid scan. foods to avoid is provided to the client.

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 CHAPTER 12 Endocrine System 417

CLIENTTEACHING
NURSING PROCESS
Items Containing Iodine Assessment
Check the labels on multivitamins, dentrifices, and Subjective Data
nonprescription medications; they may contain Obtain a thorough client history, asking about lethargy,
iodine. depression, irritability, impaired memory, and slowing of
thought processes. The client may describe speech and hear-
ing problems, anorexia, decreased libido, constipation, cold
intolerance, and changes in menstruation.
Nursing Management
Monitor vital signs, heart sounds, lung sounds, I&O, weight, Objective Data
and check for edema. Prevent client fatigue by providing Assess for hearing and speech deficits, thin hair, dry and thick-
rest periods between activities. Provide a high-fiber diet and ened skin, enlarged facial features, masklike expression, low
encourage intake of oral fluids. Administer stool softener, bulk and hoarse voice, bradycardia, decreased blood pressure and
laxative, or enema as ordered. respirations, and exercise intolerance.

Nursing diagnoses for a client with myxedema include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Activity Intolerance The client will express Assist client to gradually increase activity level but encourage
related to decreased understanding to increase rest between activities to avoid fatigue and decrease cardiac
metabolic and energy activity level gradually. oxygen demands.
level The client will maintain Measure client’s legs correctly so antiembolic hose, which help
blood pressure, pulse, and venous return, will fit properly when worn.
respirations within normal Reposition client every 2 hours and encourage client to
limits when active. continue activity when normal activity level is achieved.
The client will regain normal Assess blood pressure, pulse, and respirations frequently and
activity levels. inform physician of abnormal results.

Ineffective The client will not have Assess for chest pain and advise client to report any episodes
Tissue Perfusion chest pain at rest. of angina immediately.
(Cardiopulmonary) The client will have a Monitor client’s vital signs.
related to decreased normal heart rate and Monitor cardiac status through EKG and assessment of heart
cardiac output rhythm. and lung sounds plus checking for edema.
The client will avoid Restrict fluid and sodium during the time of cardiac
ischemic EKG changes. decompensation as ordered. Monitor intake and output and
The client will maintain weight.
adequate cardiopulmonary
perfusion.

Constipation related to The client will have regular Provide high-fiber diet. Encourage intake of oral fluids.
decreased motility of the bowel movements. Assess frequency and character of stool. Administer stool
gastrointestinal tract softener, bulk laxative, or enema as ordered.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

HASHIMOTO’S THYROIDITIS of 30 and 50, and shows a marked hereditary pattern. There is
an increased incidence in clients with Down syndrome and
Turner’s syndrome.
Hashimoto’s thyroiditis, the most common cause of hypothy- Clinical manifestations include a thyroid that is enlarged
roidism, is an autoimmune disease characterized by the produc- and has a lumpy surface. Generally, the goiter is asymptomatic,
tion of antiperoxidase antibodies, which destroy an essential but it could cause dysphagia and a feeling of local pressure.
enzyme necessary for production of T3 and T4. The disease The thymus gland is also enlarged. Other clinical manifesta-
occurs more often in females than in males, between the ages tions are similar to hypothyroidism.

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418 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Treatment of Hashimoto’s thyroiditis is similar to tests are usually normal. A needle biopsy may be done to
that of hypothyroidism. Thyroid hormone replacement confirm diagnosis.
is used. This chronic disorder can be treated but not
cured. The client will be on lifetime thyroid hormone
replacement. Medical–Surgical
Management
■ THYROID TUMORS
Surgical
All carcinomas can be treated with surgery (discussed previ-

T here are several neoplasms of the thyroid gland. The

benign thyroid cyst and adenoma are firm, encapsulated,
noninvasive, slowly growing neoplasms of unknown etiology.
ously). Radioactive iodine or external radiation therapy may
also be used. Radioiodine ablation may be used to destroy any
remaining thyroid tissue. Response of the tumor will depend
Diagnosis of benign neoplasms is done by needle biopsy. on early diagnosis and treatment. These methods of treatment
These growths tend to be nonfunctioning (not affecting the may be used individually or in combination. Client care is the
functioning of the thyroid gland), so there is no treatment same as for hyperthyroidism.
other than continued monitoring. If the adenoma is function-
ing (increasing the functioning of the thyroid gland), then it is Pharmacological
treated by radioactive iodine or surgery. Exogenous thyroid hormone may suppress thyroid activity. To
increase tolerance to surgery or radiation therapy, the physi-
cian may prescribe simultaneous exogenous thyroid hormone
■ CANCER OF THE THYROID and adrenergic blocker such as propranolol hydrochloride
(Inderal). If there is widespread metastasis, the cancers will be

C ancer of the thyroid is rare and occurs in all age groups.

Individuals who have had radiation therapy to the neck
treated with neoplastic chemotherapy.

are more susceptible. There are four major types of thyroid

cancer: Nursing Management
• Papillary carcinoma is the most common type. It can affect The nurse monitors the client’s level of anxiety and encour-
any age but is more common in females of childbearing ages the client to discuss feelings about the diagnosis and
age. It is well-differentiated, grows slowly, is usually possible surgery. The nurse also assists the client in identifying
contained, and does not spread beyond the adjacent lymph previously successful coping methods and teaches new coping
nodes. Cure rate after thyroidectomy is excellent. methods if needed. After surgical intervention, the nurse must
monitor the client for signs and symptoms of airway obstruc-
• Follicular carcinoma metastasizes to the regional lymph tion. Clients will also require education regarding long-term
nodes and spreads through the blood vessels to the bone, medical management of the disease.
liver, and lungs. It has a very low cure rate.
• Medullary carcinoma is a solid carcinoma associated
with pheochromocytoma. These tumors often secrete
calcitonin, adrenocorticotropic hormone, serotonin, and ■ GOITER
prostaglandins. It is curable if detected before signs and
symptoms occur. Without treatment, it grows rapidly,
metastasizing to the bones, liver, and kidneys.
A goiter is an enlargement of the thyroid unrelated to
inflammation or neoplasm. There are three types of goi-
ter. One type is a diffuse toxic goiter found in hyperthyroid-
• Anaplastic or undifferentiated carcinoma resists radiation. It ism. The body’s immune system creates an antibody known as
is almost never curable by resection. It metastasizes rapidly, thyroid-stimulating immunoglobin that mimics TSH, creating
generally causing death by invasion of the trachea and an overproduction of thyroid hormone. This type of goiter
adjacent structures. It generally affects individuals older may be moderate to massively enlarged. The consistency var-
than age 60. ies from soft to firm and rubbery. It generally feels smooth. It
There are several risk factors, such as radiation exposure, is often associated with exophthalmos.
especially in those children and adolescents who received Another type of goiter is a simple nontoxic goiter. It
radiation therapy to treat severe cases of acne vulgaris, or to develops when the thyroid is unable to use iodine properly or
shrink enlarged tonsils, adenoids, and thymus tissue; pro- in response to a low iodine level in the blood. These goiters
longed secretion of TSH resulting from radiation or heredity; are more common in females. They develop during times of
familial disposition; or chronic goiter. great metabolic demands such as adolescence or pregnancy. A
The first clinical manifestation is a painless lump. As it deficiency of iodine can cause goiter formation. Clinical mani-
enlarges, it destroys the thyroid, which leads to clinical mani- festations depend on the size of the goiter. There is an obvious
festations of hypothyroidism. Although rare, the tumor could enlargement of the thyroid gland. A large goiter can compress
trigger excessive thyroid hormone production, causing the cli- the esophagus or trachea, causing dysphagia, a choking sensa-
ent to display the clinical manifestations of hyperthyroidism. tion, or respiratory difficulty. If the goiter impairs venous return
There can be dysphagia, hoarseness, and vocal stridor. There from the head and neck, the client may experience dizziness
may be a detectable, disfiguring thyroid mass with a firm nod- and syncope.
ule on palpation. Diagnosis is based on history, clinical manifestations,
The thyroid scan shows a “cold” nodule (decreased and results of thyroid function tests. T3 is generally very
uptake of 131I) for papillary carcinoma. Follicular carcinoma low. Treatment concentrates on the underlying cause and
and benign adenomas show a “hot” nodule. Thyroid function may involve thyroid hormone replacement therapy, iodine

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 CHAPTER 12 Endocrine System 419

supplements, or increasing dietary iodine sources. Surgery

is done when respiration or swallowing is impaired or for
Medical–Surgical
cosmetic effect. Management
The third type of goiter is the nodular goiter. It is simi-
lar to the simple goiter except that palpation reveals multiple Medical
nodules causing the enlargement. It is found frequently in Medical management is aimed at decreasing overactivity of
females older than 40. It usually is asymptomatic. Treatment the parathyroid glands. This may be accomplished by medica-
varies with the client’s age and clinical manifestations. tion or surgery. If there is severe renal involvement, the client
may require dialysis.

PARATHYROID DISORDERS Surgical

D
Primary hyperparathyroidism can be treated by surgical
isorders discussed include hyperparathyroidism and removal of three and one-half of the four parathyroid glands.
hypoparathyroidism. Surgery can relieve bone pain in 3 days but may not reverse
renal damage.
Preoperative care includes explanations, encouraging flu-
■ HYPERPARATHYROIDISM ids, limiting calcium intake, and administering medications to
lower the blood calcium level.

H yperparathyroidism is a condition resulting from over-

activity of one or more of the parathyroid glands. It
results in increased secretion of parathyroid hormone (PTH),
Postoperative care involves administration of magnesium
or phosphate. The client may receive calcium supplements for
several days. The nursing care is similar to that provided to the
which causes calcium to leave the bones and accumulate in client with thyroidectomy (refer to hyperthyroidism). A major
the blood. This cannot be compensated by renal excretion or complication is airway obstruction.
uptake into the soft tissues. It occurs twice as often in post-
menopausal females than males. It occurs frequently between
the ages of 35 and 65. Hypercalcemia may also be caused by Pharmacological
excessive intake of thiazide diuretics, vitamin D, or calcium Pharmacological treatment is aimed toward correcting second-
supplements. ary hyperparathyroidism, which involves treating the underly-
X-rays will show skeletal decalcification. Blood PTH ing cause. Because hypercalcemia is a major manifestation,
and alkaline phosphate levels are increased. Serum calcium medications are geared to decrease the calcium level in the
level is elevated. As the result of calcium loss from the bones, blood. This includes the use of diuretics such as furosemide
a bone density test may be completed to assess the risk for (Lasix) and ethacrynic acid (Edecrin).
fractures. Other drugs that decrease the calcium level in the blood
Hyperparathyroidism is termed primary if there is an are calcitonin-human (Cibacalcin), plicamycin (Mithracin),
enlargement of one or more of the parathyroid glands, increas- and magnesium- or phosphate-based drugs. Phosphate-based
ing secretion of PTH and thus increasing the blood calcium drugs lower the calcium level based on the inverse relationship
level. The most common cause is adenoma, but other primary between phosphorus and calcium.
causes include genetics, multiple endocrine neoplasms, or
hyperplasia.
The condition is termed secondary if there is excess Nursing Management
compensatory production of PTH stemming from a Preoperatively, encourage oral fluid intake, monitor I&O,
hypocalcemia-producing abnormality other than the parathy- strain urine for calculi, and offer cranberry juice to acidify
roid gland. Some of these abnormalities are rickets, chronic the urine. Postoperatively, carefully monitor I&O, and assess
renal failure, vitamin D deficiency, or osteomalacia caused by for signs of hypocalcemia (tetany, cardiac dysrhythmias, and
laxative abuse or phenytoin (Dilantin). carpopedal spasms). Teach client the principles of good body
Many clients are asymptomatic; however, there are sev- mechanics. Reassure client that bone pain will gradually disap-
eral clinical manifestations. The client may have polyuria, pear. Encourage mild exercise as ordered.
chronic low-back pain, bone tenderness, or renal calculi. The
client may also experience nausea, vomiting, anorexia, consti-
pation, lethargy, or drowsiness. There can be changes in level
of consciousness, disorientation, stupor, coma, or personality
NURSING PROCESS
changes with a loss of initiative and memory. There may be
marked muscle weakness and atrophy especially of the legs,
Assessment
joint hyperextensibility, long bone skeletal deformity, or Subjective Data
hyporeflexia. Obtain a thorough client history and ask about muscle weakness,
Without treatment, there can be permanent damage apathy, nausea, mental status, and pain (low back or renal). Ask
to the skeleton or kidneys. There can be bone and articular about increased calcium intake, either dietary or supplements.
problems including pathologic fractures. Renal complica-
tions include colic, nephrolithiasis, urinary tract infection,
and renal insufficiency leading to chronic renal failure. Other Objective Data
complications may be stone formation in various organs, Note fatigue, drowsiness, anorexia, constipation, personality
cardiac or vascular problems, or central nervous system changes, renal colic, skeletal deformity, output, hematuria, vom-
changes. iting, weight loss, hypertension, bradycardia, or dysrhythmias.

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420 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Nursing diagnoses for a client with hyperparathyroidism include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Activity Intolerance related to The client will regain and maintain Alternate rest and activity periods. Assist client
generalized weakness caused by normal muscle mass and strength, with prescribed, individualized activities.
neuromuscular dysfunction maintain maximum joint range Assist client to identify factors that increase or
of motion, and perform self-care decrease activity intolerance. Encourage client
activity as tolerated. to perform self-care.

Acute Pain related to The client will express relief after Administer analgesics as ordered.
musculoskeletal changes analgesics, use comfort measures Provide comfort measures for bone pain, and
resulting from persistently to decrease pain, and be pain-free include turning and repositioning every 2 hours.
increased serum calcium level when serum calcium level reaches
normal. Assess pain level and compare to serum
calcium level.
Assess environment for hazards and eliminate
them. Assist the client to ambulate.
Maintain the bed in a low position with
side rails up and call light in reach. Lift and
move the client gently to prevent pathologic
fractures.
Provide a safe environment to prevent injuries
associated with pain and weakness.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

deep tendon reflexes. There may be personality changes or

■ HYPOPARATHYROIDISM EKG changes.

H
Two diagnostic assessment tests can be performed. One is
ypoparathyroidism is a condition resulting from a defi- the Chvostek’s sign, which is an abnormal spasm of the facial
ciency of PTH secretion by the parathyroids or the muscles in response to a light tapping of the facial nerve. The
decreased action of peripheral PTH. Because the parathyroids other test is Trousseau’s sign, which is a carpal spasm caused
normally regulate the serum calcium level, hypoparathyroid- by inflating a blood pressure cuff above the client’s systolic
ism will result in a decreased serum calcium level. PTH nor- pressure and leaving it in place for 3 minutes (Figure 12-13).
mally maintains the serum calcium level by increasing bone Expected test results include decreased serum calcium,
resorption and gastric reabsorption. It also maintains the increased urinary calcium, increased serum phosphorus, and
inverse relationship between calcium and phosphorus levels. decreased urinary phosphorus.
Hypoparathyroidism can be acute or chronic. Complications are related to long-standing hypocalce-
If hypoparathyroidism is idiopathic, it may be the result of mia, which leads to decreased heart contractility leading to
an autoimmune disorder or congenital absence of parathyroid cardiac failure. There can be cataract formation or papillary
glands. Acquired hypoparathyroidism is generally irrevers- edema from increased intracranial pressure. There may be
ible. The most common cause is accidental removal of the bone deformity. In cases of severe tetany, the client can expe-
parathyroid glands during thyroid or other neck surgery. It rience laryngospasm, respiratory stridor, anoxia, paralysis of
can also result from ischemic infarction during surgery, sar- vocal cords, and death.
coidosis, tuberculosis, neoplasms, trauma, or massive thyroid
irradiation. Reversible hypoparathyroidism can result from
hypomagnesemia-induced impairment of hormone synthesis, Medical–Surgical
suppression of normal gland function because of hypercalce-
mia, or delayed maturation of the parathyroid glands.
Management
The characteristic sign of hypoparathyroidism is tetany, Pharmacological
which is muscle spasms and tremors caused by a lack of Calcium gluconate or calcium chloride may be given intra-
calcium. Other clinical manifestations include dry skin, venously. Give very slowly because it is very irritating to the
brittle hair, alopecia (loss of hair or baldness), and loss of vessel wall. Too-rapid IV calcium infusion can cause cardiac
eyelashes and fingernails. The teeth are stained, cracked, arrest. Additional complications from IV administration
and decayed because of weak enamel. The client may have of calcium gluconate include seizure activity and laryngeal
altered level of consciousness, neuromuscular irritability, spasms. After the initial IV dose, calcium may be given
tingling and twitching of the face and hands, and increased orally.

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 CHAPTER 12 Endocrine System 421

toxicity. Cimetidine (Tagamet) interferes with normal para-

thyroid functioning.

Diet
The diet should be high in calcium and low in phosphorus-
containing foods. Because many foods that are high in calcium
are also high in phosphorus, the client should be given a list
A
of foods that are high in calcium but lower in phosphorus.
Foods on this list include vegetables such as asparagus, broc-
coli, collards, and tomatoes; fruits such as apricots, bananas,
cantaloupe, and many berries; and other foods such as kidney
beans, lima beans, and brown sugar. Foods that have a high
Positive Chvostek’s Sign phosphorus content and should be avoided include most
legumes, nuts, cheeses, and seafood.

Nursing Management

COURTESY OF DELMAR CENGAGE LEARNING

Monitor vital signs and for signs of hypercalcemia (anorexia,
B vomiting, disorientation, abdominal pain, and weakness).
Assess for respiratory distress. Provide a diet high in calcium-
containing foods. Emphasize the importance of having the
blood level of calcium and phosphorus checked.
Positive Trousseau’s Sign

Figure 12-13 Signs of Hypocalcemia and Hypoparathyroidism; NURSING PROCESS

A, Chvostek’s Sign; B, Trousseau’s Sign
Assessment
Unless the hypoparathyroidism is reversible, the client Subjective Data
will require lifelong calcium replacement. Vitamin D may Obtain a thorough client history, asking the client about recent
also be given to assist in the absorption of calcium. The surgery or irradiation, use of alcohol, numbness or tingling of
calcium supplements should be given 1 to 1½ hours after the skin, anxiety, headache, irritability, depression, or nausea.
meals to increase absorption. If the client cannot swallow
the large tablets, they can be dissolved in hot water and the
suspension cooled before administering to the client. The Objective Data
best sources of calcium are from the diet. The client needs Assess for dysphagia, level of consciouisness changes, laryn-
to take calcium as ordered and not abruptly stop taking it. geal spasm, stridor, cyanosis, dysrhythmias, Chvostek’s sign,
The client must be advised that calcium may cause digitalis and Trousseau’s sign.

Nursing diagnoses for a client with hypoparathyroidism include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related to The client will not exhibit Monitor Chvostek’s and Trousseau’s signs, serum calcium and
calcium deficiency signs and symptoms of phosphorus levels, as well as EKG changes.
tetany, and will prevent Keep tracheotomy tray readily available and maintain seizure
injury from hypocalcemia. precautions.
Support client while walking to prevent injury.
Monitor client taking digoxin for toxicity.

Imbalanced Nutrition: The client will have Provide diet with calcium-rich foods.
Less than Body adequate calcium intake. Give calcium replacement as ordered. The client who is taking
Requirements, related to digoxin must be monitored for toxicity.
calcium intake
Give calcium supplement 1 to 1½ hours before or after meals to
increase absorption.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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422 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

ADRENAL DISORDERS MEMORYTRICK

D isorders in this category include Cushing’s disease/
syndrome, Addison’s disease, and pheochromocytoma. The following is a memory trick to remember the
signs and symptoms of CUSHING’S Disease:
C = Cortisol
■ CUSHING'S DISEASE U = Unusually high ACTH
SYNDROME (ADRENAL S = Sleep disturbances
HYPERFUNCTION) H = Hirsutism

C ushing’s disease, primary adrenal hyperfunction, is

the result of increased pituitary secretion of ACTH,
which causes an increased production of cortisol by the
I = Infection
N = Non-healing wounds

adrenal cortex. Cortisol, a stress hormone, regulates the G = Gain weight

body’s metabolism of carbohydrates, fats, and proteins. Cush- S = Striae
ing’s syndrome refers to symptoms of cortisol excess caused
by other factors. One cause is a corticotropin-producing
tumor in another organ, such as oat-cell carcinoma of the lung
(secondary adrenal hyperfunction). The most common cause Medical–Surgical
of Cushing’s syndrome is prolonged use of glucocorticoid
or corticotropin medications for chronic inflammatory
Management
disorders such as chronic obstructive pulmonary disease, Medical
Crohn’s disease, and rheumatoid arthritis. This is iatro- The major goal is to restore hormone balance. Treatment is
genic (caused by treatment or diagnostic procedures) adre- based on the causative factor. This is accomplished primarily
nal hyperfunction. by medications. If there is adrenal cancer, the client may have
Cushing’s syndrome occurs in females more than males, either radiation therapy to the adrenal gland or surgery on
generally between 30 and 50 years of age. either the pituitary gland or the adrenal glands, or all three
Classic clinical manifestations are adiposity of the face, treatments.
neck, and trunk, which give rise to the moon-shaped face and
buffalo hump. Others include purple striae on the abdomen,
hirsutism, and thin extremities caused by muscle wasting.
Surgical
Boys exhibit an early onset of puberty, whereas girls exhibit If the underlying cause of Cushing’s syndrome is related to
development of masculine characteristics. The client may the pituitary gland, the client may have a hypophysec-
complain of fatigue, muscle weakness, weight gain, sleep tomy done. (Refer to hypophysectomy in the section on
disturbances, water retention, amenorrhea, decreased libido, hyperpituitarism.)
irritability, and emotional lability. There could be petechiae, For an adrenal tumor, an adrenalectomy is performed to
ecchymoses, decreased wound healing, or swollen ankles. decrease the high levels of circulating cortisol. This could be
There are multiple complications of Cushing’s syndrome, unilateral or bilateral. During the first 24 to 48 hours after sur-
most of which are produced by the stimulating and catabolic gery, the client is observed closely for hemorrhage and shock.
effects of cortisol. There can be increased calcium resorp- Vital signs and urine output are monitored. Glucocorticoids
tion from the bone, leading to osteoporosis and pathologic are administered with changing dosage until a maintenance
fractures. It can cause increased hepatic gluconeogenesis dose is established. The client’s blood glucose level must be
and insulin resistance, causing glucose intolerance and dia- monitored, especially for hypoglycemia.
betes mellitus. The client may have frequent infections and
slowed wound healing. There is a suppressed inflammatory
response that can mask severe infections. The client may
have decreased ability to handle stress, which can lead to psy-
chological problems from mood swings to psychosis. Other
complications include hypertension, ischemic heart disease, Cushing’s Syndrome
congestive heart failure, menstrual disturbances, and sexual
dysfunction. • Carry Medic Alert tag, indicating Cushing’s
Plasma cortisol level is elevated. Plasma ACTH level syndrome.
may be elevated or low. Adrenalangiography is done for adre- • Avoid extreme temperature changes, activities
nal tumor. Twenty-four-hour urine tests for 17-ketosteroids, that could result in trauma, and people with
17-hydroxysteroids, and free cortisol are elevated. A dexame- infections.
thasone suppression test may also be completed. If the client’s • Wash hands often and protect skin with good care.
blood and urine cortisol levels do not decrease, then Cushing’s
disease is suspected. • Maintain medication regimen.
Prognosis depends on early diagnosis, identifying the • Notify physician if weakness, fainting, fever,
underlying cause, and effective treatment. Without treatment, nausea, or vomiting occur.
about half of these clients will die within 5 years.

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 CHAPTER 12 Endocrine System 423

grains, legumes, and meat; however, milk, cheeses, and whole

Pharmacological grains are also high in sodium, depending on processing.
Aminoglutethimide (Cytadren) inhibits synthesis of adrenal Many foods high in potassium are also low in sodium. These
steroids. It can cause dizziness or drowsiness. The client foods are legumes; fruits such as figs, oranges, bananas,
should be instructed to avoid activities requiring mental alert- prunes, and raisins; and vegetables such as avocado, potato,
ness or manual dexterity. and spinach. The client should be advised to read labels for
Ketoconazole (Nizoral), while classified as an antifungal, sodium content. Processed foods and many preservatives have
inhibits adrenal steroidogenesis and is used to treat Cushing’s high sodium content and should be avoided. Reduced carbo-
syndrome. hydrates and calories help control hyperglycemia.
Mitotane (Lysodren) directly suppresses the activity
of the adrenal cortex. This cytotoxic agent is generally used
for inoperable adrenal cortex cancer. It is given for at least
3 months. The client should avoid situations that cause injury Nursing Management
or exposure to infections. Encourage client to turn frequently and ambulate to pre-
If the client had pituitary or adrenal surgery, cortisol ther- vent pressure on bony prominences. Gently handle client to
apy may be given before and after surgery to decrease physical prevent ecchymosis. Provide elbow and heel protectors and
stress. The client may need to adhere to lifetime treatment with an egg-crate mattress. Provide rest periods during personal
steroids. The client should take the drug with food or antacids hygiene activities.
to decrease gastric distress. Two-thirds dose of the steroids
should be taken in the morning, with the remaining one-third
in the early evening to mimic the body’s diurnal schedule.
Steroids can lead to osteoporosis and the possibility of patho-
NURSING PROCESS
logic fractures. Females should be warned that steroid use can
interfere with oral contraceptive effectiveness. There may be
Assessment
an adverse effect on the male’s sperm production and count. Subjective Data
The client with diabetes mellitus may have to adjust insu- Obtain a thorough client history, asking about the use of ste-
lin dosage because the steroids can affect the glucose level. roids, stress, methods of coping with stress, irritability, depres-
Steroids can mask severe infections and cause some immuno- sion, mood swings, loss of libido, and the possibility of suicide.
suppression. Wounds are slower to heal. The client should be
instructed to contact a physician before using over-the-counter Objective Data
preparations. The client should not abruptly discontinue the
steroid drug; dosage must be tapered before discontinuing. Assess for thin and fragile skin, petechiae, ecchymoses, delayed
wound healing, weight gain, increased abdominal girth, thin
extremities with muscle wasting, purple striae, hyperglycemia,
Diet and hypokalemia. Women may have hirsutism (excessive
The diet should be high in protein and potassium but low body hair in a masculine distribution), deepening of the voice,
in sodium. Foods high in protein include eggs, milk, whole and menstrual irregularities.

Nursing diagnoses for a client with Cushing’s syndrome include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Body Image The client will verbalize Encourage client to verbalize feelings about changed body
related to changes in feelings about changed image. Offer emotional support and a positive realistic
physical appearance appearance. assessment of the condition.

Risk for Infection The client will take Advise client to avoid people with infections.
related to suppressed precautions to avoid or Provide a private room with reverse or protective isolation as
inflammatory response decrease exposure to indicated.
from excessive infection.
corticosteroid production Monitor client’s vital signs, intake and output, and weight.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

and its secretions—mineralocorticoids, glucocorticoids, and

■ ADDISON’S DISEASE androgens. It can also be called adrenal hypofunction or insuf-
(ADRENAL HYPOFUNCTION) ficiency. It is fairly uncommon, occurring in 5 per 100,000

A
people in the United States (Daniels, 2007). Although it
ddison’s disease, primary hypofunctioning of the adrenals, affects all ages and both sexes, it is less common among the
involves decreased functioning of the adrenal cortex elderly.

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424 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Addison’s disease occurs when more than 90% of the adre-

nal gland is destroyed. It is an autoimmune disease in response Pharmacological
to conditions such as tuberculosis, histoplasmosis, HIV, and The client will require lifetime maintenance of steroids.
meningococcal pneumonia. It can be caused by bilateral adrena- Administration of glucocorticoids such as hydrocortisone
lectomy, hemorrhage into the adrenal gland related to antico- (Hydrocortone) and mineralocorticoids such as fludrocorti-
agulant therapy, or cancer of the adrenal gland. It is termed sone acetate (Florinef) are given two-thirds of the daily dose
secondary if it results from decreased pituitary or hypothalamus in the morning and one-third in the evening. In times of stress,
function or abrupt withdrawal of long-term steroid therapy. the dose may need to be doubled or tripled.
A classical clinical manifestation of Addison’s disease
is a bronze coloration of the skin resembling a deep suntan, Diet
especially in the creases on the hands, elbows, and knees. The diet should be high in sodium and low in potassium. It
There may be some areas of vitiligo. The client may com- should contain adequate calories and protein. If the client is
plain of fatigue, muscle weakness, lightheadedness upon ris- anorexic, six small meals may increase caloric intake. A late
ing, weight loss, and craving for salty foods. The client may afternoon or evening snack should be available if the client’s
have decreased tolerance even to minor stress. The client is blood glucose level drops.
anxious, irritable, and may become confused. The pulse may
be weak and irregular. There is hypotension and a variety of
gastrointestinal complaints. The client is also at risk for ortho- Nursing Management
static hypotension. Carefully assess the client’s circulatory status. Weigh client
The acute form is called adrenal crisis. It may occur daily. Accurately record I&O. Monitor vital signs and skin tur-
when there is trauma, surgery, other physiologic stress, or gor. Provide a private room and screen visitors for infections.
abrupt withdrawal of steroids. The clinical manifestations Teach importance of taking medications as prescribed, wearing
are the same, only more severe with a rapid onset. The crisis a Medic Alert bracelet, reporting any illness to the physician,
requires immediate treatment. The client will be placed on and having regular checkups. A kit including injectable hydro-
intravenous therapy and IV administration of hydrocorti- cortisone should be available when oral intake is not feasible.
sone (Cortef, Hydrocortone). Measures to maintain a stable
blood pressure and normal water and sodium levels are
instituted. EKG monitoring is needed to assess for compli- NURSING PROCESS
Assessment
cations associated with elevated K and Ca levels. After the
crisis, the client will be placed on a maintenance dose of
hydrocortisone.
Expected test results include low serum sodium, high Subjective Data
serum potassium, low serum glucose, low cortisol and aldo- Obtain a thorough client history, asking about recent synthetic
sterone serum levels, and decreased urinary 17-ketosteroid steroid use, adrenal surgery, infection, salt craving, nausea,
and 17-hydroxysteroid levels. weakness, vertigo, headache, disorientation, emotional status,
anxiety, and apprehension.
Medical–Surgical Management Objective Data
Medical Assess for postural hypotension, inability to perform normal
Treatment is geared toward prompt restoration of fluid and activities, syncope, dark pigmented areas on skin and mucous
electrolyte balance and replacement of deficient adrenal membrane, weight loss, vomiting, diarrhea, and very low or
hormones. very high temperature.

Nursing diagnoses for a client with Addison’s disease include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Fluid Volume The client will regain normal Monitor client’s vital signs, level of consciousness, intake and
related to low sodium fluid and electrolyte balance. output, and weight.
level, vomiting, diarrhea, Administer IV fluids as ordered and encourage fluid intake.
and increased renal
losses

Risk for Infection The client will maintain Monitor temperature every 4 hours unless elevated, then every
related to suppressed normal temperature 2 hours.
inflammatory response and leukocyte count Provide a private room with reverse or protective isolation as
and differential, and use needed. Screen personnel and visitors for infection. Teach
precautions to avoid or proper hand hygiene.
reduce risks of infection.
Monitor laboratory test results for WBC and differential.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 12 Endocrine System 425

LIFE SPAN CONSIDERATIONS Medical–Surgical Management

Surgical
Pheochromocytoma The treatment of choice is surgical removal of the tumor.
Pheochromocytoma is frequently diagnosed during
Sometimes the adrenal gland is also removed. The blood
pressure is monitored closely during the immediate postop-
pregnancy when the enlarged uterus puts pressure
erative period. The client may have hypotension, but hyper-
on the tumor, causing more frequent attacks. The tension is more common. About 10% of the clients are not
attacks could prove fatal to both mother and fetus. candidates for surgery. They are treated with medications to
Although there is an increased risk of spontaneous lower the blood pressure.
abortion, most fetal deaths occur during labor or
immediately after delivery.
Pharmacological
During acute hypertensive attacks, the drugs of choice are
phentolamine mesylate (Regitine) or nitroprusside sodium
(Nipride). Phentolamine mesylate (Regitine) and phenoxy-
benzamine HCl (Dibenzyline) are alpha-adrenergic blocking
■ PHEOCHROMOCYTOMA agents. They are used to control hypertension before surgery

P
or when surgery is contraindicated. The client should be
heochromocytoma, sometimes known as chromaffin cell warned about orthostatic hypotension and rise slowly from a
tumor, is a rare disease characterized by paroxysmal supine position to an upright position. The client should not
(a symptom that begins and ends abruptly) or sustained take over-the-counter drugs or alcohol.
hypertension caused by excessive secretion of epinephrine Nitroprusside sodium (Nipride, Nitropress) acts on the
and norepinephrine. The excessive secretion of epinephrine vascular smooth muscle to cause peripheral vasodilation. The
and norepinephrine stimulates the sympathetic nervous sys- drug is given in an intravenous infusion. An electronic infu-
tem leading to hypertension and tachycardia. Some medical sion device must be used to monitor the infusion rate. The
experts estimate that about 0.5% of clients newly diagnosed client’s blood pressure is used to titrate the infusion rate per
with hypertension have pheochromocytoma. Although the the physician’s orders.
tumor is generally benign, it can be malignant in 5% to 10% of Metyrosine (Demser) is used to block catecholamine syn-
the cases. It affects all races and both sexes. It is most common thesis. This drug must be continued for life if the tumor is inop-
in women ages 20 to 50 years. erable. Ongoing medications include adrenergic blockers such
It is caused by a chromaffin cell tumor of the adrenal as propranolol hydrochloride (Inderal), atenolol (Tenormin),
medulla, more commonly on the right side. Extraadrenal prazosin HCl (Minipress), labetalol HCl (Normodyne), or
pheochromocytomas can also occur. Epinephrine overpro- nifedipine (Procardia), a calcium channel blocker. The client’s
duction occurs with the adrenal pheochromocytoma; how- blood pressure must be monitored frequently to determine
ever, norepinephrine overproduction is associated with both the effectiveness of the medication.
adrenal and extraadrenal pheochromocytoma. It is associated Propranolol hydrochloride (Inderal) should not be
with a family history of pheochromocytoma or endocrine stopped abruptly. The client should not smoke while taking
gland cancer. It is considered to be inherited on the autosomal- this medication. Atenolol (Tenormin) may enhance the client’s
dominant gene in about 5% of the cases. sensitivity to cold. Prazosin HCl (Minipress) should be taken
The classic triad of clinical manifestations is hyperten- on an empty stomach. The initial dose should be given at bed-
sion with diastolic pressure above 115 mm Hg, unrelenting time. The client should not use cough, cold, or allergy medica-
headache, and profuse diaphoresis. Other clinical manifesta- tions without the physician’s knowledge. If the client is given
tions include palpitations, visual disturbances, nausea, or parenteral labetalol HCl (Normodyne, Trandate), the client
vomiting. These attacks may be triggered by activities or con- should remain supine for 3 hours to decrease the possibility of
ditions that displace the abdominal contents, such as heavy orthostatic hypotension. Nifedipine (Adalat, Procardia) should
lifting, exercise, bladder distention, or pregnancy. Severe be protected from light and moisture and stored at room tem-
attacks can be precipitated by administration of opiates, perature. Over-the-counter medications should not be taken.
histamine, glucagon, and corticotropin. Some attacks may
have no precipitating factor. Some other clinical manifesta-
tions are mild to moderate weight loss caused by increased Diet
metabolism and orthostatic hypotension when rising to an The diet should be high in protein with adequate calories.
upright position. The client will have tachycardia. The actual Stimulating foods such as aged cheeses and yogurt; caffeine-
tumor is rarely palpable; however, palpation could trigger a containing beverages such as coffee, tea, and soft drinks; and
hypertensive attack. beer and red wine should be avoided (Smeltzer & Bare, 2006).
The complications are similar to those of severe and
persistent hypertension. These complications are stroke,
retinopathy, heart disease, or irreversible kidney disease. Nursing Management
The client with pheochromocytoma has an increased risk of The nurse should ask about heat intolerance, severe headaches
severe complications or death during invasive diagnostic tests during hypertensive crisis, anxiety, trouble sleeping, palpitations,
or surgery. nervousness, dizziness, paresthesias, and nausea. The client is
Although pheochromocytoma can be potentially fatal, assessed for dyspnea, tremors, diaphoresis, glycosuria, hypergly-
the prognosis is good with treatment. About 90% of the clients cemia, or dilated pupils. Frequently assess blood pressure, pulse,
are cured. and respirations for elevations, and observe for signs of anxiety.

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426 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

CASE STUDY
A.F., a 44-year-old African-American man, is admitted to the medical unit from his physician’s office. He reports
that he has lost 18 pounds over the last month and has been very tired. He also reports symptoms of thirst,
frequent urination, and blurred vision. His vital signs are blood pressure 166/92 mm Hg, pulse 88 beats/min, res-
piration 16 breaths/min, and temperature 99.2°F. Physical assessment reveals hot, dry, flushed skin. Laboratory
exams reveal a blood glucose 490 mg/dL and urine negative for ketones. A.F. is a truck driver and leads a fairly
sedentary lifestyle. History reveals that he is usually 30 to 35 pounds overweight but has otherwise been in good
health. He reports that his mother died from diabetes and renal failure, and an older brother was diagnosed as
having type 2 diabetes 3 years ago.
The following questions will guide your development of a nursing care plan for this case study:
1. List physical symptoms that A.F. is experiencing that are suggestive of diabetes.
2. On the basis of the client’s history and laboratory values, would you expect A.F. to be diagnosed with type 1
or type 2 diabetes?
3. Which nursing diagnoses would you identify as priorities for A.F. right now? List two.
4. A.F. is treated with IV fluids and insulin sliding scale until his blood glucose is stabilized. Describe what an
insulin sliding scale is, and when it is used.
5. A 2,000-calorie ADA diet is ordered for A.F. He does not care to eat the apple that came on his breakfast
tray and asks if he can exchange it for another serving of scrambled eggs. How would you respond to
Mr. Carnes?
6. A.F. is being discharged and will continue to attend diabetic education classes at a local diabetic treatment
center. Assuming A.F. is to continue on a diabetic diet and will be receiving mixed insulin injections, list the
pertinent information A.F. will need to know about his disease and therapies related to:
• Diabetes and symptoms of hyperglycemia
• Role of exercise
• Effects of diet
• Self-monitoring blood glucose
• Insulin injections/technique
• Symptoms of hypoglycemia
• Sick-day care
• Long-term complications

SUMMARY
• The endocrine system is composed of glands at various • A coordinated program of exercise, diet, and medications
body locations producing secretions (hormones) that is used to achieve diabetic control. Persons with type 1
directly enter the blood or lymph circulation. diabetes always require insulin therapy in addition to
• The endocrine system provides slower and longer-lasting dietary control and an exercise program. Persons with type 2
control over various body activities and functions. diabetes are managed through diet and exercise and may
• A malfunction of any part of the endocrine system can or may not require oral hypoglycemic agents or insulin.
result in a shift of homeostasis with far-reaching systemic • The goal of diabetes management is enabling the diabetic
reactions. to manage the disease by maintaining a blood glucose level
• Assessment of the endocrine system can be challenging within an acceptable range and thereby minimizing the
because the glands are scattered. Negative findings are as incidence of acute and chronic complications.
important as positive findings. • Regardless of disorder, the client should wear a Medic
• Diabetes is a complex chronic disease with multiple acute Alert bracelet and be aware that the treatment generally
and chronic complications. It is a systemic disease caused lasts a lifetime.
by an imbalance between insulin supply and demand.

REVIEW QUESTIONS
1. A client tells the nurse that she is surprised that she 1. atherosclerosis.
developed diabetes at 40 years of age. The nurse 2. eating too much sugar.
knows that the development of diabetes in middle- 3. obesity.
aged people is most directly the result of: 4. viral infection.

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 CHAPTER 12 Endocrine System 427

2. Which of the following principles is used when plan- 3. “Walking barefoot is advised. It will improve the
ning for a client with diabetes who is to undergo circulation in my feet.”
surgery? 4. “I will check the temperature of my bath water
1. All insulin is withheld until surgery is over and before entering the tub.”
the client is eating. 7. A client with SIADH has been admitted to the
2. Insulin or oral hypoglycemics are given as usual. hospital. Which of the lab values listed below is
3. Sliding-scale insulin is used to regulate glucose congruent with this diagnosis?
levels during the operative period. 1. Serum Na 124 meq/L.
4. Hyperglycemia poses the most serious danger to 2. Urine osmolality <300 mOsm/L.
the client during surgery. 3. Urine specific gravity 1.010.
3. Which of the following nursing diagnoses would be 4. Hemoglobin A1C 4.7.
most appropriate for the client with diabetes 8. Which of the following nursing diagnoses would
insipidus? the nurse plan to institute on a client suffering from
1. Alteration in growth and development related to SIADH?
increased growth hormone production. 1. Fluid Volume Excess related to decreased urine
2. Alteration in thought processes related to output.
decreased neurologic function. 2. Ineffective Coping Mechanism related to disease
3. Fluid volume deficit related to polyuria. process progression.
4. Hypothermia related to decreased metabolic rate. 3. Risk for Hyperthermia related to alteration in
4. Meticulous skin care is especially important for the temperature regulation control.
client with hyperthyroidism because of: 4. Fluid Volume Deficit related to excessive urine
1. diaphoresis from heat intolerance. output.
2. edema from sodium and water retention. 9. A client with suspected Addison’s disease is admit-
3. poor nutrition due to nausea and vomiting. ted to the hospital. Which diagnostic tests indicate a
4. pressure from immobility due to paralysis. positive diagnosis of Addison’s disease?
5. The nurse is caring for a client immediately after 1. Elevated blood sugar.
surgery for a complete thyroidectomy. Which of the 2. Decreased cortisol.
following signs/symptoms would alert the nurse to a 3. Decreased potassium.
life threatening complication of the surgery? 4. Elevated sodium.
1. Urine output of 30 mL/hour. 10. Which of the following nursing diagnoses would the
2. Laryngeal stridor. nurse question when caring for a client with
3. Neck stiffness. Cushing’s disease?
4. Sinus tachycardia 110 beats/min. 1. Risk for Disturbed Body Image related to disease
6. Which of the following statements made by a client process.
indicates the need for further teaching regarding foot 2. Risk for Infection related to immunological
care associated with diabetes mellitus? changes.
1. “I will contact my podiatrist to have callouses and 3. Risk for Injury related to muscle weakness and
corns removed.” wasting.
2. “I will use a mirror to inspect my feet for bruises, 4. Risk for Deficient F luid Volume related to excessive
cuts, and abrasions.” excretion of water and sodium.

REFERENCES/SUGGESTED READINGS
Alexander, I. (2008). PDR nurses drug handbook. Clifton Park, NY: Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds.
Delmar Cengage Learning. (2008). Nursing Interventions Classification (NIC) (5th ed.).
American Diabetes Association. (2009). Diagnosis and classification St. Louis, MO: Mosby/Elsevier.
of diabetes mellitus. Diabetes Care 32, S62−S67. Caffrey, R. (2003). Are all syringes created equal? AJN, 103(6),
American Thyroid Association. (2004). Severe mental impairment and poor 46–49.
physiological status predict mortality in patients with myxedema coma. Cameron, B. (2002). Making diabetes management routine. AJN,
Retreived from www.thyroid.org/patients/notes/july4/04_07_28.html 102(2), 26–32.
Anthony, M. (2003). Hypoglycemia. Nursing2003, 33(2), 88. Centers for Disease Control and Prevention. (2007). National diabetes
Bacoka, J. (2001). Thyroid storm. Nursing2001, 31(12), 88. fact sheet, 2007. Retrieved May 2009 from http://www.cdc.gov/
Bartels, D. (2004). Adherence to oral therapy for type 2 diabetes: diabetes/pubs/general.htm
Opportunities for enhancing glycemic control. Journal of American Centers for Disease Control and Prevention. (2008). Frequently asked
Academy of Nurse Practitioners, 16(1), 8–16. questions: Groups especially affected by diabetes. Retrieved August
Bartol, T. (2002). Putting a patient with diabetes in the driver’s seat. 2, 2009 from http://www.cdc.gov/diabetes/faq/groups.htm#9
Nursing2002, 32(2), 53–55. Cincinnati, R., & Veliko, J. (2001). Oral medications. RN, 64(8), 30–36.

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428 UNIT 4 Nursing Care of the Client: Mobility, Coordination, and Regulation

Clarke, K. (2002). No needles needed. Nursing2002, 32(5), 49–51. National Institution of Diabetes and Digestive and Kidney Diseases
Cypress, M. (2001). Acute complications. RN, 64(4), 26–31. (NIDDK). (2008b). Diabetes insipidus. Retrieved October 18,
Daniels, R. (2009). Delmar’s guide to laboratory and diagnostic tests 2009 from http://www.nlm.nih.gov/medlineplus/ency/
(2nd ed.) Clifton Park, NY: Delmar Cengage Learning. article/000377.htm
Diabetes Insipidus Foundation Inc. (2003–Update 2006). Available National Institution of Diabetes and Digestive and Kidney Diseases
from http://www.diabetesinsipidus.org/whatisdi.htm (NIDDK). (2008c). Hyperthyroidism. Retrieved from http://www
Estes, M. E. Z. (2010). Health assessment & physical examination .nlm.nih.gov/hyperthyroidism.htm
(4th ed.). Clifton Park, NY: Delmar Cengage Learning. National Institution of Diabetes and Digestive and Kidney Diseases
Fain, J. (2001). Lowering the boom on hyperglycemia. Nursing2001, (NIDDK). (2008d). Hypoparathyroidism. Retrieved from http://
31(8), 49–50. www.nlm.nih.gov/medlineplus/encyc/article/00385.htm
Fain, J. (2003). Pump up your knowledge of insulin pumps. National Institution of Diabetes and Digestive and Kidney Diseases
Nursing2003, 33(6), 51–53. (NIDDK). (2008e). Pheochromocytoma. Retrieved from http://
Flood, L., & Constance, A. (2002). Diabetes & exercise safety. AJN, www.nlm.nih.gov/medlineplus/pheochromocytoma.htm
102(6), 47–55. Norris, J. (senior ed.). (1998). Handbook of medical–surgical nursing
Goh, K. (2004). Management of hyponatremia. American Family (2d ed.). Springhouse, PA: Springhouse Corp.
Physician, 69(10), 2387–94, 2303–5, 2480. North American Nursing Diagnosis Association International. (2010).
Goldberg, J. (2001). Nutrition and exercise. RN, 64(7), 34–39. NANDA-I nursing diagnoses: Definitions and classification 2009–2011.
Halpin-Landry, J., & Goldsmith, S. (1999). Feet first: Diabetes care. Ames, IA: Wiley-Blackwell.
AJN, 99(2), 26–33. Olohan, K., & Zappitelli, D. (2003). The insulin pump. AJN, 103(4),
Hardman, L., & Young, F. (2001). Combating hyperosmolar hyperglycemic 48–56.
nonketotic syndrome. Nursing2001, 31(3), 32hn1–32hn4. Plummer, E. (2001). Chronic complications. RN, 64(5), 34–40.
Holcomb, S. (2003). Detecting thyroid disease, part 1. Nursing2003, Robertson, C. (2001). The untold story of disease progression. RN,
33(8), 32cc1–32cc4. 64(3), 60–64.
Ignatavicius, D., & Workman, L. (2006). Medical surgical nursing – Ruiz, E. (2001). Type 2 disease in children. RN, 64(10), 44–48.
critical thinking for collaborative care (5th ed.). St. Louis, MO: Sachse, D. (2001). Acromegaly. AJN, 101(1), 69–77.
Saunders/Elsevier. Sammer, C. (2001). How should you respond to hypoglycemia?
LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical Nursing2001, 31(7), 48–50.
thinking in client care (4th ed.). New York, NY: Prentice Hall. Schori-Ahmed, D. (2003). Thyroid disease, RN, 66(6), 38–43.
Lorenz, R., & Silverstein, J. (2005). Managing insulin requirements at Seley, J. (2003). Giving the fingers a rest. AJN, 103(3), 73–77.
school. Retrieved August 2, 2009 from http://ndep.nih.gov/media/ Shelly, A. (2002). Elderly patients with diabetes. AJN, 102(2), 15–16.
SNN_March_2005.pdf Smeltzer, S., & Bare, B. (2006). Brunner & Suddarth’s textbook of
Malchiodi, L. (2002). Thyroid storm. AJN, 102(5), 33–35. medical–surgical nursing (11th ed.). Philadelphia: Lippincott
McCance, K., & Huether, S. (2005). Pathophysiology: The biologic basis Williams & Wilkins.
for disease in adults and children (5th ed.). St. Louis, MO: Mosby. Spratto, G., & Woods, A. (2009). 2009 PDR nurse,s drug handbook.
McConnell, E. (2002). Myths & facts . . . about Addison’s disease. Clifton Park, NY: Delmar Cengage Learning.
Nursing2002, 32(8), 79. Strowig, S., (2001). Insulin therapy. RN, 64(9), 38–44.
McConnell, E. (2003). Myths & facts . . . about diabetes insipidus. The Expert Committee on the Diagnosis and Classification of Diabetes
Nursing2003, 33(6), 84. Mellitus. (1997). Report of the expert committee on the diagnosis
Melmed, S., Kleinberg, D., et al. (2008) Williams textbook of and classification of diabetes mellitus. Diabetes Care, 20(7),
endocrinology (11th ed.). Philadelphia, PA: Saunders/Elsevier 1183–1197.
Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing Thibodeau, G., & Patton, K. (2009). The human body in health &
Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby. disease (4th ed.). St. Louis, MO: Mosby.
National Cancer Institute. (2009). Retrieved from http://www.cancer Tkacs, N. (2002). Hypoglycemia unawareness. AJN, 102(2), 34–39.
.gov/cancertopics/pdq/treatment/pheochromocytoma/patient U.S. Department of Health and Human Services, National Center for
National Diabetes Education Program. (2008). Overview of diabetes in Chronic Disease Control and Prevention, Division of Diabetes
children and adolescents. Retrieved August 2, 2009 from http:// Translation. (1992). Diabetes in the United States: A strategy for
ndep.nih.gov/media/diabetes/youth/youth_FS.htm#Diabetes prevention. Washington, DC: U.S. Public Health Service.
National Institutes of Health. (2009). Graves disease. Retrieved Valentine, V. (2002). Using a laser to make a point. Nursing2002,
August 3, 2009 from http://www.nlm.nih.gov/medlineplus/ency/ 32(10), 56–57.
article/000358.htm Watts, S., Anselmo, J., & Smith, M. (2003). Combating hypoglycemia in
National Institution of Diabetes and Digestive and Kidney Diseases the hospital and at home. Nursing2003, 33(3), 32hn1–32hn5.
(NIDDK). (2008a). Acromegaly. Retrieved from http://www.nlm Williams, J. (2001). We make foot exams a priority. RN, 64(5), 40–41.
.nih.gov/medlineplus/encyc/article/00321.htm

RESOURCES
American Association of Diabetes Educators, National Institutes of Health,
http://www.aadenet.org http://www.nih.gov/science/campus
American Diabetes Association, http://www.diabetes.org National Organization for Rare Disorders, Inc.
American Dietetic Association, http://www.eatright.org (NORD), http://www.rarediseases.org
Juvenile Diabetes Foundation International, The Diabetes Insipidus Foundation, Inc.,
http:// www.jdrf.org http://www.diabetesinsipidus.org
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 5 Reproductive and Sexual Health
Chapter 13 Reproductive System / 430

Chapter 14 Sexually Transmitted Infections / 481

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 13
Reproductive System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the female and
male reproductive systems:
Adult Health Nursing
• Oncology • Endocrine System
• Cardiovascular System • Sexually Transmitted Infections
• Urinary System • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Identify the anatomy of the reproductive systems.
• Describe the hormonal mechanisms that regulate the reproductive
functions, including the menstrual cycle.
• Interpret diagnostic tests for disorders of the reproductive
systems.
• List the changes in the reproductive systems that occur with
aging.
• Discuss common problems of the reproductive system.
• Differentiate between impotence and infertility.
• Discuss contraceptive methods, including actions, side effects, and
client teaching.
• Utilize the nursing process to develop a care plan for a client with a
reproductive system disorder.

KEY TERMS
abortion cystocele endometriosis
amenorrhea dysmenorrhea hematuria
contraception dyspareunia hesitancy

430

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 CHAPTER 13 Reproductive System 431

impotence orchiectomy stent

infertility polymenorrhea tenesmus
menopause postvoid residual urethrocele
menorrhagia priapism urethrostomy
metrorrhagia prolapsed uterus vasectomy
nocturia rectocele
oligomenorrhea spermatogenesis

the nipple, areola, and Montgomery tubercles. The nipples

INTRODUCTION have several openings, or ducts, that lead from the lactiferous
Through modern technology, current medical and nursing glands inside the breast. Milk is ejected through the ducts
knowledge, and health education programs, laypersons have when the infant sucks on the breast. The areola, or the darker
access to much information about their bodies and their area around the nipple, becomes darker in response to the
reproductive systems. Yet, individuals continue to be seriously increased hormone levels during pregnancy. Small, mole-like,
affected by health disorders. In some instances they may lack raised areas around the areola are the Montgomery tubercles.
knowledge of how to detect signs and symptoms of these dis- These glands produce a lubricant that keeps the nipple soft
orders. Often, they simply delay routine medical examinations and supple.
or avoid seeking medical treatment. In addition, individuals
may have difficulty discussing symptoms related to their Internal Female
reproductive system.
Routine health care must be maintained and early Structures
diagnosis made in order to reduce the incidence and seri- The vagina is an elastic, tube-like structure leading from the
ousness of reproductive health disorders. These goals can outside of the female body to the cervix. Approximately 2 to 3
be facilitated with skilled nursing assessment and client inches long, it contains many rugae that allow it to stretch dur-
education. ing intercourse and also permit the passage of the baby during
For most people, the reproductive system functions with- delivery. The pH environment of the vagina is normally acidic,
out problems throughout life. For others, minor and major providing protection from microorganisms that could cause
disorders require treatment. Some of the problems are related infections.
to alterations in structure; others are related more to altered The uterus is a 3-inch-long, 2-inch-wide, 1-inch-thick
physiology of the reproductive system. This chapter discusses hollow, muscular structure, as seen in Figure 13-2. The top
disorders of the reproductive systems by applying the steps of is the fundus, the middle is the body (corpus), and the lower
the nursing process.
First rib

ANATOMY AND PHYSIOLOGY

REVIEW
Pectoralis major muscle
The female and male reproductive systems consist of external
and internal structures and organs.

External Female Glandular tissue

Structures Lobes
Montgomery
The area known as the vulva includes the external female tubercles
structures, such as the mons pubis, labia majora, labia minora, Areola
and clitoris. The Bartholin glands and Skene’s glands, located
proximal to the vaginal opening, produce and secrete lubricat- Nipple
ing fluids. The labia majora and minora serve as protective Opening of Fifth rib
barriers for the softer internal structures. The clitoris, located
COURTESY OF DELMAR CENGAGE LEARNING

lactiferous
duct
proximal to the mons pubis and superior to the urinary Intercostal
meatus, plays a role in sexual arousal in the female and is con- muscles
Lactiferous
sidered analogous to the male penis. During foreplay, the clito- duct
ris engorges and stimulates orgasm or climax in the female. It Cooper's
is covered by a small hood called the prepuce. The perineum is ligament
the distal portion of the vulva, located below the vaginal open- Adipose tissue
ing and superior to the anus.
The breasts are also a part of the external female reproduc-
tive system (Figure 13-1). Their external structures include Figure 13-1 Cross Section of the Female Breast

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
432 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Superior

Ovary Fallopian tube Ureter

Posterior Anterior

Sacrum
Uterus

Rectouterine
pouch Peritoneum

Myometrium

Endometrium
Cervix
Symphysis
pubis
Urinary
bladder
Rectovaginal
septum Clitoris

COURTESY OF DELMAR CENGAGE LEARNING

Rectum Urethral
Vagina meatus
Anus
Labia minora

Labia majora

Inferior

Figure 13-2 The Female Reproductive System

portion is the cervix. Four sets of ligaments hold the uterus Luteinizing hormone (LH) is then released. LH triggers
in its normal anteverted (forward) position and permit it the a chain of events that stimulates the ovary to release the ovum.
freedom to grow and move during pregnancy. The uterus has This point in the menstrual cycle is called ovulation. Another
three distinct layers. The innermost layer is the endometrium, hormone, progesterone, causes the glands and blood vessels
which sloughs with menstruation each month. The middle of the endometrial lining to grow and thicken in preparation
layer is the myometrium, which is constructed of many muscle for implantation of a fertilized ovum. If fertilization does not
fibers that are interwoven for strength, stretch, and contractil- occur, the progesterone level decreases, the endometrium
ity. The outer layer is the perimetrium, which is an external sloughs off, and the woman experiences menstruation. If fer-
serous membrane covering. tilization does occur, the progesterone level remains elevated
The fallopian tubes are connected to the uterus on either to ensure the optimal environment for implantation of the
side. They are continuous with the mucous membrane lining zygote about 6 to 8 days after fertilization. Figure 13-3 illus-
of the endometrium on the inside. Billions of cilia line each trates the menstrual cycle.
fallopian tube and make a sweeping motion toward the uterus,
especially at the time of ovulation. This sweeping action moves Male Reproductive
the ovum along the path toward the uterus. The movement
may also impede the progress of the sperm, which must swim Structures
upstream against the downward current produced by the cilia. The male reproductive organs and associated structures are
The cervix is the lower portion of the uterus and extends illustrated in Figure 13-4. The scrotum is a fleshy structure sus-
into the vaginal vault. Like the vagina, the cervix has muscle pended below the perineum, anterior to the anus. It is divided
layers that allow it to stretch to a diameter of at least 10 cm into two parts, each of which contains a testis, an epididymis,
(about 4 inches) during delivery. and a portion of the spermatic cord (vas deferens). The left
An almond-shaped ovary, about 2 inches long and 1 inch side of the scrotum is usually lower than the right because the
wide, is located within the broad ligament on either side of left spermatic cord is often longer.
the uterus, just below the fimbriae, the fingerlike projections The testes, two smooth, oval endocrine glands, are
at the distal end of the fallopian tubes. The ovaries contain all suspended in the scrotum. This location helps maintain
of the ova (eggs) that a woman will have from puberty until proper temperature and also protects the testes from trauma.
menopause. Each month, the ovary responds to hormonal sig- Certain cells of the epithelium lining the seminiferous tubules
nals from the anterior pituitary gland to ripen one or more ova. of the testes produce half a billion sperm each day (sper-
Follicle-stimulating hormone (FSH) is released by the anterior matogenesis). They also secrete the androgenic (causing
pituitary and sends a message to the ovary to release estrogen, masculinization) hormone testosterone. Spermatogenesis is
which causes the ovum to ripen and enlarge. The entire first regulated by follicle-stimulating hormone (FSH), produced
part of the cycle is known as the proliferative phase. by the anterior pituitary gland. The production of testosterone

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 13 Reproductive System 433

°C

37

Basal Body Temperature

I.U. I.U.
40 LH
30 FSH 200
20
100
10

250–400 pg
hormone levels

125–250 pg
Progesterone
1Ng
Estrogen
Ovary

40 pg 10–15 Ng

Follicular Phase Luteal Phase

OVULATION
Implantation
endometrial growth

hCG Detectable

4 mm
Uterus

2 mm

Menstrual Proliferative Secretory

Phase Phase Phase

COURTESY OF DELMAR CENGAGE LEARNING

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28

Day of cycle

FSH = Follicle-Stimulating Hormone

LH = Luteinizing Hormone
HCG = Human Chorionic Gonadotropin

Figure 13-3 Cyclic Changes Associated with the Menstrual Cycle

is regulated by luteinizing hormone (LH), also produced by The penis is a cylindrical organ through which urine is
the anterior pituitary gland. After the sperm mature in the passed and semen is ejaculated. Half of the penis is located
epididymis, they travel through the vas (ductus) deferens, a within the body. The external half of the penis is flaccid, unless
long tube attached to the epididymis. The vas deferens, along the male is sexually aroused, at which time it becomes erect
with associated nerves and blood vessels, forms the spermatic because of engorgement with blood. A fold of skin, the prepuce,
cord. surrounds the tip of the penis in the uncircumcised male.
The vas deferens travels up and around the bladder and
carries sperm from the epididymis to the seminal vesicle, a
small pouch that produces secretions that, when mixed with COMMON DIAGNOSTIC TESTS
sperm and prostatic fluid, form semen. Commonly used diagnostic tests for clients with symptoms of
The prostate is an encapsulated gland that encircles the reproductive system disorders are listed in Table 13-1.
proximal portion of the urethra. The prostatic fossa, a depres-
sion on the cranial border of the prostate, allows entry of the
ejaculatory ducts. Within the prostate is a cluster of 30 to 50 INFLAMMATORY DISORDERS

I
tubuloalveolar glands that secrete prostatic fluid. The prostate
gland is of clinical significance because as men age, it is a com- nflammatory disorders discussed include pelvic inflamma-
mon site for malignant disease or benign enlargement that can tory disease, endometriosis, vaginitis, toxic shock syndrome,
cause urethral obstruction. and epididymitis/orchitis/prostatitis.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
434 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Ductus deferens
Bladder
Ureter

Symphysis pubis
Seminal
vesicle
Urethra

Erectile tissue
-Corpus
cavernosum Prostate gland

-Corpus Ejaculatory duct

spongiosum

Glans penis

COURTESY OF DELMAR CENGAGE LEARNING

Urethral orifice

Duct of
Testis
bulbourethral Bulbourethral
Epididymis gland (Cowper's) gland
Scrotum

Figure 13-4 The Male Reproductive System

Table 13-1 Common Diagnostic Tests for Reproductive System Disorders

Laboratory Tests • Magnetic resonance imaging (MRI)
• Alpha-fetoprotein (AFP) • Mammography
• Cultures Surgical Tests
• Human chorionic gonadotropin (hCG) • Breast biopsy
• Pap smear • Dilation & curettage (D&C)
• Prostate-specific antigen (PSA) • Endometrial biopsy
• Prostatic smear • Laparoscopy
• Serum alkaline phosphatase • Prostatic biopsy
• Serum calcium • Testicular biopsy
• Semen analysis
Other Tests
• Segmented bacteriologic localization culture COURTESY OF DELMAR CENGAGE LEARNING
• Colposcopy
Radiologic Tests • Nocturnal tumescence penile monitoring
• Computed tomography (CT) scan • Pelvic examination
• Dynamic infusion cavernosometry and • Schiller test
cavernosography (DICC)
• Ultrasound
• Hysterosalpingogram

may cause PID. The CDC estimates that each year more than
■ PELVIC INFLAMMATORY 1 million American women will experience an episode of
DISEASE acute PID, and more than 100,000 women will become infer-

P
tile as a result (CDC, 2008). Infections are usually ascend-
elvic inflammatory disease (PID) is an inflammatory ing by nature; that is, the pathogens are introduced into the
process involving pathogenic invasion of the uterus, reproductive system from outside and travel upward from
fallopian tubes (salpingitis), and ovaries (oophoritis), along the vagina to the fallopian tubes and then out into the pelvis.
with vascular and supporting structures within the pelvis. Risk factors associated with the incidence of PID include mul-
Pathogenic microorganisms such as chlamydia, gonococcus, tiple sexual partners, frequent intercourse, IUDs (intrauterine
streptococcus, staphylococcus, and herpes simplex virus II, contraceptive devices), douching, and childbirth.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 13 Reproductive System 435

The symptoms of PID include a low-grade fever, pelvic

pain, abdominal pain, a “bearing down” backache, a foul- CLIENTTEACHING
smelling vaginal discharge, nausea and vomiting, abnormal Inserting Vaginal Suppositories
uterine bleeding, dysmenorrhea (painful menstruation),
dyspareunia (painful intercourse), and intense pelvic ten- • Have the client wash her hands, then cleanse
derness upon examination. Peritonitis or pelvic abscesses the vulva with a mild soap and warm water to
may develop as complications of PID if the pathogens spread remove any external discharge.
into the pelvic cavity. Future infertility (inability or dimin- • Client should lie down in a supine position with
ished ability to produce offspring) can be related to scarring her knees flexed.
and strictures of the fallopian tubes, which develop from the
chronic inflammatory process within the pelvis. These prob- • With one hand, the client can separate the labia
lems have been associated with ectopic pregnancies because and gently insert the suppository high inside the
the fertilized ovum becomes trapped inside the fallopian tube vagina.
before it can complete its trip to the uterus. • The client should remain supine for a minimum
PID is often diagnosed during a pelvic examination. Vagi- of 30 minutes to ensure adequate absorption of
nal and cervical cultures are obtained at the time of the exam the medication through the vaginal mucosa.
to determine the causative agent. A pelvic ultrasound may be
ordered to rule out other causes of pelvic pain. Instruct the client
on the purpose of the procedures and any special preparations
that may be required, such as having a full bladder. because it will facilitate drainage of the pelvis. If vaginal sup-
positories are used, the client should lie in a supine position
Medical–Surgical for 30 minutes.

Management Nursing Management

Medical Support the client with a nonjudgmental attitude. Maintain
The client who is not acutely ill from PID may be treated client in semi-Fowler’s position to facilitate drainage. Monitor
as an outpatient at home with oral antibiotics and bed rest, vital signs and I&O. Teach client proper pericare, hygiene, and
unless the infection is herpes simplex virus II. Clients with hand hygiene. Administer antibiotic therapy as ordered.
herpes simplex II infections may require more intensive care
in the hospital with IV antibiotic therapy. The physician may
also order medicated vaginal suppositories for the vaginal NURSING PROCESS
discharge. The acutely ill client may require hospitalization for
IV antibiotic therapy. Assessment
Surgical Subjective Data
If the inflammation is extensive, or if medical treatment is not Obtain information about the client’s sexual activity, includ-
successful, the client may require a hysterectomy. ing the number of partners. Unprotected intercourse is the
most frequent method of entry for the microorganisms that
cause PID. Also include the client’s history of contraception
Pharmacological (measures taken to prevent pregnancy), previous vaginal
Antibiotics used may include doxycycline monohydrate infections and treatments, obstetrical history, and normal
(Vibramycin), metronidazole (Flagyl), cefoxitin (Mefoxin), hygiene practices such as douching and tampon use. Descrip-
clindamycin (Cleocin), and gentamicin (Garamycin). IV flu- tion of nagging pelvic pain and a low-grade fever are often
ids are frequently administered to promote adequate hydra- expressed.
tion, and analgesics are given for pain management.
Objective Data
Activity Assess for an elevated temperature, flushed, dry skin, the pres-
During hospitalization, the client is placed on bed rest with ence of a malodorous vaginal discharge, and positive vaginal
bathroom privileges. A semi-Fowler’s position is preferred or cervical cultures.

Nursing diagnoses for a client with pelvic inflammatory disease include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to Using a pain rating scale Assess client’s pain level every 4 hours, noting the location,
inflammation of the pelvic of 0 to 10, the client will duration, sensation, intensity, and factors that increase or
structures caused by report that her pain has decrease the pain. Administer analgesics as ordered.
invasion of pathogens decreased.

(Continues)

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436 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing diagnoses for a client with pelvic inflammatory disease include the
following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will follow If suppositories are ordered, instruct the client in the proper
related to the etiology of prescribed treatment method of insertion. Provide instructions to the client and
the pelvic inflammatory regimen, self-care, and partner (if available) about the causes of PID and ways to
process, treatment preventive measures. prevent the inflammation.
regimen, self-care, and Teach proper pericare and hygiene, especially hand hygiene
preventive measures before and after changing sanitary pads. Change sanitary pads
every 3 to 4 hours.
Encourage client to make time for rest periods during the acute
phase of the inflammation and to avoid strenuous activities such
as straining or heavy lifting.
Instruct client about pelvic rest, which includes no douching,
tampons, or intercourse.
Recommend that the client wear underpants with a cotton crotch.
Teach client to cleanse the perineal area from front to back after
each voiding or bowel movement.
Discuss and encourage the use of safe sexual practices and
the use of barrier contraceptives to prevent recurrence of PID
symptoms.
Encourage client to make follow-up appointment.
Encourage client to notify the NP or physician at the first sign of
The client will contact her PID symptoms. Recommend that the client monitor her own tem-
health care provider for perature, upon discharge, twice daily for 2 weeks and notify the
follow-up and if her symptoms physician or nurse practitioner (NP) if the temperature increases or
persist, worsen, or return. remains elevated.

Hyperthermia related to The client’s temperature Monitor client’s vital signs every 4 hours.
physiologic responses will return to normal range Administer antipyretic and antibiotic as ordered by the
to the inflammatory or after the initiation of physician.
infectious process therapy.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

or larger lesions. If the endometriosis becomes encapsulated

■ ENDOMETRIOSIS in an ovarian cyst it is called a “chocolate cyst.”
The disease appears to be progressive and has a tendency to
E ndometriosis is the growth of endometrial tissue, the
normal lining of the uterus, outside of the uterus within
the pelvic cavity. It occurs most frequently in women 30 years
be recurrent. Some women with minimal endometriosis experi-
ence severe monthly symptoms, such as lower backache, painful
intercourse, a feeling of heaviness on the pelvis, and spotting.
and older and tends to be familial. It predominantly affects Cau- Other women have a more extensive disease but have minimal
casian females who have not given birth and is most common symptoms. Thus the amount of endometriosis present may or
among the higher socioeconomic population. Endometriosis may not be correlated with the severity of the client’s symptoms.
has been called the “career woman’s disorder,” because it is often Endometriosis is one cause of female infertility because
diagnosed in the late twenties or thirties when the working of the amount of scar tissue and adhesions around the pelvic
woman makes plans for childbearing. organs, ligaments, and fallopian tubes. Pregnancy inhibits the
The endometrial tissue implants itself on other pelvic growth and bleeding of the endometrial implants because
structures (Figure 13-5). Two of the most common areas for ovulation and menstruation are suppressed.
endometrial implants are the pouch of Douglas and the ova-
ries. The tissue implants respond to the monthly hormonal Medical–Surgical Management
changes in the same way as the endometrial tissue inside
the uterus does. Bleeding of the implants during the menses Medical
results in the formation of adhesions and scar tissue. The Endometriosis may be tentatively diagnosed by palpation of
endometriosis appears as brownish or black “powder burns” endometrial implants within the pelvis or a pelvic ultrasound
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 CHAPTER 13 Reproductive System 437

Ileum
Umbilicus Appendix Ovary
Posterior surface of
uterus and uterosacral
ligaments

Pelvic colon

Posterior
cul-de-sac
Scar on
abdominal Rectovaginal
wall septum

Uterine wall

Anterior
cul-de-sac

COURTESY OF DELMAR CENGAGE LEARNING

and bladder

Vulva
Perineum

Figure 13-5 Common Areas of Endometriosis

may be ordered. To confirm the diagnosis, laparoscopy, tropin. The resulting amenorrhea (absence of menstruation)
performed under general anesthesia is the best method of will suppress the growth of the endometrial tissue and is used
diagnosis by direct visualization of the pelvic structures. Con- in moderate to severe cases of endometriosis. Occasionally,
sideration for treatment depends on the client’s age and desire Danocrine is given after surgical removal or cauterization of the
for future childbearing. Sometimes pregnancy relieves the endometriosis to relieve symptoms from residual disease.
symptoms even after delivery. All medications used to treat endometriosis cause mild
to moderate side effects that may affect the client’s desire to
Surgical take them or her compliance with continuous usage. Examples
The older multigravida who is experiencing severe, debilitating of problems that may be experienced include oily skin, fluid
symptoms that affect her lifestyle and normal functions, role, retention, weight gain, acne, hot flashes, metrorrhagia, mastal-
or activity may desire a hysterectomy. If the lesions are large gia, depression, and masculization.
or extensive, a laparotomy may be performed for adequate
removal; however, if the implants are small and scattered, lap-
aroscopic cauterization or laser ablation may be most desirable. NURSING PROCESS
Lysis of pelvic adhesions is performed at the same time.
Assessment
Pharmacological Subjective Data
The goals of pharmacological therapy are to suppress ovulation Obtain a description of the pelvic pain, which increases at the
and menstruation, reduce symptoms, and cause the implants time of menstruation. The client may voice concerns about
to shrink. Medications used in the treatment of endometriosis dyspareunia, pelvic discomfort with intercourse. This may
must effectively suppress the monthly hypothalamic-pituitary- result in marital tension if the client avoids sexual intimacy to
ovarian hormonal stimulation of ovulation. Some medications reduce her pain. Be alert to what the client says as well as what
act on the body as “pseudopregnancy” agents that produce ano- is left unsaid. The client may describe prolonged, excessive
vulation, breast tenderness, nausea, weight gain, and hirsutism. menstrual periods that are getting closer and closer together.
Other hormonal therapies cause a temporary medically induced Another sign, although not as significant, is pain with defeca-
menopause state. Hormonal treatments include contraceptives tion during the menstrual period.
(pills, patches, vaginal rings), medroxyprogesterone (Depo- Also note the onset of menses, regularity of cycles, and
Provera), gonadotropin-releasing hormone (Gn-RH) agonists any changes that client has noted in the frequency, comfort,
and antagonists, and aromatase inhibitors (CDC, 2008). Nafarelin duration, and amount of menstrual flow. Note the onset of the
acetate (Synarel) is a nasally administered gonadotropin analog client’s symptoms in relationship to the menstrual cycle, the
that inhibits cyclic hormone release. Danazol (Danocrine) is an severity as reported by the client, any alterations in lifestyle
androgen hormone that must be taken continuously for at least related to the pain or other symptoms, and the client’s future
6 to 8 months. This medication inhibits the release of gonado- plans for childbearing.
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438 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Objective Data these factors alter the pH of the vagina. Symptoms include a
thick, white, cheesy or curd-like discharge with a musty, sweet
The nurse’s role is usually focused on collecting subjective odor, accompanied by vaginal or vulvar itching and irritation.
data from the client interview and assisting the physician Upon examination, the vaginal mucosa will have patches of
during actual procedures. white discharge present. If the patches are scraped off, the
Nursing Management tissue underneath will appear reddened and may bleed. Exter-
nally, the vulva may be reddened and edematous. The client
Encourage the client to express her concerns and fears. may have scratches from attempting to ease the itching.
Teach the client about prescribed medications. Emphasize the The preferred treatment is vaginal application of antifungal
importance of regular checkups and to report any abnormal creams or suppositories such as miconazole (Monistat), clotri-
vaginal bleeding. mazole (Mycelex-G, Gyne-Lotrimin), or nystatin (Mycostatin).
Nursing diagnoses for a client with endometriosis may Alternative therapies include douching with white vinegar solu-
include the following: tion (1 tablespoon per 1 pint of water) twice a day for a week.
• Acute Pain related to bleeding from endometrial implants This treatment restores the acid balance of the vagina and washes
in the pelvic cavity away the Candida albicans. Eating cultured yogurt with active aci-
dophilus or applying the yogurt directly to the labia helps restore
• Anxiety related to treatment options, possible side effects, the normal bacteria and protective mechanisms in the vagina.
and infertility Trichomoniasis is frequently passed from partner to part-
• Ineffective Sexuality Patterns, or Sexual Dysfunction, related ner during intercourse. A copious green-yellow, foul-smelling,
to altered body function or structure (painful intercourse) frothy vaginal discharge is characteristic. It may produce itch-
• Situational Low Self-Esteem, related to the inability to conceive ing or external burning and irritation. Metronidazole (Flagyl)
should be taken orally by both partners.
Flagyl is normally contraindicated in the first trimester of
pregnancy, so obtaining a menstrual history or a pregnancy test
■ VAGINITIS may be needed before administering this medication. Inform

S
the client and her partner to avoid any alcohol intake during
everal common types of vaginitis are caused by bacteria, therapy. Flagyl causes a strong antabuse-like effect, which
protozoa, viruses, and yeasts. The vaginal mucosa is nor- results in severe nausea and vomiting. Clients should read labels
mally protected by an acid mantle. The acidic (pH less than on over-the-counter medications being taken concurrently with
5.0) environment inhibits the growth of many pathogenic the Flagyl because many preparations contain alcohol bases.
microorganisms. Because the vaginal opening is close to the Instruct the client and her partner to abstain from inter-
external environment, microorganisms have an opportunity course during therapy and to finish all of the medication.
to invade the reproductive tract. Some organisms that cause Gardnerella vaginalis often produces a gray-white vaginal
vaginitis are transmitted to the female from the male partner discharge with a strong fishy odor or is asymptomatic. If itch-
during sexual contact. Natural protective barriers may vary ing or burning is present, it may suggest another microorgan-
with the fluctuating hormonal levels during the woman’s ism. For the treatment of Gardnerella, and other bacterial
monthly cycle because the hormones affect the vaginal pH. At vaginitis, the physician may order Flagyl or an oral antibiotic
ovulation, the vaginal pH becomes slightly less acidic because such as tetracycline hydrochloride (Achromycin) or ampicillin
of the high level of estrogen. Times when the woman’s system (Omnipen). Sulfa-based creams such as Sultrin, Triple Sulfa,
has a lower estrogen level, such as immediately after the men- and AVC may be used vaginally in conjunction with the oral
ses and after menopause, are times when there is a higher risk medications once or twice a day for 6 to 14 days to completely
for infection because the epithelium is less active, no glycogen treat this type of infection.
is present, and the pH may be as high as 7.0. Chlamydial vaginitis infections are often asymptomatic
Diagnosis is made after performing a vaginal examination but have been associated with infertility problems. A culture
and obtaining a cervical culture and a sample of the vaginal of vaginal secretions is necessary to specifically identify the
discharge. When the client contacts the physician or nurse organism. The treatment is usually oral antibiotics for at least
practitioner to report symptoms of vaginitis, the nurse should 7 days. A repeat culture is recommended following treatment
instruct her to avoid douching or using tampons before being to ensure that the parasites have been eradicated.
examined because douching will wash away the discharge
needed to be examined and tampons will absorb it.
Common types of vaginitis include candidiasis caused
by Candida albicans (yeast infection), trichomoniasis caused CLIENTTEACHING
by Trichomonas vaginalis (a protozoan), Gardnerella vaginalis
(a bacterium), and Chlamydia trachomatis (a parasite). Other Ways to Decrease Risk of Vaginitis
causes of vaginitis may include streptococcus, staphylococcus, • Wear cotton-crotch underwear.
gonococcus, and herpes simplex II. Usually the symptoms
• Avoid sitting in a wet bathing suit in warm
depend on the causative agent. The client’s description of her
symptoms along with the examination of the discharge help weather for long periods.
confirm the diagnosis. Most infections have a characteristic • Seek prompt medical attention at the first signs
discharge and irritation with burning or itching that may be of infection.
internal, external, or both. • Eat an 8-oz container of yogurt with active
Predisposing factors for candidiasis, also called monilia, cultures daily while taking antibiotics.
may include obesity, diabetes, pregnancy, oral contraceptives,
antibiotics, bubble baths, and frequent douching. Many of

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 CHAPTER 13 Reproductive System 439

Postmenopausal vaginitis (atrophic) is caused by a

decreased level of estrogen in the vaginal tissue. The client CLIENTTEACHING
may describe painful intercourse (dyspareunia), itching, burn- TSS and Tampon Use
ing, or irritation. Estrogen replacement therapy often relieves
the symptoms of this type of vaginitis. The medication may be Instruct client to avoid tampon use for several
administered orally, vaginally, or by transdermal patch. cycles. If she chooses to use tampons in the future,
they should be changed every 2 to 3 hours. Avoid

NURSING PROCESS the superabsorbent types.

Assessment
and headache (Neighbors & Tannehill-Jones, 2006). There
Subjective Data may be a macular erythematous (flat, red) rash followed in 1 to
Obtain information from the client regarding the nature of her 2 weeks by peeling of the palms and soles. Disorientation may
symptoms, the onset, menstrual history, contraceptive meth- occur from the release of toxins and dehydration. Symptoms
ods, recent or current use of antibiotics or other medications, of TSS develop suddenly and can be fatal.
recent illness, diabetes mellitus, sexual history, pregnancy
history, usual hygiene practices such as douching, deodorant
sprays, bubble baths, wearing of pantyhose, type of under-
Medical–Surgical
wear, and use of deodorized tampons or pads. Management
Objective Data Medical
Blood, urine, genitourinary, and throat cultures may be
Observe the vaginal discharge and note any odor. Vaginal or obtained and are usually negative except for Staphylococcus
vulvar irritation and possible scratches may be seen. aureus. The goals of treatment are focused on controlling
the falling blood pressure, replacing fluid volume, halting
Nursing Management the infectious process, and maintaining adequate ventilation
Emphasize the significance of hand hygiene before and after efforts. IV fluids are administered per the physician’s order.
applying vaginal medications. Notify client that her sexual The client may require mechanical ventilation and CPAP
partner should also be treated. (continuous positive airway pressure). Dialysis may be needed
Nursing diagnoses for a client with vaginitis, regardless of if kidney failure occurs.
the etiology, include the following:
• Acute Pain, related to irritation, excoriation, or ulceration Pharmacological
of vaginal tissue Broad-spectrum antibiotic therapy is recommended. Culture
• Deficient Knowledge, related to the origin of the infection, and sensitivity tests will indicate which type of antibiotic is best.
prevention, and treatment options Examples include dicloxacillin sodium (Dynapen), clexacillin
sodium (Tegopen), nafcillin sodium (Nafcil), and methicillin
• Impaired Tissue Integrity, related to the presence of vaginal
sodium (Staphcillin). The medication regimen is continued for
discharge, itching, or irritation
at least 2 weeks to ensure control of the pathogens.
• Sexual Dysfunction, related to discomfort during intercourse
or fear of transmitting the infection to the sexual partner
Activity
• Risk for Impaired Skin Integrity, related to internal and
external irritation from discharge and itching Bed rest is usually prescribed.

Nursing Management
■ TOXIC SHOCK SYNDROME Maintain client on prescribed bed rest. Administer antipyret-

T
ics and antibiotics as ordered. Monitor vital signs, I&O, and
oxic shock syndrome (TSS) is a rare, life-threatening con- skin turgor. Encourage oral fluid intake.
dition most often associated with Staphylococcus aureus,
which enters the bloodstream. Toxins produced by group A
streptococcus have also been associated with causing TSS. A
strong relationship has been found between the use of tampons NURSING PROCESS
(especially superabsorbent) during menstruation and the onset
of TSS symptoms. It has been hypothesized that the fibers Assessment
from the tampon lower the level of magnesium in the woman’s Subjective Data
body and, therefore, produce a favorable environment for the
growth of pathogenic microorganisms. The condition was Obtain information on recent use of tampons, length of
first diagnosed in the mid-1970s, and the incidence increased time tampon is left in before changing, use of contraceptive
throughout the 1980s. A high percentage of women who are sponges, sore throat, headache, myalgia, and fatigue.
affected by TSS are younger than age 30. TSS can also occur
in nonmenstruating women, men, and children. Objective Data
The client presents with a sudden high temperature of Assess erythematous rash, edema, peeling of palms and soles,
102°F or greater, vomiting, diarrhea, progressive hypotension, hypotension, fever, level of consciousness, nonpurulent con-
and flulike symptoms of malaise, muscle soreness, sore throat, junctivitis, and hyperemia of vagina and oropharynx.

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440 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing diagnoses for a client with toxic shock syndrome include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Hyperthermia related to The client will have normal- Administer antipyretics as ordered. Give cooling sponge bath.
inflammatory process range temperature within Encourage oral fluids as tolerated.
48 hours.
Monitor body temperature.

Deficient Fluid Volume The client will have normal Administer intravenous fluids as ordered. Encourage oral fluids
related to diarrhea, fluid and electrolyte if client is not vomiting. Monitor I&O.
vomiting, fever, and balance within 24 hours. Monitor blood pressure.
decreased intake
Administer antiemetic and antidiarrheal medications as ordered.
Assess skin turgor and mucous membranes.

Risk for Impaired Skin The client will maintain skin Encourage or assist with position change every 2 hours.
Integrity related to integrity. Provide or assist with personal hygiene, especially after diarrhea.
dehydration and effects
of circulating toxins Assess bony prominences for reddened areas.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ EPIDIDYMITIS/ORCHITIS/
PROSTATITIS

E pididymitis can be a sterile or nonsterile inflammation

COURTESY OF DELMAR CENGAGE LEARNING

of the epididymis. A sterile inflammation is caused by
direct injury or reflux of urine down the vas deferens. Uri-
nary reflux that is related to strain exerted by a male while
his bladder is full can be caused by lifting heavy objects or
doing strenuous exercises. Nonsterile inflammation may
occur as a complication of gonorrhea, chlamydia, mumps,
tuberculosis, prostatitis, or urethritis. Prolonged use of an
indwelling catheter or an invasive procedure can also lead to
nonsterile inflammation. Figure 13-6 Bellevue Bridge for Scrotal Support
Signs and symptoms of epididymitis include sudden
severe scrotal pain, warmth, redness and swelling, testicular
tenderness usually on one side that worsens when having to development of fibrotic tissue. This fibrotic tissue causes the
a bowel movement, dysuria, pyuria, chills, fever, penile prostate to harden, so prostatitis may be difficult to differentiate
discharge, and blood in the semen. Treatment includes bed from prostate cancer. It may take 3 to 6 months for the granu-
rest, antibiotics, scrotal support (Figure 13-6), and ice com- lomatous form to resolve. Signs and symptoms of prostatitis
presses to the area. Bilateral epididymitis can cause sterility. include perineal pain, fever, dysuria, and urethral discharge.
Untreated epididymitis leads quickly to testicular tissue
necrosis, septicemia, and death.
Orchitis is an inflammation of the testes that most often
occurs as a complication of a bloodborne infection originating Medical–Surgical Management
in the epididymis. Other causes of orchitis include gonorrhea, Medical
trauma, surgical manipulation, and tuberculosis and mumps that When it is suspected that the client currently has urethritis,
occur after puberty. In most instances, both testes are involved, he should not be catheterized. The infection spreads rapidly
and often sterility results. In orchitis, unilateral involvement to the genital organs because of the trauma of catheterization
does not cause sterility. Signs and symptoms of orchitis include and the possible spread of bacteria from the nonsterile distal
sudden scrotal pain with pain radiating to the inguinal canal, part of the urethra. The physician may order that segmented
scrotal edema, chills, fever, nausea, and vomiting. Treatment bacteriologic localization cultures be obtained.
includes bed rest, scrotal support, and ice to the area.
Prostatitis, an inflammation of the prostate, is a common
complication of urethritis caused by chlamydia or gonorrhea.
Infecting organisms may reach the genital tract by direct spread Pharmacological
through the urethra or may be borne by blood or lymph. The Treatment of epididymitis and orchitis includes antibiot-
condition may be acute or chronic, with the chronic form leading ics and injection of procaine around the spermatic cord.

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 CHAPTER 13 Reproductive System 441

Pharmacological treatment of prostatitis includes antibiotics,

analgesics, and stool softeners. NURSING PROCESS
Activity Assessment
Treatment of prostatitis includes bed rest. While the client Subjective Data
is in bed, his scrotum should be elevated and cold packs Ask the client about the presence of urethral discharge or
applied to the area. Encourage the client to drink a large dysuria as well as the nature and location of the pain. A
amount of fluids and use sitz baths for comfort. These description of pain may include arthralgia, low-back pain, and
interventions are used to reduce inflammation, swelling, myalgia. A positive history of recent bacterial or viral infec-
and discomfort. Periodic digital massage of the prostate tion is of special significance. Ongoing nursing assessment
by the physician increases the flow of infected prostatic includes monitoring of pain, using a pain scale to objectify
secretions. data. Ask the client if he is experiencing nausea, because this
could be a sign that his condition is deteriorating. Assess the
client’s educational and emotional needs because he may be
Nursing Management worrying needlessly about possible sterility or impotence.
Monitor vital signs, especially temperature and I&O. Encour-
age intake of oral fluids. Objectively assess client’s pain and Objective Data
administer analgesics as ordered. Maintain client on bed rest. Assess vital signs, especially temperature. An increase in tem-
Keep scrotum elevated when the client is in bed and have client perature may be an indication that the client’s condition is wors-
use an athletic support when ambulatory. Apply cold pack ening. Scrotal edema and purulent urethral discharge may be
under scrotum as ordered. present. Monitor intake and output. Ask about constipation.

Nursing diagnoses for the male client with an inflammatory disorder include
the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related The client will not Monitor client’s vital signs, especially his temperature. Report
to worsening of the experience worsening of hyperthermia, hypotension, nausea, and tachycardia to the
inflammatory process his condition. physician immediately.

Deficient Fluid Volume The client will maintain fluid Monitor client’s I&O. Encourage him to drink plenty of fluids
related to nausea and balance. when not nauseated.
vomiting

Acute Pain related to Using a pain scale of 0 to Assess client’s pain level every 4 hours. Administer analgesics
Inflammation 10, the client will report as ordered.
pain has decreased to 2 or Encourage client to maintain bed rest. Provide diversional
less within 48 hours after activities to increase compliance.
treatment initiation.
Encourage client with prostatitis to take a sitz bath, but never
the client with epididymitis or orchitis as local heat may
increase destruction of sperm cells.
Fill a plastic glove with crushed ice and place it under the
scrotum when heat is contraindicated. Remove the ice for short
intervals every hour to prevent ice burns.

Anxiety related to The client will verbalize Reassure client that with proper treatment, sterility and
concerns about possible decreased anxiety. impotence are not likely complications of prostatitis.
sterility or impotence

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ FIBROCYSTIC BREAST
BENIGN NEOPLASMS CHANGES

B enign neoplasms include fibrocystic breast changes,

fibroid tumors, and benign prostatic hyperplasia. F ibrocystic breasts (formerly called fibrocystic breast dis-
ease) contain lumpy, nodular, glandular tissue. Fibrocystic

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442 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

breast changes are common between 30 and 50 years of age of the abnormal areas in the office. If fluid is obtained from
and occur in more than half of women at some point in their the area, it is sent to pathology for examination. If no fluid is
lifetime. Many cases will subside after menopause. The inci- obtained, it may be a solid cyst or tumor, and biopsy may be
dence of the potential for developing breast cancer is increased required.
3 to 4 times with fibrocystic breast changes. There appears In the office, a breast biopsy may be performed with a
to be a familial tendency toward the development of breast local anesthetic. If there is any question of malignancy, or if
cancer. the physician suspects that the lesion will be malignant on
Lumps may occur as single or multiple cysts that are the basis of the mammography report, the biopsy may be per-
frequently fluid-filled. It is difficult to differentiate fibrocystic formed in the hospital under general anesthetic so that addi-
tissue changes from other breast lesions because the dense tional tissue may be removed if necessary. A frozen section
fibrocystic areas may mask areas of breast cancer. Figure 13-7 may be obtained and sent to the laboratory for a preliminary
shows the differences among cysts, fibroadenomas, and carci- examination to rule out a malignant lesion.
nomas of the breast.
The pathophysiology of a fibrocystic breast is found in
the formation of fibrous tissue caused by hyperplasia of the Medical–Surgical
epithelial cells in the breast lobules and ducts. The prolifera- Management
tion of the fibrous tissue deviates from the expected normal
cyclic response to female hormone shifts during the menstrual Surgical
cycle. Aspiration or surgical excision may be indicated for diag-
Routine mammograms provide baseline information and nostic or therapeutic reasons. The cystic tissue may be
differentiate the palpable breast lumps between benign and aspirated with a small-gauge needle and syringe. The nurse
malignant types. A computer-directed biopsy may also be prepares the client for the procedure and assists the doctor
performed. or NP with the procedure. The nurse assists the client into
Women should be taught breast self-examination (BSE) a supine position on the examination table and sets up the
as adolescents and encouraged to practice it at the end of each equipment and instruments needed. The area to be biopsied
menstrual cycle, when it is easier to palpate the breast tissue. is cleansed. Upon completion of the aspiration or biopsy,
Figure 13-8 provides specific information on how to perform the nurse labels the specimen and sends it to the pathology
a BSE. department.
A yellow-greenish, sticky discharge from the nipple is If the areas of fibrocystic tissue are extensive and have not
occasionally present with fibrocystic breasts. A Pap smear may responded to conservative treatments and methods, or if the
be done on the discharge to rule out the presence of malignant risk of cancer is high, the tissue may be excised completely.
cells. Note the presence of any breast discharge and report it Removal of fibrocystic tissue does not guarantee that the cli-
to the health care provider as soon as possible. The physician ent will not develop breast cancer in the remaining tissue, and
or nurse practitioner (NP) may perform a biopsy or aspiration she must continue to perform monthly BSE.

GROSS CYST FIBROADENOMA CARCINOMA

Age 30–50; diminishes after Puberty to menopause; Most common after 50 years
menopause peaks between ages 20–30
Shape Round Round, lobular, or ovoid Irregular, stellate, or crab-like
Consistency Soft to firm Usually firm Firm to hard
COURTESY OF DELMAR CENGAGE LEARNING

Discreteness Well defined Well defined Not clearly defined

Number Single or grouped Most often single Usually single
Mobility Mobile Very mobile May be mobile or fixed to skin,
underlying tissue, or chest wall
Tenderness Tender Nontender Usually nontender
Erythema No erythema No erythema May be present
Retraction/dimpling Not present Not present Often present

Figure 13-7 Characteristics of Common Breast Masses

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 CHAPTER 13 Reproductive System 443

A B C

COURTESY OF DELMAR CENGAGE LEARNING

D E

Figure 13-8 Performing a Breast Self-Examination; A, Standing in front of mirror, check breasts for puckering, dimpling, scaliness, or
discharge from nipples; B, Clasp hands behind head and press hands forward, watching for changes in the shape or contour of breasts. Press
hands on hips and bend toward mirror while pulling shoulders and elbows forward (shown); C, Gently squeeze each nipple, looking for
discharge; D, Raise one arm and use fingers of other hand to check breast for lumps or masses under skin. Use a pattern of motion (circular,
up-and-down, etc.) to cover entire breast; E, Repeat “D” while lying flat on back with one arm over head and a towel under the shoulder.

CRITICAL THINKING down the fibrocystic tissue because it reacts with the poly-
unsaturated fats in the cell membrane. It may also have some
Breast Self-Examination effect on the balance of female hormones.

How would you teach a client to do a breast self-

examination? Make a teaching plan.
Diet
Most health care providers recommend limiting or completely
eliminating caffeine-containing products from the woman’s
diet. This would include teas, colas, coffee, and chocolate.
Pharmacological These products are all available in caffeine-free forms. Dietary
Some physicians recommend up to 600 units of vitamin E fat should be decreased to less than 20% of total calories
daily. It is believed that the vitamin supplement helps break (Mayo Clinic, 2008b).

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444 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing Management sticky discharge from one or both breasts. Inquire about the
client’s dietary habits, especially caffeine intake, frequency
Emphasize the importance of the client performing BSE one of BSE, and the date of the most recent mammogram, if
week following menses and having a mammogram as appro- applicable.
priate for age and risk factors. Teach the client how to perform
BSE and to wear a firm, supportive bra.
Objective Data
NURSING PROCESS When examined, single or multiple lumps may be palpated
in one or both breasts. The lumps are not always discrete but
Assessment should be freely movable. Because fibrocystic breast lumps
are more tender near the menses, the client should be seen
Subjective Data for an exam the week after her menstrual period. The tissue
The client may report that the lumps are more tender as she contains less fluid during that time and palpation is easier and
approaches her menstrual period and that there is a greenish, less uncomfortable.

Nursing diagnoses for a client with fibrocystic breast changes include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will verbalize Demonstrate BSE for the client either in person or by video with
related to the cause and demonstrate her a follow-up return demonstration by the client.
of fibrocystic breast understanding of the Observe the client as she performs the BSE so that immediate
changes and method of cause of fibrocystic breast feedback can be given. Explain the best timing for the BSE and
breast self-examination changes and her role in the rationale for performing the procedure after the menses.
treatment.
Assist client with mammogram. Encourage mammography
at regular intervals dependent upon the client’s age and risk
factors.
Teach the client about dietary modifications, such as limiting
caffeine.

Anxiety related to the The client will display Explain the differences between malignant breast lesions and
underlying potential and behaviors of decreased fibrocystic breast changes to help alleviate the client’s anxiety.
risk of breast cancer anxiety related to the
potential for breast cancer.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

mass or several masses, a pelvic ultrasound or a laparoscopy is

■ FIBROID TUMORS ordered to confirm the diagnosis.

F ibroids (leiomyomas) are benign tumors that grow in

or on the uterus. A higher incidence is seen with nul-
liparous women and those who are more than 35 years old.
Medical–Surgical
Management
The fibroids may appear below the serosal membrane or the
mucosa. An early symptom is often menorrhagia, an exces- Medical
sively heavy menstrual flow. Later, the client may experience The physician may opt to wait and observe the growth pattern
increasing pelvic pressure as the tumors grow, along with of the fibroids before advising the client to have surgery. This
dysmenorrhea, abdominal enlargement, and constipation.
Growth of the fibroids is usually slow but can be stimulated by
estrogen. During pregnancy, when the estrogen and progester-
one levels increase dramatically, the tumors grow much faster.
Concern arises for the fetus when the fibroids begin to enlarge CULTURAL CONSIDERATIONS
and crowd the uterus. Overcrowding may compress the fetus
or initiate the onset of preterm labor. With either situation, the Fibroid Tumors
pregnancy must be monitored carefully.
A medical diagnosis of uterine fibroids may initially be Fibroid tumors are most prevalent in African-
based on the client’s symptoms and the findings of the pelvic American and Mediterranean clients with dark skin.
examination. If on palpation the uterus feels like an irregular

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 CHAPTER 13 Reproductive System 445

“wait-and-see” attitude may be swayed by the significance of the 0 to 10 scale and administer analgesics as ordered. Encourage
client’s symptoms, size of the fibroids, amount of discomfort a diet high in iron-containing foods to prevent iron-deficiency
the client is experiencing, and amount of menorrhagia and/or anemia.
metrorrhagia, vaginal bleeding between menstrual periods.
Reexamination is encouraged at least every 6 months.
NURSING PROCESS
Surgical
If the menorrhagia is significant with each menstrual cycle, a Assessment
dilation and curettage (D&C) may be performed to determine
the exact etiology of the bleeding. A myomectomy, a surgical Subjective Data
procedure to remove the tumor, may be performed if the client Obtain the client’s description of menstrual flow, dys-
desires future pregnancies. In the case of severe menorrhagia, menorrhea, and/or pelvic pain and pressure. The client
with a dropping hemoglobin level or multiple tumors, the phy- may also report difficulty fitting into clothes because of
sician may recommend a hysterectomy as the option of choice. abdominal enlargement, constipation, or urinary frequency
or urgency.
Diet
A diet with many sources of iron helps prevent iron-deficiency Objective Data
anemia, which may result from the extra blood loss. Count the number of sanitary pads the client saturates in an
hour; observe the presence or absence of clots in the blood,
Nursing Management a hemoglobin level of less than 12 mg/dL, and the client’s
pale skin color. Her blood pressure may be slightly lower than
Monitor vital signs and hemoglobin level. Assess client’s blood normal and her pulse may be increased as a compensatory
loss for amount, color, and clots. Objectively assess pain with a mechanism.

Nursing diagnoses for a client with fibroids include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Deficient Fluid Volume The client will have a Assess client’s blood loss for amount, color, and clots.
related to excessive blood hemoglobin above Provide an accurate count of the saturated sanitary pads,
losses 12 mg/dL and will maintain along with the length of time taken to saturate a pad.
fluid balance. Monitor vital signs at least every 4 hours, or more
frequently if the client is having active blood loss.
Monitor laboratory reports for Hgb level.

Acute Pain related to pressure The client will verbalize Assess pain on 0 (least) to 10 (most) pain scale and note
on pelvic structures caused by less discomfort and pelvic location, onset, and duration. Administer analgesics as
growing tumors and cramping pressure. ordered.
during the menses

Evaluation: Evaluate each outcome to determine how it has been met by the client.

to void). However, a temporary reduction of these symptoms

■ BENIGN PROSTATIC may occur as the bladder muscles hypertrophy in response to
HYPERPLASIA the increased work they must do to force the urinary stream

B
past the obstruction.
enign prostatic hyperplasia (BPH) is a progressive ade- Although this bladder muscle compensatory response
nomatous enlargement of the prostate gland that occurs may temporarily reduce symptoms, eventually the muscle
with aging. More than 50% of men older than age 60 and decompensates, becoming noncompliant and hypotonic. This
90% of men older than age 70 have some symptoms of BPH decompensation leads to atony of the mucous membranes
(National Institutes of Health, 2006). Although this disorder between the muscle bands, which causes stagnant urine to col-
is not harmful, the urinary outlet obstruction that may be lect in the small compartments (cellules) of the membranes. In
associated with the disorder is a problem. addition, the man is unable to completely empty the bladder
Because the urethra is encircled by the prostate, common when voiding (postvoid residual). Because these changes in
early symptoms of BPH are related to partial or complete urinary function promote urinary alkalosis by increasing the
obstruction of the urethra. Early symptoms include hesitancy urine pH, a perfect environment for bacterial growth is created.
(difficulty initiating the urinary stream), decreased force of This bacterial growth can cause a urinary tract infection (UTI),
stream, urinary frequency, and nocturia (awakening at night which may eventually lead to kidney damage.

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446 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Medical–Surgical Bladder

Management Resectoscope

Medical
The physician performs a digital rectal examination (DRE) to
identify any enlargement of the lateral lobes or nodular lumps
on the surface of the prostate gland. Diagnostic tests ordered to
learn more about the client’s condition may include a prostate-
specific antigen (PSA), blood test, post-void bladder scan,
Enlarged prostate
cystoscopy, rectal ultrasonography, and prostate biopsy. The

COURTESY OF DELMAR CENGAGE LEARNING

physician will carefully monitor the client’s condition to detect Cut pieces of
any exacerbation of symptoms such as increased hesitancy, prostatic tissue
urgency, hematuria, or repeated UTI.
Many alternatives to surgical treatment of BPH have been
introduced over the past several years, including balloon dilation
of the prostate, a prostate urethral stent, as shown in Figure 13-9,
and thermotherapy. Balloon dilation of the prostate during an Rectum
endoscopic examination breaks the prostatic capsule and facili-
tates decompression of the prostate. A stent is material that is Figure 13-10 Transurethral Resection of the Prostate
used to hold tissue in place or, in this instance, to provide support Gland via Resectoscope
to the urethra, which is being compressed by the prostate. An
alternative to a transurethral resection of the prostate (TURP) is is performed when the prostate mass is large. In a retropu-
a thermotherapy transurethral microwave procedure (TUMP) bic prostatectomy, the bladder is not opened but instead is
(Daniels, Nosek, & Nicoll, 2007). This outpatient procedure retracted and prostatic tissue is removed through an incision
does not correct the problem of incomplete bladder emptying, in the anterior prostatic capsule. Both of these alternatives
but does reduce urinary flow symptoms. Another minimally involve an abdominal incision. In a perineal prostatectomy, a
invasive procedure is the transurethral needle ablation (TUNA) perineal incision is made and the prostatic tissue is removed
system that delivers low-level radiofrequency energy via twin through an incision in the posterior prostatic capsule.
needles to burn away enlarged prostate tissue and improve urine
flow with fewer side effects than the TURP (NIH, 2006).
Surgical
The traditional surgical intervention for 90% of all prostate sur-
geries for BPH is a TURP. This surgery is performed via a resec-
toscope, an instrument that includes a cutting and cauterization
device (Figure 13-10). The client receives either a general or a
spinal anesthetic, and the resectoscope is passed through the A B
urethra to remove small pieces of prostate tissue while control-
ling bleeding. The bladder is continuously irrigated with normal
saline or another solution during the procedure. This irrigation
is continued during the postoperative period to reduce clot
formation that can interfere with urinary drainage.
The traditional surgical alternative to a TURP is open
surgery. A suprapubic resection (Figure 13-11), in which the
prostate is removed from around the urethra via the bladder,
Bladder

Prostate Urethra C
COURTESY OF DELMAR CENGAGE LEARNING
COURTESY OF DELMAR CENGAGE LEARNING

D E
Stent
Figure 13-11 Suprapubic Prostatectomy; A, Bladder
Exposed through Low Transverse Incision; B, Bladder Entered;
C, Blunt Dissection of Prostate; D, Prostate Fossa Sutured to
Figure 13-9 Urethral Stent Bladder Mucosa

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 CHAPTER 13 Reproductive System 447

Although these traditional surgeries successfully relieve void, and the force of the urinary stream. In addition to a
bladder obstruction, they are costly, and postoperative com- careful general medical history, any information pertaining
plications can endanger or seriously affect the quality of a to a history of chronic urinary tract infections needs to be
man’s life. These complications include hemorrhage, water noted.
intoxication, infection, thrombosis, damage to surrounding Postoperative nursing assessment includes assessing for
structures, sexual dysfunction, and urinary incontinence. pain (on a 0 to 10 scale) related to bladder spasms. The cli-
Laser prostatectomy is based on thermal action. The ent’s emotional needs should also be assessed, especially for
transurethral ultrasound-guided laser-induced prostatectomy anticipatory grieving, body image disturbance, anxiety, incon-
(TULIP) is performed with a probe that is passed transure- tinence, or concerns about alteration in sexuality patterns or
thrally into the prostatic urethra. While the adjacent prostate possible sexual dysfunction. Observe for client behavioral or
area is visualized by ultrasound, the laser energy is directed at verbal cues indicating a need for further information or reas-
the prostate tissue, resulting in tissue necrosis and sloughing. surance about his condition and treatment.
The client is less likely to experience water intoxication because
this surgical method allows blood vessels to seal rapidly, keep-
ing irrigant fluid from being forced into the circulation. Objective Data
Monitor vital signs but avoid the use of a rectal thermometer.
Pharmacological A bright red urine color persisting for more than a few hours
Finasteride (Proscar) can shrink the prostate in some men. Alpha after surgery may be a sign of hemorrhage. Report hemor-
blockers relax the smooth muscles along the urinary tract with- rhage, hyperthermia, hypotension (low blood pressure), and
out compromising normal urinary control reflexes. Examples are tachycardia to the physician immediately.
terazosin hydrochloride (Hytrin), doxazosin mesylate (Cardura), After a TURP, the client will have a three-way Foley
alfuzosin (Uroxatral), and tamsulosin Hcl (Flomax). They are catheter and continuous bladder irrigation for at least 24
also used to treat hypertension, so the side effect of orthostatic hours. Accurately record I&O to ensure that the client has
hypotension is possible. Belladonna and opium (B & O) sup- adequate oral intake to promote urinary flow and reduce
positories are used to reduce postoperative bladder spasms, and the infection risk. In measuring output, the amount of irrigant
narcotic analgesics are used to relieve postoperative pain. must be subtracted from the total output in order to determine
the actual urinary output. After the catheter is removed,
Nursing Management assess the client for postvoid residual and incontinence.
Palpate the abdomen for bladder distention, check the bed
When inserting a Foley catheter, remove no more than 1,000 linens and clothing for signs of incontinence, and ask the
mL initially. Provide preoperative care as ordered. Monitor client if he is experiencing loss of urinary control.
and accurately record I&O to prevent water intoxication; Assess for water intoxication, which may be the result
monitor vital signs and color of urine. Provide routine postop- of absorbing irrigating fluid in addition to the IV fluids. The
erative care. After catheter removal, encourage client to void most common early symptoms of water intoxication are
with the first urge to prevent increased bladder pressure. changes in the client’s mental status. These may be manifested
by agitation, confusion, and, later, convulsions. The client may
also have a slow bounding pulse with an increase in systolic
NURSING PROCESS and decrease in diastolic blood pressure.
A suprapubic or retropubic prostatectomy does not
Assessment require a three-way Foley. Instead, the client will have a ure-
thral catheter, a tissue drain from the prostatic fossa, and an
Subjective Data abdominal dressing. Assess for incisional pain and do a dress-
Ask the client about the presence of urinary frequency, ing check. Especially check the linens underneath the client’s
hesitancy, dribbling, number of times he gets up at night to back for drainage.

Nursing diagnoses for a postoperative client having a TURP for benign

prostatic hyperplasia include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client will state that Assess for pain using a pain scale every 2 to 4 hours.
bladder spasms or pain has decreased. Maintain traction on the urethral catheter by anchoring the
incision catheter to the leg with tape, ensuring that accidental additional
traction will not occur with leg movement.
Monitor for signs of bladder spasm pain such as facial
grimacing, nonflow of irrigating solution into bladder, and
urinating around the catheter. Administer analgesics and
antispasmodics as ordered.
Teach deep breathing, relaxation techniques.
(Continues)

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448 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing diagnoses for a postoperative client having a TURP for benign

prostatic hyperplasia include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Imbalanced The client will not Accurately record I&O including irrigation fluid.
Fluid Volume related to experience water Monitor for changes in the client’s behavior, especially confusion
postoperative irrigation intoxication. and agitation, which may be the first signs of cerebral edema.
Monitor for hypertension, bradycardia, weakness, and seizures.

Stress or Urge Urinary The client will achieve Educate the client that temporary urinary incontinence frequently
Incontinence related to urinary control after occurs after surgery, and reassure him that this is normal.
poor sphincter control removal of the catheter. Teach the client perineal exercises that will help him regain
after catheter removal urinary control. These exercises consist of tightening and relaxing
after surgery gluteal muscles and are to be used each time the client urinates.

Sexual Dysfunction The client will regain sexual Monitor client’s statements to determine if he has any
related to surgery function postoperatively. misunderstanding of the surgery and sexual function.
Instruct client to avoid sexual intercourse until physician
approval is given and that it may take time for his previous level
of sexual function to return.
Encourage client to use a variety of forms of sexual expression,
such as kissing, stroking, and cuddling.
Provide client with opportunities to voice his feelings and ask
questions.
Teach client that it is normal and not harmful if his urine has a
milky appearance due to retrograde ejaculation.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

part of a breast; skin dimpling, redness, scaliness, and irrita-

MALIGNANT NEOPLASM tion; nipple pain, retraction (Figure 13-12), or discharge other

M
than breast milk.
alignant neoplasms include breast, cervical, endome- Women at greatest risk for developing breast cancer are
trial, ovarian, prostate, testicular, and penile cancers. those who:
• Had a mother or sibling with breast cancer
■ BREAST CANCER • Never had children or had their first child after the age of 30

B
• Never breast-fed
reast cancer is the second major cause of cancer death • Have a history of fibrocystic breast changes
among women. Statistics indicate that 1 woman in 8 will • Started menstruating before age 10
develop breast cancer some time during her life. The Ameri-
can Cancer Society (ACS) estimates that 192,370 new cases • Are obese
were diagnosed in the United States in 2009. The 5-year • Consume a high-fat diet and a moderate amount of alcohol
survival rate is 98% for localized stage and 89% for all stages
combined (ACS, 2008). Older adult women (older than
61) have twice the incidence of breast cancer as do younger
women. Less than 1% of all breast cancers occur in men; in
2008, approximately 1,990 new cases of breast cancer were
diagnosed in men (ACS, 2008).
The key to cure is early detection by physical examina-
tion, mammography, and BSE. A new painless mass or lump is
the most common presenting symptom.
Because it is so uncommon, breast cancer in men is all the
more dangerous. Late diagnosis is quite common; therefore,
males need to be educated in the technique of and encouraged
to perform BSE. Signs and symptoms of breast cancer include Figure 13-12 Nipple Retraction of Left Breast (Courtesy of
breast masses, lumps, thickening, and generalized swelling of Steven M. Lynch, MD.)

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 CHAPTER 13 Reproductive System 449

• Smoke
• Experienced a late menopause MEMORYTRICK
• Are physically inactive Staging Breast Cancer
• Take postmenopausal hormone therapy
• Have had previous chest radiation to treat different cancer Using a staging system provides a standardized
A woman generally presents at the health-care office after method for health care providers to summarize how
the discovery of a lump in her breast. If she has been perform- far the breast cancer has spread. The most common
ing BE routinely each month, she is likely to be familiar with system used is the American Joint Committee on
even minute changes in her breast tissue. Breast cancers often
occur in the upper, outer quadrant of the breast and may extend Cancer’s TNM system. This staging system classifies
into the tail of the breast and spread upward into the axilla cancers based on their T, N, and M stages:
(Figure 13-13). It is important to teach clients to examine the T = Tumor (the size and how far has it spread
axillary region as well as the breast during BSE (Figure 13-8). within the breast and to nearby organs)
Women also seek medical advice because they notice
a discharge from the breast, dimpling of the skin, retraction N = Nodes (spread to lymph nodes)
of the nipple, pain, a unilateral change in breast size, or an M = Metastasis (spread to distant organs)
orange-peel appearance (peau d’orange) of the skin (Figure
13-14). Dimpling and puckering are usually associated with (American Cancer Society, 2009b)
the breast tissue or tumor attaching to the skin or the underly-
ing muscle mass, which does not permit movement. The nurse
should not be misled by the client’s report of a tender lump The presence of tiny, palpable clusters of calcium, or
or mass and assume it is fibrocystic breast changes. All new “microclusters,” may be an early sign of breast cancer. These
or enlarged lumps or masses in the breast require immediate should be followed closely with mammography every 6 to 12
assessment. months to detect subtle changes in shape or size.
The American Cancer Society (2009) recommends that
women ages 20 to 39 perform BSE each month and have a
clinical breast examination every 3 years. For women age 40
and older, BSE should be performed monthly, a clinical exami-
nation every year, and a mammogram every year.
Mammography may be performed by the stereotactic
computer-guided technique. This advanced method allows
needle biopsies to be taken at the same time if necessary. The
physician or nurse practitioner may recommend this method
after an initial mammogram has shown suspicious areas. This
12 technique is less costly than excisional biopsy and can be per-
Tail of Spence formed with little discomfort to the client. The client is placed
Upper in a prone position on the special examination table with the
inner
quadrant breast hanging down through the opening in the table. The
Upper operator moves the position of the table to visualize the entire
COURTESY OF DELMAR CENGAGE LEARNING

outer
3 quadrant breast area via computerized guidance.
After the breast has been biopsied and the tissue has been
9 Lower examined by the pathologist, if a malignancy is confirmed, the
Lower outer client may be advised to proceed with surgical removal (lumpec-
quadrant
inner tomy or mastectomy) of the affected tissue. Figure 13-15 shows
quadrant 6
the staging of breast cancer.

Figure 13-13 Quadrants of the Left Breast Medical–Surgical

Management
Medical
Radiation and chemotherapy are used as adjuvant therapy,
but surgery is the primary treatment. Other types of treat-
ment for breast cancer include targeted therapy, immuno-
therapy, photodynamic therapy, gene therapy, hyperthermia,
and antiangiogenesis therapy. For more information about
these treatments go to the American Cancer Society website
at www.cancer.org.

Surgical
Figure 13-14 Peau d’ Orange (Courtesy of Dr. S. Eva There is an abundance of lymphatic vessels proximal to the
Singletary, University of Texas, M.D. Anderson Cancer Center.) breast. Malignant cells can thus escape into the general lymphatic

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450 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

I II
• Tumor is 2 cm or less across • Tumor is between
• No lymph nodes test 2 and 5 cm
positive for cancer Lymph • 1–3 axillary lymph nodes
cells nodes test positive for
• No evident cancer cells
metastases • No evident
Tumor Tumor metastases

Supraclavicular node Lateral Brain

axillary nodes
Supracapular
nodes

III IV
• Tumor is larger than • Tumor is of any size
growing into chest wall or skin

COURTESY OF DELMAR CENGAGE LEARNING

Apical 5 cm/ no lymph
nodes Anterior nodes test positive Lungs • Lymph nodes
pectoral for cancer cells/ no may/may not test
nodes evident metastases positive for cancer
Bone
or cells
Tumor • Tumor is between • Evident metastases
0 and 5 cm and Tumor into other areas
Peau lymph nodes test (lungs, bone, brain,
d'orange positive for cancer Peau
liver)
cells with no d'orange
Liver
evident metastases

Figure 13-15 Breast Cancer Staging

system and be spread throughout the body. A lumpectomy is immediately after surgery and for some time after. The nurse
surgical removal of the cancerous mass. A simple mastectomy with good interpersonal communication skills can help the cli-
removes the tumor mass and only a small portion of the adja- ent identify and verbalize her feelings of loss, thus promoting
cent tissue. In the modified mastectomy, the entire breast tissue the psychological healing process and acceptance of altered
and nearby lymph nodes are removed; the muscles of the chest body image.
wall are left relatively intact (Figure 13-16A). With the radical
mastectomy, the entire breast, lymph nodes, and underlying
pectoralis muscle are removed (Figure 13-16B). Figure 13-17
shows the various options in the surgical management of
breast cancer. The greater the extent of the surgical removal,
the longer the client’s recovery process and the greater the
need for rehabilitation in using the upper extremity on the
affected side. A
The more lymph nodes that are removed, the greater
the chance the client will have lymphedema, an accumu-
lation of lymph in soft tissue. An elastic sleeve may be
worn for compression, and range-of-motion (ROM) exer-
cises may reduce edema. A sodium-restricted diet may be
ordered.
Reconstructive surgery after a mastectomy may be deter-
mined by the amount of breast tissue and muscle remaining
after the initial procedure, the position of the mastectomy scar,
and the probability of recurrent breast cancer. Breast recon-
struction can help the client deal with the disfigurement that B
results from the mastectomy.
The client’s desire for reconstruction and her psychological
status play an important role in determining the personal value
of additional surgery. In the United States particularly, the
breast is associated with childbearing and female sexuality. It
may be difficult for the client to express her concerns to her
partner regarding her sexuality and desirability after the mas- Figure 13-16 Mastectomy Clients; A, Modified Radical;
tectomy. She may have difficulty facing the physical alteration B, Radical (Courtesy of Steven M. Lynch, MD.)

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 CHAPTER 13 Reproductive System 451

COURTESY OF DELMAR CENGAGE LEARNING

Lumpectomy Simple Modified Radical
mastectomy mastectomy mastectomy

Figure 13-17 Surgical Options for Breast Cancer

Breast prostheses constructed to look and feel like real

breast tissue are available. The prosthesis fits into a special
pocket inside the brassiere. Some types are available for swimsuits
and strapless tops. The construction of the prosthesis varies After a Mastectomy
from sponge rubber to fluid- or air-filled.
Volunteers from the local cancer society often visit new • Avoid carrying items in the affected arm or
mastectomy clients to assist them in the physical and psycho- wearing purse straps over the affected shoulder.
logical transition and adjustment after breast surgery. • Have vaccinations, blood pressure, and lab tests
or blood drawn on the unaffected side only.
Pharmacological • Obtain immediate medical attention for all
Some of the agents used to treat breast cancer include anti- injuries and infections of the affected side to
neoplastic drugs such as antiestrogens: megastrol acetate
prevent complications.
(Megace), and tamoxifen (Nolvadex). Additional agents
include androgens for postmenopausal clients includes tes-
tolactone (Teslac) or rotating combinations of chemotherapy
agents such as cyclophosphamide (Cytoxan), an alkylating Tamoxifen (Nolvadex) is used in certain high-risk women to
agent, doxorubicin hydrochloride (Adriamycin), an anti- reduce the incidence of breast cancer (Spratto & Woods, 2009).
tumor antibiotic; 5-fluorouracil (Adrucil) and methotrex-
ate sodium (Rheumatrex); antimetabolites; and prednisone
(Orasone), a glucocorticoid via intravenous or oral routes. Other Therapies
These drugs may be used before or after surgery. These anti- Breast tissue and lymphatic regions may be radiated before
neoplastic agents act in several ways to either inhibit cellular or after surgical excision of the tumor. This treatment may be
growth or interfere with DNA replication. A laboratory test done prophylactically to prevent the metastasis of malignant
called tissue assay determines if estrogen or progesterone cells to other areas, or it may be done as a palliative measure
stimulates the cancer cells to grow. If the cancerous growth to maintain the client’s comfort. Figure 13-18 illustrates
is stimulated by estrogen, antiestrogen drugs are used to brachytherapy, the use of radioactive implants (needles, seeds,
treat the breast cancer. When the tumors are not estrogen- wires, or catheters) at the site of breast cancer.
dependent, estrogen is used as a chemotherapy agent to
treat breast cancers. Examples of two estrogen medications
are diethylstilbestrol diphosphate (Stilphostrol) and ethinyl Nursing Management
estradiol (Estinyl). Encourage all clients to perform BSE and have a mammogram
Paclitaxel (Taxol) has demonstrated positive results in and clinical evaluation as recommended. Actively listen to cli-
clinical trials with breast cancer therapies. It acts by prohibit- ent’s fears and concerns and reinforce the information from
ing cell replication. One of the benefits of this agent is that it the physician or nurse practitioner. Provide routine preopera-
causes milder nausea than many of the other chemotherapy tive care. Identify the client’s support system. Encourage client
agents that are used. It has the potential to cause severe to contact the local American Cancer Society and Reach to
anaphylactic reactions resulting from a histamine release. To Recovery support groups.
avoid this problem, the client should be medicated with the Postoperative care includes monitoring vital signs, drains,
following medications before Taxol infusion therapy: a cor- and dressing, and for signs of hemorrhage or shock. Encourage
ticosteroid such as dexamethasone (Decadron), a histamine client to turn, cough, and deep breathe. If arm is not restricted
blocker such as cimetidine (Tagamet), and an antihistamine by the dressing, elevate it with the hand highest to encourage
diphenhydramine hydrochloride (Benadryl). fluid flow through the venous and lymph routes.

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452 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Tumor site
NURSING PROCESS
Assessment
Subjective Data
The client may describe a newly discovered breast lump and
other changes in the breast, such as dimpling, puckering, or
A B discharge. Ask how long the lump has been present, whether
it is movable, whether it is tender, the frequency that BSE is
performed, the date of the most recent mammogram, and

COURTESY OF DELMAR CENGAGE LEARNING

current medications being taken. Assess pain using a pain
scale to objectify data. Other questions should include the
risk factors.

C D Objective Data
Assess vital signs and weight and review the report of the
Figure 13-18 Brachytherapy for Treatment of Breast last mammogram. Examine the breasts for lumps and dis-
Cancer; A, Hollow metal needles are placed at site; B, Hollow charge from the nipples. During the postoperative phase,
plastic catheters replace metal needles; C, Radioactive material is assess the client’s vital signs and incisional site. Monitor
placed in catheters, with metal buttons holding the catheters in client’s statements and behaviors to determine emotional
place; D, Radioactive implants remain in place for treatment. status.

Nursing diagnoses for a client with breast cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fear related to breast The client will express Encourage client to express specific feelings of fear.
cancer, possible fears. Take extra time to clarify or explain procedures and
metastasis, surgery, and The client will state one treatments. Provide written information along with verbal
disfigurement positive method of coping. information.
Encourage support of family members and significant others,
and a preoperative visit by a member of the cancer society,
Reach to Recovery, and local support group.

Disturbed Body Image The client will discuss Remain attentive to signals from the client indicating readiness
related to removal of the her feelings related to the to look at the surgical site and encourage doing so when
breast loss of her breast and readiness is displayed.
demonstrate acceptance Be alert for client’s comments regarding body changes.
of the change in physical
appearance. Encourage client recommended for chemotherapy to obtain
a wig before therapy begins. Approximately 80% of clients
undergoing chemotherapy will experience hair loss, and, if
the client becomes accustomed to wearing a wig before hair
begins to fall out, the client may feel more comfortable later.
Inform client that she may have decreased sensation and
lymphatic fluid retention in the arm on the affected side.
Teach client to keep arm on affected side elevated above the
level of the heart to promote lymph drainage, and to wear a
properly fitting elastic compression sleeve on the affected arm
that will help reduce the lymphedema.
Anticipate the client’s need to grieve the loss of her breast.
Encourage use of rehabilitation services (Reach to Recovery).

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 CHAPTER 13 Reproductive System 453

Nursing diagnoses for a client with breast cancer include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing The client’s breath sounds Preoperatively, teach the client how to turn, cough, and deep
Pattern related to the will remain clear to breathe.
proximity of the surgical auscultation. Postoperatively, assess the client’s breath sounds, rate,
incision to respiratory The client will effectively and quality of respirations every 4 hours. Monitor O2
muscles and pain with cough and deep breathe saturation with pulse oximeter. Encourage deep breathing
respiratory effort every 2 hours. or the use of incentive spirometry every hour. Provide O2 as
needed.
Medicate the client or encourage use of the PCA pump before
performing exercises or deep breathing.

Self-Care Deficit The client will gradually Begin passive range-of-motion exercises on the first or second
related to limited use regain ROM and provide postoperative day as ordered. Demonstrate postoperative
and range of motion self-care. exercises for the affected arm or request a consult from the
on the affected side physical therapy department.
and postoperative Observe the client as exercises are performed and reinforce
discomforts correct performance.
Encourage active ROM as soon as ordered by the physician to
strengthen the operative side. This may be difficult at first due
to tissue soreness from surgery.
Encourage client to provide self-care as much as able.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Breast Cancer
C.W., age 57, is married, with two children ages 24 and 22. During a bath, she noted a small, movable
lump in her right breast, grew concerned, and went to see her health-care provider. Family history is
significant for fibrocystic breast disease and breast cancer on the maternal side (mother, aunt, sister).
Personal history: onset of menses at age 10 with regular 28-day cycle, 5-day flow. She is 5 feet 5 inches
tall and weighs 175 pounds. Her history is negative for alcohol use, but she smokes one to one-and-a-half
packs of cigarettes daily. She did not breastfeed the children. Her last mammogram was 15 years ago. BSE
is not practiced routinely. States: “I’m not sure just how to do the exam anyway.”
Physical examination reveals a pea-sized lump in the upper right quadrant of the right breast and mul-
tiple clusters of lumps throughout each breast. Dimpling is present superior to the nipple. No nipple dis-
charge was noted. The remainder of the exam was unremarkable. Vital signs were within normal limits.
A mammogram revealed a suspicious mass, and a biopsy performed using stereotactic visualization was
positive for cancer cells. A modified mastectomy was performed the next day with biopsies of adjacent
lymph nodes. Six of ten nodes were also positive.
The morning after surgery, C.W. displayed behaviors that the nurse interpreted as anxiety. She confided
in the nurse that she was afraid she was going to die, as her mother had, from the cancer. C.W. had a
large chest pressure dressing with two Jackson-Pratt drains in place. She stated that she was glad she had
the PCA pump to take care of the pain.
(Continues)

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454 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 1 Bathing/Hygiene and Dressing/Grooming Self-Care Deficit, related to
temporary altered function of arm as evidenced by large chest pressure dressing and two drains in
place
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Self-Care: Activities of Daily Living (ADLs) Self-Care Assistance: Bathing/Hygiene
Comfort Level Self-Care Assistance: Dressing/Grooming
Pain Management

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

C.W. will meet her daily hygiene Assess C.W.’s ability to use Provides baseline information of
needs before discharge. affected arm to perform ADLs. C.W.’s abilities and limitations.
Provide assistance as needed to Assisting with tasks and
complete hygiene tasks, such as encouraging C.W. to participate
bathing and grooming. will facilitate the return of
function and self-esteem.
Encourage gradual resumption Empowers C.W. to help perform
of activities as C.W. indicates her own care, validating her self-
readiness. image and worth, and she will
regain strength and maintain the
mobility of the extremity.

EVALUATION
C.W.’s hygiene needs were met.

NURSING DIAGNOSIS 2 Fear, related to removal of the breast as evidenced by her fear of dying as
her mother had
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Anxiety Control Anxiety Reduction
Coping Coping Enhancement

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

C.W. will have less fear about Encourage C.W. and family to Relieves fear, and perceptions
breast removal. verbalize their feelings and that differ from that of
concerns related to the diagnosis the health-care worker are
and treatment. identified.
Assess C.W.’s normal or previously Enables the nurse to help C.W.
used coping behaviors. use or change coping behaviors.
Involve C.W. and her family in Makes them more likely to feel
care planning. a part of the team rather than
simply accepting a passive “client
role.”

EVALUATION
C.W. verbalized having less fear about the removal of her breast.

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 CHAPTER 13 Reproductive System 455

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 3 Acute Pain, related to surgical manipulation of tissues and excision of tissue
as evidenced by client statement that she was glad she had the PCA pump to take care of the pain
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Symptom Severity Pain Management
Pain Level Patient-Controlled Analgesia (PCA) Assistance

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

C.W. will verbalize that pain is Assess C.W.’s pain level and Alerts the nurse to increasing
controlled. response to analgesia every pain and C.W.’s tolerance of the
2 hours. pain medication.
Instruct C.W. how to use the PCA Allows C.W. control over analgesia
pump. and provides consistent pain relief.
Evaluate the effectiveness of Allows the nurse to identify
analgesia every 2 hours. any untoward effects and
effectiveness of the medication.
Reposition C.W. every 2 hours. Helps improve vascular flow
and relieves pressure on bony
prominences.
Elevate the right arm on pillows. Decreases edema and discomfort
due to pressure on nerves in
the area.

EVALUATION
C.W. reports pain is controlled at less than 2 on a 1 to 10 scale.

is insidious because it is asymptomatic. Cervical cancer has a

■ CERVICAL CANCER high cure rate in the early stages, and it is easily detected by the

A
routine annual Pap smear. The overall 5-year survival rate is
n abnormal condition of the cervix known as dysplasia 74% (ACS, 2009c). The two main types of cervical cancer are
may be an early sign of developing cervical cancer. Dys- squamous-cell carcinoma (80% to 90%) and adenocarcinoma
plasia is a change in the size and shape of the cervical cells, and (10% to 20%) (ACS, 2009c).
it is classified as mild, moderate, or severe. An abnormal Papani- The nurse should immediately bring any abnormal Pap
colaou (Pap) smear may be the first indication of a problem. smear results to the attention of the physician or nurse prac-
Cervical cancer is the most preventable gynecological can- titioner so the client can be notified and the appropriate
cer. Sexual habits constitute a major factor in the development of follow-up treatment initiated. A repeat Pap smear may be
cancer of the cervix. Sexually transmitted infection, particularly indicated after treatment with a vaginal antibiotic cream, or a
the human papillomavirus (HPV), is a particularly significant colposcopy may be performed.
factor (ACS, 2009c). Other factors associated with cervical can- Staging of the cancer progresses from I to IV (Figure 13-19).
cer include smoking, long-term use of oral contraceptives, immu- Carcinoma in situ (CIS) means that the cancerous cells remain
nosuppression, multiple pregnancies, family history, diet low in within the cervix and have not yet spread to adjacent areas. The
fruits and vegetables, obesity, a history of multiple sexual partners greater the number on the staging table, the more the cancer has
and maternal use of diethylstilbestrol (DES) during pregnancy. metastasized to other structures.
The most common sign of cervical cancer is abnormal bleeding,
which progresses from a thin, watery, blood-tinged discharge to
frank bleeding. Contact bleeding may also occur after intercourse.
Advanced disease is indicated by odor, pain in the lower back and Medical–Surgical
groin, difficulty in voiding, hematuria, and rectal bleeding. The Management
Pap smear is the key to early detection. Promotion of regular
pelvic exams and education regarding risk are essential. Surgical
Although cervical cancer can occur at any age, it occurs Treatment modalities may include conization, a surgical exci-
most frequently in women between 30 and 50 years of age. It sion of a cone-shaped section of the abnormal cervical tissues.

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456 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

STAGING SYSTEM FOR CANCER OF THE CERVIX

Stage Characteristics

I • Carcinoma is strictly confined to cervix (extension to corpus should be disregarded)

IA • Preclinical carcinoma
IA1 • Minimal microscopically evident stromal invasion
IA2 • Microscopic lesions no more than 5 mm depth measured from base of epithelium surface or
glandular from which it originates, and horizontal spread not to exceed 7 mm
IB • All other cases of stage I; occult cancer should be marked "occ"

II • Carcinoma extends beyond cervix but has not extended to pelvic wall; it involves vagina, but
not as far as lower third
IIA • No obvious parametrical involvement
IIB • Obvious parametrical involvement

III • Carcinoma has extended to pelvic wall; on rectal examination, there is no cancer-free space
between tumor and pelvic wall; tumor involves lower third of vagina; all cases with hydro-
nephrosis or nonfunctioning kidney should be included, unless they are known to be due
to another cause
IIIA • No extension to pelvic wall, but involvement of lower third of vagina

COURTESY OF DELMAR CENGAGE LEARNING

IIIB • Extension to pelvic wall, or hydronephrosis or nonfunctioning kidney due to tumor

IV • Carcinoma has extended beyond true pelvis or has clinically involved mucosa of bladder or rectum
IVA • Spread of growth to adjacent pelvic organs
IVB • Spread to distant organs (lungs, liver)

Figure 13-19 Cervical Cancer Screening

This procedure is desirable if the client is of childbearing age and I&O. Encourage client to ambulate as ordered and to turn,
and wants children in the future. cough, deep breathe, and use a spirometer. Assist with active
Laser surgery, cryosurgery (freezing of the cells with liq- and passive ROM exercises. Provide careful catheter care.
uid nitrogen), or cauterization (burning) may be performed
as alternative methods of treatment if the cervical lesions are
easily visible for the procedure. A total hysterectomy or radical NURSING PROCESS
pelvic surgery may be required to eradicate the cancer. If the
spread of the disease has become too extensive, treatment will
be directed toward palliative measures.
Assessment
Subjective Data
Other Therapies The client may describe postcoital bleeding (bleeding after
The physician may recommend the use of radium implants intercourse) or spotting between menstrual periods or after
or radiation therapy before the surgical excision of the cervix. menopause and, occasionally, a foul-smelling vaginal dis-
The nurse must be cautious in providing nursing care for the charge. As the disease progresses, she may describe increased
client with radium implants. Pregnant nurses or female nurses or bloody discharge, weight loss, and pain that radiates down
of childbearing age should not care for this client or spend the lower back and legs.
extended periods at the bedside. Direct client care should be
organized to optimize time spent at the bedside. A sign should Objective Data
be hung on the door to indicate that radiation is being used Objective data may include the presence and appearance of a
in the room and provide a warning for visitors to limit their vaginal discharge. The cervix may appear eroded or raw and
visit time. With the implants in place, the client will remain on may bleed easily when touched with a cotton-tipped applica-
complete bed rest. tor or Pap scraper. Necrotic tissue may be present and cause
In addition, chemotherapy may be utilized as an adjunct a foul odor. Pap smear results can indicate dyplasia. Tissue
therapy to help shrink the tumor or slow its growth. samples obtained through colposcopic examination may show
cellular changes. In advanced disease, weight loss and anemia
Nursing Management may be present. Laparotomy may be performed to stage the
disease and along with other laboratory and diagnostic testing
Provide therapeutic emotional support to the client to help to identify metastases, which are most likely to occur in the
her cope with the diagnosis. After surgery, monitor vital signs rectum, vagina, bladder, and pelvis.

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 CHAPTER 13 Reproductive System 457

Nursing diagnoses for a client with cervical cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to The client will verbalize Be aware of the client’s emotional state throughout the course
unknown outcome and having less anxiety about of care and use effective interpersonal communication to
possible treatments treatment and possible facilitate the client’s acceptance of her condition and the
outcome. treatments.
Explain diagnostic tests and procedures to client to decrease
her anxiety.
Provide therapeutic emotional support to client to help her
cope with feelings.

Sexual Dysfunction The client will return to Inform client that she may experience dyspareunia related to
related to vaginal normal sexual function after vaginal dryness after radiation therapy. Instruct client to use a
bleeding, discomfort, and recovery from treatment for water-soluble lubricant during intercourse or to use lubricated
procedures cervical cancer. condoms to decrease irritation.
Listen to client’s concerns.

Impaired Urinary The client will regain normal Assess the function of the Foley catheter to ensure patency and
Elimination related urinary elimination. drainage. Provide careful catheter care. Promote urination when
to sensory motor catheter is removed.
impairment from radiation Record I&O, including color of urine. Encourage the client to
effects drink fluids to flush the kidneys and decrease risk of UTI.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

diagnosis. An endometrial biopsy, which examines the tis-

■ ENDOMETRIAL CANCER sue from the uterine lining under a microscope, is the best

P
diagnostic tool to identify cellular changes. This may be done
ostmenopausal women are at the greatest risk for endo- on an annual basis when the client has a routine examination.
metrial cancer, especially if they have taken estrogen The medical follow-up treatment plan depends on the biopsy
replacement therapy for several years (usually more than 5 results. D&C has a potential for spreading the cancer cells to
years). Research has shown that unopposed estrogen stimula- adjacent tissues because the malignant cells may escape into
tion of the endometrial lining has a strong relationship with the bloodstream at the time of the procedure. This is not
the development of endometrial cancer. During the normal usually a problem with the biopsy because the amount of tis-
menstrual cycle, estrogen and progesterone rise and fall. sue removed is so small and blood loss is minimal. A D&C is
These hormonal fluctuations affect the stimulation of the also more expensive, higher risk, and requires some type of
endometrial tissue to grow and be sloughed off. Without the anesthesia.
progesterone effects, the endometrial tissue is not sloughed
off at regular intervals and may undergo cellular changes, lead-
ing to a high risk for endometrial dysplasia or cancer. For this Medical–Surgical
reason, many physicians and nurse practitioners have recom- Management
mended estrogen-progesterone therapy for clients who experi- Treatments for endometrial cancer may range from radiation,
ence menopausal symptoms. radium implants, chemotherapy, or surgery to a combination
In summer 2002, the data and safety monitoring board of any of the above. The choices of treatment are related to the
for the Women’s Health Initiative study of estrogen/proges- staging of the cancer.
tin recommended stopping the trial because of an increased
risk of invasive breast cancer (Fletcher & Colditz, 2002). It
is recommended that long-term use of this combination be PROFESSIONALTIP
stopped.
Other risk factors associated with endometrial cancer
may include never having borne a child, being Caucasian, Radiation Exposure Risk
being middle class, never having had sexual intercourse, use of
oral contraceptives, total number of menstrual cycles, use of Because of the risk of radiation exposure to the
tamoxifen, obesity, diabetes, and family history. caregiver from the radiation implant device, keep
Cancer of the endometrium usually does not produce procedures that require exposure to the client’s
symptoms until it becomes relatively advanced. Routine perineal area at a minimum.
Pap smear and pelvic examinations are inadequate for early

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458 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Medical cancer, does not produce symptoms until it is in an advanced,

inoperable stage. It is sometimes called “the silent killer.” Its
Intravenous fluid administration will be implemented to symptoms are vague and may be ignored for a long time before
replace fluids lost by the excessive bleeding. A blood transfu- the client seeks medical attention. According to Lehman
sion may be ordered for a low hemoglobin. A hemoglobin (2007), the first national consensus statement on ovarian can-
above 10 gm/dL is preferred before surgical intervention. The cer symptoms was issued and recognizes that the symptoms
physician may order whole blood or packed red blood cells to of bloating, abdominal or pelvic pain, difficult eating, feeling
increase the hemoglobin rapidly. full quickly, and urinary urgency or frequency are more likely
to occur in woman with ovarian cancer than women in the
Surgical general population (Lehman, 2007).
Surgery for endometrial or cervical cancer includes hysterec- Ovarian cancer causes more deaths than does any other
tomy. A total hysterectomy is removal of the cervix and the gynecological cancer, an estimated 14,600 in 2009 (ACS,
uterus. In a subtotal hysterectomy, only the uterus is removed 2009d; Lehman, 2007). The incidence is greatest in women
and the cervix remains. A radical or pan hysterectomy includes between 45 and 65 years of age. Nulliparity (never having
removal of the ovaries, cervix, uterus, fallopian tubes, pelvic borne a child), smoking, alcohol use, infertility, and a high-fat
lymph nodes, and part of the vagina. Vaginal hysterectomy diet are factors that place the client at higher risk for develop-
procedures have been refined with the laparoscopic approach ing ovarian cancer. Metastasis occurs in more than 75% of
so that many clients are released from the hospital within 24 to cases before diagnosis, and often the cancer has spread beyond
36 hours postoperatively. If the cancer has spread beyond the the pelvis. The colon is the most frequent site of ovarian can-
uterus into the pelvic region, an abdominal hysterectomy may be cer metastasis, then the stomach, and diaphragm.
the best approach for visualization during surgery. The physician Unfortunately, medical research has not yet developed an
may recommend a course of radiation therapy after surgery. early diagnostic or screening tool to detect ovarian cancer. It
is believed, however, that there is an increased risk of ovarian
Pharmacological cancer for clients with breast cancer and vice versa. A family
Drug therapy includes the use of the chemotherapy agents history of two or more female relatives with breast or ovarian
doxorubicin (Adriamycin), cisplatin, carboplatin, and pacli- cancer provides a sound rationale for more frequent breast
taxel (Taxol). Two or more drugs may be combined for and pelvic examinations. Often, the physician or NP palpates
treatment such as cisplatin and doxorubicin. Side effects of an ovarian mass on a routine bimanual examination. This
chemotherapy depend on the drug taken, the amount, and the finding is cause for further investigation by pelvic ultrasound
length of time the client has been taking the drug. or CT scan to determine the size, character, and consistency
(solid or fluid-filled) of the mass and whether other pelvic
structures are involved. Some experts believe that there is a
Other Therapies link between the occurrence of ovarian cysts and the develop-
There is a tendency for endometrial cancer to confine itself to ment of ovarian cancers in certain women.
the uterus, which increases the client’s 5-year survival prog- General diagnostic studies, such as a lower GI series,
nosis. Endometrial cancer also usually responds well to the chest x-ray, intravenous pyelogram (IVP), transvaginal ultra-
therapies available at this time, including radiation. Radiation sound, and laparoscopy may be useful in determining the
may be delivered to the pelvic region via external sources, or extent of the primary and secondary lesions. A blood test,
it may be delivered via intracavitary devices or implants with CA-125 assay, measures a tumor marker CA-125 that is often
radium or cesium. There is a potential danger for injury to higher than normal in women with ovarian cancer (Lehman,
adjacent pelvic structures during radiation therapy. The nurse 2007). If the client develops peritoneal fluid or ascites as the
should be alert for signs of complications, such as bleeding cancer progresses, it may be removed by paracentesis for cyto-
from the rectum, moderate to severe abdominal pain, consti- logic examination.
pation, or diarrhea. Recurrent disease is common and may occur in 2 years or
less. Continued medical surveillance is recommended every
Nursing Management 2 months for a period of 2 years for the earliest possible detec-
tion of new lesions. The 5-year survival rate is 45% (ACS,
One of the earliest symptoms reported by many clients is vagi- 2009d).
nal bleeding. For the postmenopausal client, it is imperative that
all bleeding be investigated immediately unless it is from hor- Medical–Surgical
Management
monally induced periods. Late in the progression of the cancer,
the client may experience symptoms similar to those discussed
with cervical cancer. Pain is often associated with the spread of
cancer to adjacent organs and is considered a late sign. Surgical
Objective data may be collected from the client’s physi- Surgical excision of the ovary is rarely successful because of
cal exam findings, biopsy reports, and a history of hormone the extensiveness of the disease. A total abdominal hysterec-
replacement therapy with or without the estrogen-progesterone tomy with a bilateral salpingo-oophorectomy or omentectomy
combination. is performed for most stages of the disease. Most often, a
combination of radiation, chemotherapy, immunotherapy,
and surgery produces the best results, even if they are only
■ OVARIAN CANCER palliative for the client. The client must be actively involved

O
and informed of her treatment options as well as her prog-
varian cancer most often originates in the epithelial nosis to enable her to make sound choices in the treatments
tissue of the ovary, and, like cervical and endometrial chosen.

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 CHAPTER 13 Reproductive System 459

hospice setting. Other types of medication that may be given

Pharmacological include tranquilizers, antiemetics, and laxatives.
Chemotherapy drugs that are used with ovarian cancer treat-
ment include cyclophosphamide (Cytoxan), doxorubicin
hydrochloride (Adriamycin), mitomycin (Mutamycin), cispla- Nursing Management
tin (Platinol), paclitaxel (Taxol) and carboplatin. For intrave- Accurately measure the client’s legs to ensure the proper fit of
nous chemotherapy, carboplatin is preferred over cisplatin due antiembolic stockings. Provide comfort measures of back rub
to being as effective and having less side effects (ACS, 2009d). and position change. Teach client about skin care if receiving
In 2006, the National Cancer Institute encouraged physicians radiation. Assess bowel sounds and for abdominal distention.
to use a combined approach of intraperitoneal (IP) chemother- Maintain an accurate I&O record.
apy in addition to intravenous chemotherapy (Lehman, 2007).
Intraperitoneal chemotherapy administers paclitaxel (Taxol)
or cisplatin (Platinol) directly into the client’s abdominal cav- NURSING PROCESS
ity. This technique can add a year to the lives of women with
advanced stages of ovarian cancer. Combination chemotherapy Assessment
is the standard approach for treatment of ovarian cancer. Subjective Data
These may be administered by regional or intraarterial perfu-
sion techniques. These percutaneous modes direct the drugs to The client may describe fatigue, malaise, diarrhea or constipa-
the lesion’s vascular supply. If the cancer has not metastasized, a tion, pelvic pressure, frequency of urination, loss of appetite,
regimen of chemotherapy using a single drug, such as Cytoxan, nausea, weight gain or loss, vaginal bleeding or spotting with
may be administered over the course of 5 days and repeated intercourse, a foul-smelling vaginal discharge, and pain in the
again at regular intervals over the course of a year. A combination lower back. The list of symptoms is very vague and could be
of the chemotherapy agents, used in a rotating series, is often related to many reproductive and nonreproductive disorders.
more effective for reproductive cancers in advanced stages. For
example, the client would receive one drug over the course of Objective Data
5 days, then switch to another drug for 5 days, and then a third Objective data pertinent to all cancers of the pelvic reproduc-
drug for 5 days. This series may be repeated over the year in a tive organs may include information from the client’s previous
similar pattern to that used with a single agent. health history, reproductive history (onset of menses, pregnan-
Sometimes two or three different medications are nec- cies, contraceptive methods, infections, hormonal replacement
essary to achieve pain control. Intravenous medications are therapy, and surgeries), the discovery of a palpable mass during a
often given by a PCA pump with continuous low-dose narcot- bimanual examination, an abnormal appearance of the cervix or
ics. This method seems more effective for the client than IV adjacent tissues, abnormal Pap smear results greater than Class II
bolus doses every 4 hours. Medications may also be given slow dysplasia, abnormal cervical or endometrial biopsies, increased
IV push (an RN procedure), orally in tablets or liquids, intra- abdominal girth, or the presence of ascites and pleural effusion.
muscularly, or by transdermal patches (Duragesic). A liquid Diagnostic tests and laboratory studies may include all or
mixture of syrup, cocaine, morphine, alcohol, flavoring, and some of the following: Pap smear, pelvic ultrasound, chest x-ray,
water called “Brompton’s mixture, elixir, or cocktail” may be IVP, kidney/ureters/bladder x-ray (KUB), CBC with differential,
ordered. The client may drink up to 20 mL every 3 to 4 hours blood chemistry studies, bleeding and clotting time, endometrial
for pain relief. Most of these methods of narcotic administra- biopsy, cervical biopsy, D&C tissue specimens, Schiller’s test and
tion are equally effective and may be used in the home care or colposcopy, laparoscopy, barium enema, and bone scan.

Nursing diagnoses for a client with endometrial or ovarian cancer include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Preoperative:
Fear related to tentative The client will verbalize Facilitate client’s expression of fear by encouraging the
diagnoses, pending fears and have behaviors client’s open discussion of her concerns. Be alert for
surgical procedures, consistent with reduced fear nonverbal cues as well.
cancer treatment and its before and after surgery. Arrange a consultation with a social worker or chaplain, if
side effects, incapacitating appropriate.
or extended illness with
resulting dependence, and
possible death
Chronic Pain related to The client will have pain Administer analgesics as ordered.
the spread of cancer controlled at a level that Provide comfort measures, such as position changes and
throughout the pelvis and allows continual functioning back rub.
adjacent structures in her activities of daily living
as long as possible.
(Continues)

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460 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing diagnoses for a client with endometrial or ovarian cancer include

the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Postoperative:
Impaired Skin Integrity The client’s skin integrity will Provide client with proper skin-care instructions during and
related to surgical be maintained. after radiation therapy that may include avoiding soaps,
interventions, radiation, creams, powder, deodorants, and other substances around the
and chemotherapy side incision that may irritate the skin; not washing off the radiation
effects markings; and avoiding tight clothing around the area.
Teach client to look for signs of reactions to radiation
therapy, such as tenderness, flushed color (like a sunburn),
delayed wound healing, and itching.
Perform daily cleansing of the incisional area with water only.
If client is on complete bed rest due to radium implant
therapy, provide a complete bedbath as well as morning and
bedtime skin care.
Organize time near the client’s bedside to brief periods to
avoid overexposure to radiation.
Wear rubber gloves when disposing of soiled materials.
Put soiled dressings in a biohazard waste container.

Impaired Urinary The client will have Explain dietary modifications designed to reduce residue.
Elimination, Bowel adequate bowel and The diet should be limited in dairy products, raw fruits,
Incontinence, or bladder function during the grains, and vegetables. Meats must be well cooked and
Constipation related to the postoperative period. possibly ground.
proximity of surgical site to If client is not receiving radium implant therapy, weigh her
bowel and bladder, spread daily on the same scale at the same time of the day.
of cancer to adjacent
structures, manipulation Review client’s normal elimination patterns from the baseline
of organs during surgery, assessment data to help identify early changes in bowel or
administration of narcotic bladder elimination.
analgesics, lack of activity, Forewarn client of radiation enteritis and cystitis, and
and changes in dietary common tissue responses to radiation therapy. Instruct her
intake to report symptoms, such as diarrhea, cramping, frequency,
urgency, and dysuria.
Assess bowel sounds and abdominal distention at least
every 4 to 8 hours.
Carefully monitor the client’s urinary pattern and maintain an
accurate intake and output record.
Observe urine and stool for color, consistency, amount, and
the presence of blood.
Monitor client for other gastrointestinal problems, such as
nausea, vomiting, and tenesmus (spasmodic contraction of
the anal or bladder sphincter, causing pain and a persistent
urge to empty the bowel or bladder).

Impaired Physical Mobility The client will not develop Accurately measure client’s legs to ensure the proper fit of
related to intracavity deep vein thrombosis. the hose. Apply thigh-high antiembolic stockings (TEDS) as
radiation ordered.
Assist client to ambulate when allowed.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 13 Reproductive System 461

■ PROSTATE CANCER PROFESSIONALTIP

P rostate cancer is the second leading cause of cancer deaths
in men. According to 2009 estimates by the ACS, 192,280
new cases were diagnosed. Survival rate for all cases is nearly
Risk Factors for Prostate Cancer
• Advancing age (more than 55 years)
100%. Incidence increases with age, as 70% of all prostate • First-degree relative with prostate cancer
cancers are diagnosed in men older than age 65. Improved
detection methods have greatly increased the number of indi- • African American heritage
viduals having positive outcomes. Diagnostic tests that may • High level of serum testosterone (Estes, 2010)
be performed are measurement of serum prostate-specific
antigen (PSA), transrectal ultrasonic examination, DRE, and
prostatic biopsy. Studies indicate that the PSA alone for rou- The ultrasound allows the surgeon to selectively freeze pros-
tine screening is not especially useful. The American Cancer tate gland tissue while the temperature of the prostatic urethra
Society (2009f) recommends a yearly PSA level and digital is kept at 44°C by irrigation with heated water. This approach
rectal examination to screen for prostate cancer in men age 50 is an option for those who cannot tolerate more extensive sur-
and older with a life expectancy of more than 10 years. gery, have a localized tumor, or do not have successful radia-
Most prostatic cancers are adenocarcinomas, slow-growing tion treatment. It can be performed more than once, involves a
tumors that spread through the lymphatics. Early symptoms shorter hospital stay, and produces fewer side effects.
include dysuria, a weak urinary stream, and increased urinary
frequency. Later symptoms are related to complete urethral Pharmacological
obstruction or hematuria. Blood in the urine (hematuria), Hormonal agents such as diethylstilbestrol (DES), luteinizing
which can lead to anemia, occurs because of the rupture of hormone releasing hormone agonist (LHRH) leuprolide acetate
blood vessels that have been overstretched. (Lupron), and nonsteroidal antiandrogens flutamide (Eulexin)
may be used in the management of advanced prostate cancer. Che-
Medical–Surgical Management motherapy drugs used to treat prostate cancer include paclitaxel
Treatment depends on the extent of the disease and the age (Taxol), carboplatin (Paraplatin), mitoxantrone (Novantrone),
of the client. and vinblastine (Velban). A combination of prednisone and doc-
etaxel (Taxotere) is used in clients with advanced prostate cancer.
Medical
Radiation is the traditional alternative to surgical removal of
Nursing Management
the malignant prostate gland; however, radiation may fail to Encourage all male clients older than age 40 to have an annual
eradicate the tumor or may lead to diarrhea, bowel obstruc- rectal examination of the prostate and a PSA serum level.
tion, lymphocele formation, edema of the extremities, pul- Monitor vital signs (no rectal temperature), urinary output,
monary embolism, wound infections, infection, impotence, and fluid intake. Assess urine for signs of bleeding. Objectively
incontinence, or radiation cystitis. An alternate successful assess for pain and administer analgesics as ordered. Keep
radiation treatment option for early-stage prostate cancer is perineal area clean and dry.
transrectal assisted radioactive seed implant. With the use of
ultrasound, the physician is able to precisely position the rice- NURSING PROCESS
sized radioactive seeds inside the malignant prostate gland.

Surgical
Assessment
Surgical treatment of prostatic cancer involves removal of the Subjective Data
entire prostate gland, including the capsule and adjacent tissue. The client may seek care for BPH, which often accompanies
The urethra is then anastomosed to the bladder neck. Sometimes cancer of the prostate. He may describe back pain or sciatica,
the perineal approach is used, but the usual approach is retropubic frequency, dysuria, or nocturia.
prostatectomy. Since 2003, a newer approach is the robotic-assisted
laparoscopic radical prostatectomy using a robotic interface called Objective Data
the “da Vinci” system. The surgeon sits at a panel controlling the Complete a physical assessment, including palpation of the
robotic arms to perform the operation through small incisions in abdomen and skin assessment. Palpate the abdomen to deter-
the client’s abdomen. This method has shown less blood loss and mine if there is any bladder distention. Skin assessment is
shorter recovery time than the standard radical prostatectomy. important because the client is at risk for skin breakdown.
Because of the proximity of the bladder sphincters to the There may or may not be hematuria present. Vital signs, the
prostate gland, urinary incontinence may be a complication. incisional site, and intake and output must all be assessed.
Other complications include sexual dysfunction and the uni- Report hyperthermia, hypotension, tachycardia, or increased
versal surgical risks of hemorrhage, infection, thrombosis, and incisional drainage to the physician immediately.
strictures. Removal of the testes (orchiectomy) may also be A catheter is used postoperatively to maintain urinary
done as a palliative measure to help eliminate the androgenic drainage and as a splint for the urethral anastomosis rather than
effect that promotes tumor growth. for hemostasis, so there are minimal bladder spasms. Monitor
Cryosurgery (freezing) was used in the 1960s but aban- catheter patency by assessing the drainage for color, amount,
doned because of tissue sloughing and fistula development. and presence of clots. If the tubing is not draining freely,
With the advent of the transrectal ultrasound and the transure- reposition or milk it. Call the physician if these measures fail
thral warming device, cryosurgery is again a viable alternative. to restore patency. During the first week of the postoperative

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462 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

period, monitor the client for fecal incontinence related to when the perineal surgical approach is used because the inci-
relaxation of the perineal sphincter. This complication occurs sion is made between the scrotum and the rectum.

Nursing diagnoses for a client (postoperative) with prostate cancer include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Urinary Retention related The client will not Monitor the client’s urinary output, noting the amount, color,
to urethral obstruction, experience urinary and presence of clots. The urine should not appear bright red
secondary to urethral retention. for more than a few hours postoperatively, after which time it
anastomosis. should be dark red.
Reposition or milk the catheter tubing if not patent. If these
interventions fail, notify the physician.
Monitor the client’s intake, encouraging a fluid intake of 2,500
to 3,000 mL/day.

Bowel Incontinence The client will achieve Teach the client that temporary fecal incontinence frequently
related to loss of rectal rectal sphincter control. occurs after a perineal incision. Teach the client perineal
sphincter control exercises that will help him regain bowel control.
becauseof perineal Avoid the use of rectal thermometers, rectal examinations, and
incision enemas.

Risk for Impaired Skin The client will not Keep the client clean and dry, especially if he is experiencing
Integrity related to experience skin fecal or urinary incontinence and reposition every 2 hours.
incontinence breakdown.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

client may have a blood test for alpha-fetoprotein (AFP) and

■ TESTICULAR CANCER human chorionic gonadotropin (hCG). These proteins are

A
called tumor markers, and when elevated levels are present in
lthough testicular cancer accounts for only 1% of all cancer the blood it suggests testicular cancer.
in men, it is the most common cancer in young men
between the ages of 15 and 35. According to the ACS (2009g),
advances in treatment have made the 5-year survival rate 96%. Surgical
The etiology is unknown, but the incidence is highest in men Biopsy of the testis is contraindicated because of the
with undescended testicles and those whose mothers had increased potential for metastases. Surgical removal of the
taken hormones during pregnancy. A small, hard, painless testis, spermatic cord, and inguinal canal contents, with
lump is usually the first symptom noted. examination of the nodes, is indicated for testicular cancers.
Because early diagnosis of testicular cancer is so essential If unilateral removal of a testis is indicated, the remaining
for a positive surgical outcome, men need to be taught how to healthy testis will continue to maintain sperm and androgen
perform a testicular self-examination (TSE) and be encour- production.
aged to routinely perform that examination (Figure 13-20).
TSE is performed as follows:
• Perform TSE after a bath or shower when scrotum is warm Pharmacological
and most relaxed. Although chemotherapy and radiation are used as adjuvant
• Grasp testis with both hands and palpate gently between treatments, radical inguinal orchiectomy remains the primary
thumbs and forefingers. intervention. Combination chemotherapy with cisplatin (Pla-
• The testis should feel smooth, egg-shaped, and firm to the tinol), vinblastine sulfate (Velban), and bleomycin sulfate
touch. (Blenoxane) is effective.
• The epididymis, located behind the testis, should feel like
a soft tube.
CRITICAL THINKING
• Any abnormal lumps or changes in the testes should be
reported to a physician.
Testicular Self-Examination
Medical–Surgical Management
How would you teach a client to do a testicular
Medical self-examination? Make a teaching plan.
Testicular ultrasound is used to study the testes for enlarge-
ment or lesions. In addition to a testicular ultrasound, the
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 CHAPTER 13 Reproductive System 463

COURTESY OF DELMAR CENGAGE LEARNING

Figure 13-20 Performing a Testicular Self-Examination

Nursing Management the client needs to be assessed for pain, using a pain scale to
objectify data. Assess his emotional and educational needs.
Encourage all male clients older than age 15 to perform testicu- Monitor his behaviors and statements for signs of anxiety or
lar self-examination monthly. Cancer is suspected in a testicle depression.
that is hard. Postoperatively, monitor vital signs and incisional
drainage. Maintain strict asepsis when changing dressings. Pro-
vide opportunities for the client to voice fears and concerns. Objective Data
A physical examination should include palpation of the abdo-
NURSING PROCESS men and assessment of the scrotum. Positive findings in the
Assessment scrotum include a firm, painless mass in the testis and an
enlarged scrotum. Because gynecomastia (breast enlarge-
Subjective Data ment) is another symptom of testicular cancer, the client’s
breast tissue should be assessed for enlargement.
The client may describe a feeling of heaviness in the scrotum
and may mention weight loss. During the postoperative phase,

Nursing diagnoses for the client with testicular cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury due to The client will experience Monitor the client’s vital signs and incisional drainage. Report
infection and hemorrhage minimal bleeding and avoid hyperthermia, tachycardia, hypotension, increased incisional
related to surgery infection. drainage, and swelling or redness around the incision to the
physician immediately.
Maintain strict asepsis when handling wound dressings.

Disturbed Body Image The client will maintain Provide client with opportunities to voice concerns and ask
related to surgery or regain a positive body questions. Monitor the client for statements and behaviors that
image. indicate concern about loss of masculinity.
Educate client that unilateral removal of a testis will not cause
him to be sterile or demasculinized. Suggest sexual counseling
if he does not appear to be resolving these issues. Sperm may
be frozen before treatment.

(Continues)

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464 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing diagnoses for the client with testicular cancer include the
following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will demonstrate Teach the client that he needs to be on bed rest for 12 to
related to surgery and understanding of 24 hours postoperatively.
post operative care postoperative activity Instruct the client to wear tight-fitting underwear or an athletic
restrictions and medical supporter when ambulating and to avoid heavy lifting for 4 to 6
follow-up. weeks.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ PENILE CANCER Nursing Management

P
Provide emotional support if penectomy is required. Moni-
enile cancer is rare and has a high correlation with poor tor vital signs and I&O. Elevate the scrotum to prevent
hygiene and delayed or no circumcision. The bacteria har- edema. Objectively assess pain and administer analgesics as
bored in the foreskin of the uncircumcised male are irritants ordered.
to the glans penis and the prepuce. The chronic nature of this
irritation is thought to be carcinogenic. Males with a history of
sexually transmitted infections (STIs) are also predisposed to
developing penile cancer. Symptoms of penile cancer include
NURSING PROCESS
a painless, nodular growth on the foreskin, fatigue, and weight
loss. Metastases are common in the inguinal nodes and adja-
Assessment
cent organs. Subjective Data
Although the tumor is painless, ask the client if he is experi-
Medical–Surgical encing any pain, to rule out other possible diagnoses. Also ask
Management about fatigue or weight loss. Preoperatively, assess the client
for emotional and educational needs. Ask questions that can
Medical determine his understanding of the surgical procedure and
the need for counseling. Postoperative assessment includes
The primary penile cancer treatment is surgery. Treatment monitoring for pain and using a pain scale to objectify data.
with radiation alone is ineffective, and chemotherapy alone is
used only for palliative treatment of penile cancer with deep,
distant metastases; however, the client may receive adjuvant Objective Data
therapy with either radiation or chemotherapy. The client’s physical assessment should include inspection
of the penis for the presence of painless, nodular growths.
Surgical During the postoperative phase, monitor vital signs, inci-
If the tumor is not extensive and no metastases are involved, sional site, and intake and output. Hypotension, tachycardia,
the remaining penis should be long enough for the client to excessive incisional drainage, redness or swelling around the
void standing and avoid soiling himself. If a penectomy is incision, or bright red or low urinary output could be signs of
necessary, a perineal urethrostomy may be created. complications.

Nursing diagnoses for a client with penile cancer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury due to The client will experience Monitor client’s vital signs and incisional drainage. Report
infection and hemorrhage minimal bleeding and avoid hyperthermia, tachycardia, hypotension, increased incisional
related to surgery infection. drainage, and swelling or redness around the incision to the
physician immediately.
Maintain strict asepsis when handling wound dressings.
Anxiety related to surgery The client will discuss Provide client with information about the operative procedure,
anxieties. postoperative and discharge care. When available, a video
may be used to present this information, with the nurse being
available to answer the client’s questions.

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 CHAPTER 13 Reproductive System 465

Nursing diagnoses for a client with penile cancer include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Sexuality The client will maintain Recommend the client to seek sexual counseling for both
Patterns related to the satisfactory sexuality himself and his partner if he is unable to maintain normal
altered body function or patterns postoperatively. sexuality patterns.
structure

Evaluation: Evaluate each outcome to determine how it has been met by the client.

the absence of menstruation by the age of 16. Possible causes

MENSTRUAL DISORDERS are related to anatomical or genetic abnormalities (Turner’s

A
syndrome). The treatment depends on the cause. Secondary
bnormalities of menstruation may be associated with an amenorrhea is defined as the absence of menstruation after 6
increase or decrease in secretion from any of the following months of regular periods or after 12 months of irregular peri-
glands: hypothalamus, pituitary, ovaries, adrenals, and thyroid. ods. Several etiologies are possible for secondary amenorrhea,
The normal menstrual pattern is controlled by a series of hor- including anatomic abnormalities, nutritional deficits (anorexia
monal negative feedback mechanisms. The average menstrual nervosa), excessive exercise with significant decreases in body
cycle occurs every 28 to 30 days when the endometrial lining of fat, endocrine dysfunction, emotional disturbances, side effects
the uterus sloughs off in the absence of a fertilized ovum. of medications, pregnancy, and lactation.
Diagnosis is based on the length of menstruation absence.
A complete physical examination is performed, including a
■ DYSMENORRHEA pelvic examination to rule out many other factors. A preg-

P
nancy test will be one of the first tests ordered, to rule out
ainful menstruation, dysmenorrhea, also called “menstrual pregnancy. A progestin challenge test may be administered
cramps,” is more common in nulliparous women and in in an attempt to force the body to respond hormonally.
women who are not having intercourse. The exact pathophysi- Medroxyprogesterone acetate (Depo-Provera) is taken orally
ology is unknown, but it may be related to endocrine secre- for 5 to 10 days as ordered by the physician. When the medi-
tions such as prostaglandin F, which causes uterine cramping, cation is finished, the client should have a menstrual period
irritation, and contractions. Other causes may include uterine within 3 or 4 days. A menstrual flow after taking the medica-
anatomical anomalies, chronic illness, or psychological factors. tion may be an indicator that the client has not been ovulating.
The primary symptom is pelvic pain before or at the onset If no bleeding occurs, further investigation may be necessary
of menses that may be caused by spasms of the uterus, cervical to uncover other causes. Hormonal imbalances, microscopic
stenosis, uterine fibroids, emotional factors, endometriosis, pituitary tumors, and nutritional deficits are common etiolo-
pelvic inflammatory disease, or the presence of an intrauterine gies of secondary amenorrhea. A microscopic pituitary tumor
contraceptive device (IUD). The client may also state that the will cause an elevation in the prolactin level and result in
pain radiates across the lower back and downward into the legs. anovulation and amenorrhea. A serum prolactin level should
The condition is diagnosed on the basis of the client’s com- be ordered, especially if the client has noticed any breast dis-
plaints and description of the timing of the onset of symptoms. charge. Normal prolactin level should not exceed 15 ng/dL.
Obtain information pertaining to the menstrual history and With pituitary tumors, the prolactin level may exceed 400 ng/
general health status of the client. A thorough physical exam is dL. In these cases, the drug of choice is bromocriptine mesy-
performed by the physician, including a bimanual exam to rule late (Parlodel), which had been used in the past to suppress
out other possible causes. A pelvic ultrasound may be ordered. lactation in mothers who did not breastfeed their newborns. A
One effective preventive intervention may begin before careful examination of the client is needed before administra-
the young woman begins menstruation. A positive parental tion of Parlodel because of an increased potential for cardio-
attitude toward the onset of menstruation can aid the young vascular problems associated with this medication. Because of
girl in adjusting to the physiologic and psychological changes this risk, the medication is no longer used for the postpartum
that occur with puberty. client to suppress milk production. Other medical or surgical
Some medications are effective in the treatment of dys- interventions depend on the cause of the amenorrhea.
menorrhea. Analgesics such as acetaminophen (Tylenol) and
ibuprofen (Motrin) are useful in relieving pain. Oral contra-
ceptives have been used for some clients to inhibit ovulation, ■ OTHER DISORDERS

O
which appears to be an associated cause. Prostaglandin inhibi-
tors such as naproxen sodium (Aleve) and mefenamic acid ther menstrual disorders include menorrhagia and
(Ponstel) are useful if taken at the earliest sign of discomfort. metrorrhagia. Both types of abnormal bleeding can be
problematic for the client and require further investigation.
Polymenorrhea is a term used to describe short menstrual
■ AMENORRHEA cycles of less than 21 days in length. The causes are similar to

A
those of the other menstrual disorders. Oligomenorrhea, is
menorrhea, the absence of menstruation, may be pri- a diminished menstrual flow, but it is not classified as amenor-
mary or secondary. Primary amenorrhea is defined as rhea. It may be associated with low-dose oral contraceptives

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466 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

that inhibit the growth of the endometrium and result in inappropriate nutritional status, a previous reaction to or
minimal tissue sloughing at the end of the cycle. Other causes side effects from oral contraceptive use, a sedentary lifestyle,
may be metabolic or hormonal. Again, treatment is specific to marital status, a history of preeclampsia in pregnancy, and
the etiology. multiparity.
For conditions associated with heavy bleeding or bleed- More than 150 symptoms have been reported that have
ing between periods, a dilation and curettage (D&C) may been related to PMS. These include weight gain, bloating,
be performed. In this case, the procedure may be diagnostic irritability, edema, headache, mood swings, inability to con-
and therapeutic. Tissue removed from the uterus is examined centrate, food cravings, acne, and numerous others. For many
microscopically and histologically to evaluate its stage in the women, the PMS symptoms are merely a monthly nuisance,
menstrual cycle. A hysterectomy may be indicated if abnor- but for others, the symptoms are so incapacitating that they
malities are discovered or if the bleeding is so excessive that cannot function in their normal roles or responsibilities.
the client is significantly compromised. The client may require The onset of symptoms is usually 7 to 10 days before the
a blood transfusion to correct low hemoglobin and hematocrit menstrual period starts; symptoms end after the menstrual
levels before any other procedures are performed. Supplemen- flow begins.
tal iron generally is prescribed by the physician to also help Research has correlated hormonal imbalances of estro-
correct the deficiency. gen, progesterone, ACTH, and androgens with the symptoms
of PMS. The presence of prostaglandin F in the tissue may also
be a cause of some of the symptoms. Prostaglandins are associ-
NURSING PROCESS ated with many inflammatory responses in the tissues.
The first step in identifying PMS is a physical examina-
Assessment tion to rule out other possible disorders of the reproductive
system. The client may be asked to keep a monthly calendar
Subjective Data of symptoms to see if there are patterns in severity, type, or
Ask the client about the onset of the bleeding and its relation- onset. Blood tests may be ordered to assess estrogen and
ship to the timing of her normal menstruation, the color of the progesterone levels, as well as checking the glucose level. Low
bleeding, amount, number of pads saturated, presence of clots, blood glucose level has been associated with irritability that
and presence of pain with the bleeding. A history of current sometimes accompanies PMS symptoms. The client should
medications, contraception, and the possibility of pregnancy receive counseling, if needed, to facilitate coping with life
are additional data needed. Explore any preexisting health stressors that may be complicating the complexity of the PMS
problems that could affect bleeding and clotting times, as well symptoms.
as life stressors.

Objective Data Medical–Surgical

Assessment of vital signs may indicate hypertension and Management
tachycardia. Monitor laboratory test results. Pharmacological
Some physicians and NPs recommend medication such as
Nursing Management acetaminophen (Tylenol), naproxen (Naprosyn), mefenamic
Acknowledge the client’s feelings about the problem. Explain acid (Ponstel), and ibuprofen (Advil) for the relief of minor
diagnostic tests and procedures. Encourage good nutrition, discomforts of PMS. Several PMS symptoms are thought to
good posture, and exercise. Emphasize the importance of be related to a low progesterone level. For some clients, the
follow-up care. use of progesterone suppositories or oral progesterone to
Possible nursing diagnoses for a client with any of the supplement their own production during the secretory phase
menstrual disorders discussed in this section may include: of the menstrual cycle has been useful. Selective serotonin
• Acute Pain related to uterine cramping or heavy bleeding reuptake inhibitors used to treat and relieve PMS symp-
toms include citalopram hydrobromide (Celexa), fluvoxamine
• Decreased Cardiac Output related to excessive blood loss maleate (Luvox), fluoxetine hydrochloride (Prozac), sertra-
• Fatigue related to decreased hemoglobin and hematocrit line hydrochloride (Zoloft), escitalopram oxalate (Lexapro),
levels and paroxetine hydrochloride (Paxil) (Daniels, Nosek, &
• Disturbed Body Image related to the absence of Nicoll, 2007).
menstruation
Diet
■ PREMENSTRUAL SYNDROME A thorough diet history should be included in the assessment

O
data collected. Certain nutritional deficits or cravings have
ne-third to one-half of women between 20 and 50 years been linked to the worsening of PMS. Items such as sugar, salt,
of age experience some of the symptoms known as pre- caffeine, and chocolate are in this category. Many studies have
menstrual syndrome (PMS). Once, this condition was thought shown that limiting intake of these substances may be helpful.
by many physicians to be a psychological problem of women; Caffeinated beverages may increase anxiety, irritability, and
however, recent research has supported data that many physi- deplete vitamin B stores in the body. Dairy products interfere
ologic as well as psychological factors are involved. PMS often with the absorption of magnesium, which helps stabilize the
occurs during the secretory phase of the menstrual cycle, mood. Chocolates have been related to increased sugar crav-
after ovulation. Risk factors associated with the development ings, mood swings, fluid retention, and increased vitamin
of PMS include age (older than 30), multiple life stressors, B demands. Oranges and other fruits or vegetables that are

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 13 Reproductive System 467

highly acidic may worsen PMS. Foods that are recommended caffeine, nicotine, and refined carbohydrate intake, and
are whole grains, nuts, pasta, legumes, root vegetables, fruits increase calcium intake to reduce PMS symptoms (Daniels,
such as apples and pears, poultry, and seafood. A good vitamin Nosek, & Nicoll, 2007).
supplement rich in vitamin B-complex, calcium, magnesium,
and zinc should be taken daily, especially during the PMS
period. Herbal tea formulas have shown some promise as
NURSING PROCESS
alternative methods of relieving PMS.
Assessment
Activity Subjective Data
A regular exercise routine, coupled with the use of stress-manage- Ask the client to describe her symptoms and the impact on her
ment techniques such as deep breathing and relaxation exercises, lifestyle. Many times, clients will seek medical attention for their
help the client cope with the increased sense of anxiety or irrita- PMS symptoms when the emotional impact has caused friction
bility that may accompany PMS. Meditation, positive affirmation, in the home, marriage, work, or family environment. Symptoms
visualization, and imagery may be helpful, as well as acupressure, described may include weight gain, bloating, irritability, head-
neurolymphatic or neurovascular massage, and yoga. ache, mood swings, inability to concentrate, or food cravings.
Ask the client to relate symptoms to time of menstrual cycle.

Nursing Management Objective Data

Encourage client to keep a monthly PMS calendar of events. Assess the client for weight gain and edema. Review labora-
Recommend that the client limit sodium, sugar, alcohol, tory test results.

Nursing diagnoses for a client with premenstrual syndrome include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Excess Fluid Volume The client’s intake and Educate client that a certain amount of fluid retention is normal
related to hormonal output will be balanced, before the onset of the menstrual period and cannot be
imbalance and increased and edema will be avoided, but by limiting sodium and sugar intake, she may be
sodium or sugar intake decreased. able to influence the amount of fluid retained.

Health-Seeking The client will develop Teach client how to keep a monthly PMS calendar of events.
Behaviors, related to effective health-promotion Discuss prescribed medications with the client, including the
finding methods to cope skills to increase coping dosage, expected effects, and side effects.
with symptoms of PMS with PMS symptoms or to
decrease symptom severity Discuss relationship of foods to PMS.
or frequency.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

structures, loss of skin turgor and elasticity, and thinning of

■ MENOPAUSE the hair on the head, axilla, and pubic regions. Other signs of
decreasing hormones (estrogen and progesterone) are vaginal

M enopause, or climacteric, is the cessation of menstrua-

tion. It may occur as a natural hormonal decline or it
may be surgically induced by removal of the uterus and ova-
dryness, thinning of the vaginal mucosa, weight gain, dry skin,
and stress incontinence. The estrogen level plays an important
protective role in maintaining an adequate calcium balance in
ries. Many people think of menopause as the “change of life” the bones and preventing coronary artery disease. Without
and accept it as part of aging. Most women will begin to expe- calcium, bones become brittle, and there is an increased risk
rience signs and symptoms of approaching menopause around of fractures and osteoporosis. A baseline bone density study
50 years of age; however, the range of onset is from 45 to 60 may be recommended before menopause.
years old. During this perimenopause transition, menstrual Some women experience psychological responses to
cycles become further apart and the flow decreases. The onset menopause, such as mild to moderate depression, nervous-
is usually gradual, and it may take more than a year before the ness, and insomnia. Consultation with a psychologist, min-
woman has completely ceased menstruation. Reproductive ister, or counselor may be useful in facilitating the transition
capability is also lost with menopause. For some women this through this period for some women.
is a sad time perceived as the loss of womanhood; for others Women may also experience mild to moderate periods of
it is a welcome relief. Postmenopause is considered the time profuse perspiration called “hot flashes.” These usually move
period one year after the last menstrual cycle and lasts the rest from the waist upward. They are caused by the decreased estro-
of a woman’s lifetime. gen level and its effect on the hypothalamus. The sensation may
The decreasing level of ovarian hormone production last from 30 seconds to 10 minutes. It appears that many differ-
affects women in a variety of ways, more than just the end of ent things can trigger a hot flash—drinking hot beverages, eat-
menstruation. There may be a relaxation of the pelvic support ing spicy foods, smoking, and consuming caffeine and alcohol.

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468 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Medical–Surgical Activity
Management One important way that the client can decrease the potential
for calcium loss from weight-bearing bones is to exercise. A
Pharmacological planned 30-minute program performed at least 3 times per
For some women, estrogen replacement therapy is rec- week is adequate to maintain bone density. Exercises such as
ommended, especially if they are experiencing moderately walking or swimming are excellent. Swimming provides good
uncomfortable symptoms. Estrogen replacement therapy non–weight-bearing activity and promotes active movement
(ERT) may help decrease some symptoms, such as insomnia, of all extremities. Biking is a good exercise to maintain joint
hot flashes, mood swings, and lack of concentration. Estro- mobility in the lower extremities, but it does not require the
gen elevates the high-density lipoproteins (healthy ones) use of the same muscle groups as walking.
and lowers the low-density lipoproteins (unhealthy) in the
circulation. Estrogen may be administered orally, as a trans- Nursing Management
dermal patch, or as a vaginal cream. Conjugated estrogen Encourage the client to exercise regularly, especially walking.
(Premarin), estradiol (Estrace), and synthetic conjugated Explain nutritional requirements for vitamins and calcium.
estrogens Cenestin and Enjuvia are examples of oral estro- Advise the client to try water-soluble gels for vaginal dryness
gens available. Estrogen creams or water-soluble gels such as and body lotion to prevent dry skin.
Lubrifax or K-Y may be used to combat the vaginal dryness
and resulting dyspareunia (The North American Menopause
Society, 2009). NURSING PROCESS
Assessment
Diet
Provide the client with instructions regarding the importance Subjective Data
of an adequate daily intake of calcium-rich products, such as The client may describe decreasing regularity of menstrua-
dairy products. Many low-fat, high-calcium products are avail- tion or hot flashes. Obtain information from the client about
able if the client has a concern about weight gain. Calcium gynecological and obstetrical history, including menstruation.
supplements may also be taken in a tablet form. The woman It is helpful to know when the client began experiencing symp-
should consult her health care provider before adding a cal- toms in predicting the length of time they may continue.
cium supplement because too much calcium increases the risk
for other health problems. Herbal teas, vitamin E, magnesium, Objective Data
and primrose oil have been used as alternative methods to These include a physical examination and Pap smear. The
alleviate or decrease hot flashes and promote relaxation for results of the Pap smear can indicate if there is less estrogen
some women. present in the cervical tissue than normal.

Nursing diagnoses for a client experiencing menopausal symptoms include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Health-Seeking The client will develop Encourage client to continue to see her health care provider for
Behaviors related to effective health promotion annual Pap smears and breast examinations.
perceived physiological skills to increase coping Explain nutritional requirements for vitamins and calcium that
and psychologic impact with menopausal increase with menopause.
of decreased estrogen symptoms or to decrease
symptom severity or Encourage client to begin a regular exercise program that
frequency. includes weight-bearing activities such as walking to prevent
loss of calcium from the bones.

Impaired Tissue Integrity The client will maintain skin Recommend that the client try estrogen creams or water-
related to vaginal integrity, and vagina will not soluble gels such as Lubrifax or K-Y to combat the vaginal
dryness and dry skin be dry. dryness and resulting dyspareunia.
Encourage client to use body lotion to prevent dry skin.

Decisional Conflict The client will make Discuss the advantages and disadvantages of estrogen
related to taking informed decisions about replacement therapy with the client.
supplemental estrogen taking supplemental Remind client that if she has a uterus and takes hormonal
therapy estrogen. replacements, she will continue to have monthly menstrual
cycles.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 13 Reproductive System 469

be washed in warm, soapy water once every 1 to 2 weeks. Pro-

STRUCTURAL DISORDERS longed use of a mechanical device such as a pessary may result

S
in vaginal necrosis and ulceration. Periodic examination by a
tructural anomalies are separated into female and male health care professional is recommended.
disorders.
Surgical
■ CYSTOCELE, URETHROCELE, Surgery for a prolapsed uterus may require a hysterectomy.
If the prolapse is accompanied by a cystocele or rectocele,
RECTOCELE, PROLAPSED an A&P repair may also be performed. An A&P repair (ante-
UTERUS rior/posterior colporrhaphy) may be performed vaginally to

C
replace the bladder, urethra, or rectum in the correct anatomic
ystocele, urethrocele, rectocele, and prolapsed uterus are position. Another procedure, the Marshall-Marchette-Krantz,
often associated with relaxation of the pelvic muscles may be performed to attach the bladder to the inferior surface
that support the uterus, bladder, and rectum. A cystocele of the pubic bone. Postoperatively, the client may be sent
is a downward displacement of the bladder into the anterior home with an indwelling Foley catheter because of the poten-
vaginal wall. A urethrocele is a downward displacement of tial inability to void. This is a common postoperative situation
the urethra into the vagina, and a rectocele is an anterior that usually resolves itself spontaneously within 1 or 2 weeks
displacement of the rectum into the posterior vaginal wall. after discharge.
Prolapsed uterus is a downward displacement of the uterus
into the vagina (Figure 13-21). Possible causes for the four Activity
conditions are multiple pregnancies, third- or fourth-degree The Kegel exercise is performed by tightening and releasing
perineal lacerations with childbirth, and age-related weaken- the perineal muscles. An important muscle group, called the
ing of the pelvic muscles. “levators,” helps lift and support the organs inside the pelvis.
A prolapsed uterus is often accompanied by a cystocele
and/or rectocele. With a first-degree prolapse, the cervix is
visible at the vaginal introitus, or opening, without straining.
With a second-degree prolapse, the cervix extends beyond
the vaginal opening to the perineum. With a third-degree pro- CLIENTTEACHING
lapse, the uterus protrudes outside of the vagina. This severe
condition is called procidentia uteri. Kegel Exercises
• Suggest that the client practice when she has
Medical–Surgical a full bladder. If she can successfully start and
Management stop the flow of urine from the bladder, she is
identifying and using the correct muscle groups.
Medical and surgical interventions for the treatment of each of
these conditions are focused on relief of discomfort and resto- • The muscles should be tightened and held for 5
ration of the structure and function of the pelvic organs. to 10 seconds and then released slowly.
• Repeat the exercises at least 10 times.
Medical • Kegel exercise can be practiced anytime and
The pessary is a small molded plastic or rubber apparatus that anyplace.
fits into the vagina behind the pubic bone and in front of the • A secondary benefit of increasing the strength
rectum. Its function is to provide an artificial or mechanical and contractility of the pelvic and perineal
support for the uterus. Pessaries are not uncomfortable and muscles is seen in an improvement in pelvic
should not be felt by the client if properly fitted and in the sensations for both partners during intercourse.
correct position. The client should be taught how to insert
and remove the pessary so it can be cleaned. The pessary may
COURTESY OF DELMAR CENGAGE LEARNING

A B C D

Figure 13-21 A, Cystocele; B, Urethrocele; C, Rectocele; D, Uterine Prolapse

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
470 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing Management it as “a leaky bladder.” She may notice that her panties are damp
or that she dribbles urine. Many women complain of frequent
Teach client Kegel exercise and encourage daily practice. urination in small quantities with a feeling of urgency without
Describe to the client how a high-fiber diet and drinking burning or dysuria. The client may notice constipation or a
plenty of fluids will help prevent constipation. Postoperatively, sense of bearing-down pressure in the pelvis with a rectocele.
monitor vital signs and I&O. Cleanse perineal area following Many of these symptoms will decrease or subside completely
surgical asepsis. Encourage early ambulation. when lying down. Ask about the client’s childbearing history,
onset of current symptoms, and any other pertinent gyneco-
NURSING PROCESS logical data.

Assessment Objective Data

These include the visualization of a bulging of the bladder,
Subjective Data urethra, or rectum into the vagina. The bulging increases when
The client often describes stress incontinence, a loss of urine the client is asked to bear down. Urinalysis results should be
when she coughs, sneezes, laughs, or jumps. She may describe evaluated.

Nursing diagnoses for a female client with a structural disorder of the

reproductive system include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Stress Urinary The client will have less Teach the client Kegel exercise and encourage daily practice.
Incontinence related to stress incontinence. Encourage client to empty bladder frequently.
relaxation of the pelvic
muscles

Constipation related to The client will not have Encourage client to defecate at same time each day.
relaxation of the anterior constipation. Encourage client to eat high-fiber foods, drink plenty of fluids,
rectal wall into the vagina and exercise regularly.
and decreased function

Risk for Infection related The client will be free of Monitor client’s vital signs.
to exposure of internal signs and symptoms of Encourage client to practice proper personal hygiene and wear
tissues to external infection. clean undergarments daily.
environmental factors

Sexual Dysfunction The client will have a Be sensitive to client cues related to her sexual concerns.
related to discomforts fulfilling sexual relationship Help the client set realistic goals during her recovery period to
with intercourse without discomfort. facilitate a new outlook on her relationship.
Encourage client to openly discuss her feelings with her partner.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

A spermatocele is a benign nontender cyst of either the

■ HYDROCELE, SPERMATOCELE, epididymis or the rete testis. It contains milky fluid and sperm.
VARICOCELE, TORSION OF THE Usually, this condition is painless and does not require medi-
SPERMATIC CORD cal treatment.

A
A varicocele is dilation of the veins of the scrotum that occurs
hydrocele is a benign, nontender collection of clear, when the venous system that drains the testicle lengthens and
amber fluid within the space of the testes and the tunica enlarges. This dilation occurs when incompetent or absent valves
vaginalis or along the spermatic cord. Scrotal swelling may in the spermatic venous system permit blood to accumulate,
result, which can be painful if it develops suddenly. Inflam- resulting in increased hydrostatic pressure. This condition is most
mation of the epididymis or testis or a lymphatic or venous commonly found on the left side because of the increased retro-
obstruction may cause this condition. Congenital hydrocele grade pressure of the renal vein, the length, and fewer competent
in the newborn occurs when the canal between the peritoneal valves. It is theorized that the hyperthermia that occurs with this
cavity and the scrotum does not close completely during fetal condition decreases spermatogenesis, resulting in decreased fertil-
development. Aspiration of the fluid is only a temporary mea- ity. Symptoms may include a bluish discoloration of the scrotal
sure and can lead to secondary infection. Therefore, treatment skin or palpation of a wormlike mass when the male bears down.
for the condition is surgery. This condition seldom requires treatment.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 13 Reproductive System 471

Torsion of the spermatic cord occurs when the vascular Torsion of the spermatic cord is one disorder that does
pedicle of the testis twists, resulting in partial or complete require immediate surgery to perform surgical detorsion
venous occlusion. The three forms of this disorder are (1) rota- (untwisting) and suturing of the testicle to the scrotum.
tion of the spermatic cord, (2) torsion of a testicular appendage,
or (3) torsion of the spermatic cord and epididymis. Testicular
torsion may be related to recent trauma, and the onset of symp- Nursing Management
toms often occurs suddenly. Symptoms of testicular torsion may Maintain the client on bed rest with scrotal support and ice
include abdominal and scrotal pain, scrotal edema, nausea and to the area. Objectively assess the client’s pain and administer
vomiting, and, possibly, a slight fever. The pain caused by tes- analgesics as ordered. Monitor vital signs, incisional drainage,
ticular torsion is not relieved by bed rest or scrotal support. and dressing. Use strict asepsis when changing dressings.

Medical–Surgical NURSING PROCESS

Management Assessment
Medical/surgical management of male structural disorders is
specific to the condition. In some newborns, a hydrocele may Subjective Data
resolve without medical intervention. Clients of all ages may have Ask the client about the type and location of his pain and
aspiration performed to reduce the swelling caused by fluid or a related symptoms such as alteration in urinary patterns,
hematoma; however, this solution is usually only temporary, and warmth, fatigue, nausea, or vomiting. Assess the client’s knowl-
surgical removal of the sac provides the only permanent solution edge of his condition, treatment, follow-up care, and the impli-
to the problem. Although a spermatocele usually does not require cations of sterility and impotence to the client’s life.
treatment, sometimes surgical aspiration or excision is necessary.
Because a common complication of a varicocele is male
infertility, ligation of the spermatic vein may be performed if Objective Data
infertility is a concern. Sometimes this does not resolve infer- Inspect and palpate the genitals to detect the presence of
tility problems because varicoceles may recur after surgery. scrotal swelling, testicular enlargement, scrotal immobility,
When fertility is not a concern, the varicocele may be treated redness, and warmth of the scrotum. Large varicoceles may be
simply with scrotal support. visible through the scrotal skin as a bluish discoloration.

Nursing diagnoses for a male client with a structural disorder of the

reproductive system may include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related The client will experience Monitor client’s vital signs and incisional drainage. Maintain
to inflammation and minimal bleeding and avoid strict asepsis when handling wound dressings.
hemorrhage infection. Report hyperthermia, tachycardia, hypotension, increased
incisional drainage, and swelling or redness around the incision
to the physician immediately.

Deficient Knowledge The client will demonstrate Monitor statements made by the client to determine if there
related to the understanding of the is any misunderstanding about how the surgery will affect his
condition and possible possible complications of masculinity and fertility.
complications his condition. Provide client with opportunities to voice his feelings and ask
questions.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

to complete sexual intercourse. There are three types of impo-

FUNCTIONAL DISORDERS tence: functional, atonic, and anatomic. Psychological factors
AND CONCERNS that lead to concerns about sexual performance may contrib-

I
ute to functional impotence. These factors include aging and
ncluded in this category are impotence, infertility, and difficulty with communication or relationships.
contraception. Atonic impotence may be the result of medications such
as antihypertensives, sedatives, antidepressants, or tranquil-
izers. For example, antihypertensives lower blood pressure in
■ IMPOTENCE all arteries of the body, and reduction of the blood pressure to
penile arteries may lead to failure of the penis to fill sufficiently

I mpotence is defined as the inability of an adult male to

have an erection firm enough or to maintain it long enough
to achieve erection. The use of alcohol, cocaine, and nicotine
can also decrease potency. Disease processes leading to atonic

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472 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Fibrous plaque blocked arteries, revascularization is done to bypass blocked

arteries and remove veins that are causing excessive drain-
age. For clients who are not candidates for revascularization,
penile prostheses are another option. One type is a semirigid
implant, which is a silicone cylinder that may be flexible or
inflexible. Another type is a hydraulic implant that has a cyl-
inder that can be inflated by squeezing a pump located in the
scrotum or at the end of the penis. Because of its ability to fill
and empty, the hydraulic implant, unlike the silicone implant,
which is always semirigid, most closely mimics flaccidity

COURTESY OF DELMAR CENGAGE LEARNING

and erection. The disadvantages of surgical interventions are
expense and postoperative complications, the most serious
being postoperative infection.

Pharmacological
Medications that promote erections are sildenafil citrate
(Viagra), vardenafil hydrochloride (Levitra), and tadalafil
(Cialis), which belong to a class of drugs called phosphodi-
Figure 13-22 Dorsal Curvature of the Penis in Peyronie’s esterase (PDE) inhibitors. These drugs should not be used
Disease Caused by Fibrous Plaque by men for whom sexual activity is not advisable because
impotence include diabetes and vascular and neurological of underlying cardiovascular problems (Spratto & Woods,
disorders. Diabetic clients are at increased risk for impotence 2009). One side effect of drug therapy is prolonged erection
because of their tendency to develop atherosclerosis and that does not occur in response to sexual stimulation (pria-
autonomic neuropathy. Vascular and neurological disorders pism). Oral neurotransmitters have been used with variable
include atherosclerosis, hypertension, spinal cord injuries, success, and sublingual apomorphine shows some promise as
and multiple sclerosis. End-stage renal disease and chronic an erectogenic agent. When administered sublingually rather
obstructive pulmonary disorders can also decrease potency. than subcutaneously, as was done in the past, there are fewer
Peyronie’s disease is the development of nonelastic, fibrous side effects. Self-injections of vasodilators or other drugs may
tissue just beneath the penile skin, leading to anatomic impotence. result in serious complications.
The resulting loss of elasticity leads to a decreased ability of the
penis to fill with and store blood during an erection. Peyronie’s
disease often causes the penis to bend upward, possibly leading to
pain and an inability to penetrate the vagina (Figure 13-22).
NURSING PROCESS
Assessment
Medical–Surgical Subjective Data
Management The client may describe a history of illicit and prescribed
Medical drug use, and alcohol consumption. Previous diagnoses,
The first step in treating impotence is to determine whether lifestyle, sexual functioning, and family disorders must be
the client’s lifestyle is a factor. Further assessment may include explored. Assess the client’s emotional and educational
nocturnal penile tumescence monitoring or dynamic infusion needs to determine whether anxiety about sexual perfor-
cavernosometry and cavernosography (DICC). Treatment mance or lack of knowledge are contributing factors to
will be based on the assessment findings and test results. impotence.
Treatment may include changes in lifestyle to reduce the need
for medications, manage stress, lose weight, and exercise. Objective Data
These changes often help improve the client’s physical health,
self-image, and attitude about his ability to function sexually. If the client has surgery, the nurse needs to monitor vital signs,
External devices can be used to promote an erection. A incisional site, and I&O.
vacuum constriction device (VCD) may be used to increase
the blood supply to the penis, causing engorgement and
rigidity. The client inserts his penis into a plastic cylinder and
Nursing Management
squeezes a pump to withdraw the air from the cylinder, creat- Teach client how to take prescribed medications. If an implant
ing a vacuum that draws blood into the penis. Once an erec- has been inserted, teach client the signs of infection such as
tion has been achieved in this manner, a rubber ring is moved tenderness, fever, and dysuria.
from the bottom of the cylinder to the base of the penis. This Nursing diagnoses for a client who is impotent may
permits the blood to be safely trapped in the penis for up to include the following:
one-half hour. Advantages of the VCD over surgical interven- • Sexual Dysfunction related to altered body function or
tion are less expense and fewer complications. structure
• Ineffective Sexuality Patterns related to altered body
Surgical function or structure
Surgical interventions for impotency include revascularization • Disturbed Body Image related to impotence
and penile implants. For clients with impotence related to • Deficient Knowledge related to impotence

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 CHAPTER 13 Reproductive System 473

• Endocrine imbalance testing, which measures pituitary,

■ INFERTILITY gonadotropin, testosterone, estrogen, and progesterone levels

A
• Male–female interaction studies (Huhner test) to determine
pproximately one in every eight couples experiences motility and number of sperm 2 to 4 hours after intercourse
infertility, the inability to produce offspring. Infertility • Laparoscopy to discover conditions such as endometriosis,
may be primary or secondary. In primary infertility, the couple adhesions, or scar tissue that potentially immobilize the fimbriae
have never achieved a pregnancy or have never carried a preg- or polycystic ovarian disease (Stein-Leventhal syndrome)
nancy to viability. Secondary infertility involves problems that
arise after the couple has had a successful pregnancy. Many fac-
tors may be investigated as causes of infertility in both female
Medical–Surgical Management
and male clients. Forty percent of infertility factors are female- There is no one treatment for infertility problems. The goal of
related, 40% are male-related, and 20% are a combination of treatment is successful achievement of a pregnancy that is car-
multiple factors that involve both partners. The more factors ried to full term and produces a healthy offspring.
that are involved, the more difficult the infertility resolution.
The etiology of infertility may be related to anatomic Medical
or endocrine problems. The female anatomic or structural Infertility treatment may include artificial insemination with
abnormalities may include blocked passages through the either the partner’s sperm or donor sperm. This method is
cervix or fallopian tubes caused by failed development or by particularly useful if the male partner has a low sperm count,
past infections, such as PID, or STIs. Uterine and cervical abnormal sperm, or no sperm production. With the proce-
abnormalities may also occur. The cervix may be too narrow dure, the semen is placed directly into the cervix or uterus
or closed, and sperm are unable to navigate through the pas- with a small flexible catheter and a syringe.
sage. The uterus may have a partial or complete septum inside
that limits the internal cavity space. Immune problems involve Surgical
the development of antibodies by the woman’s system to the Assisted reproductive technology (ART) has revolutionized
male’s sperm. These antibodies may be present in the cervi- infertility treatment. It is fertility treatment in which the eggs
cal mucus and kill the sperm on contact. Hyposecretion or are surgically removed and combined with sperm in the labo-
hypersecretion of FSH, LH, estrogen, or progesterone have ratory and then returned to the woman’s body. One method is
been associated with infertility. in vitro fertilization. This may be by GIFT (gamete-intra-fallo-
The causes of infertility in males include varicoceles, cryp- pian transfer) or ZIFT (zygote-intra-fallopian transfer). With
torchidism, impaired sperm, insufficient number of sperm, and the GIFT technique, the female partner receives monthly
hormonal imbalance. The use of hot tubs, saunas, tight under- cyclic hormone injections that cause ova to ripen. The hor-
wear, and laptop computers may decrease the sperm count. mones may cause more than one ovum to ripen during each
The first step in treating an infertile couple is to obtain a cycle, which enhances the possibility that more than one
history of sexual practices. In addition, detailed health histories ovum will be fertilized and implanted in the uterus. A semen
need to be obtained and physical examinations performed. specimen is collected from the male partner 1 to 2 hours
A basic infertility workup may be initiated when the client before the GIFT procedure and the sperm placed into a spe-
has been unable to conceive after 6 to 12 months of unpro- cial catheter. The ripened ovum is obtained from the female
tected intercourse. One simple, noninvasive procedure is the via laparoscopy or ultrasound aspiration and is loaded into
use of a basal body temperature chart. The chart is kept for a the catheter in a sequential manner with the sperm and then
minimum of 3 months and then reviewed for normal ovulatory injected through the fimbrial end of the fallopian tube, also
fluctuations in the basal temperature. During the first half of the by laparoscopy. This procedure takes approximately 1 hour to
menstrual cycle, the body temperature may remain below 98°F. complete. Pregnancy is confirmed within 7 to 10 days with a
At ovulation, there is often a slight decrease in the temperature blood hormonal test (Beta hCG) or an ultrasound, or both.
for a 24-hour period. This is the optimal period of fertility. After The ZIFT procedure is similar to GIFT; however, several
ovulation, the woman’s basal body temperature should go above ova are obtained just before ovulation and are placed in a special
98°F and remain in that range for a period of 14 days. The length fluid for several hours while the sperm are prepared. The ova
of the luteal phase (secretory phase) of the cycle following ovu- and sperm are then carefully mixed and closely observed for 2 to
lation is a critical factor in some infertility disorders. Variations 3 days. The fertilized ova (now zygotes) are transferred into the
in the temperature chart may indicate that the client has had an fallopian tube or into the uterine cavity. Another name for the
anovulatory cycle or has a shortened luteal phase. Because the ZIFT procedure is IVF-ER (in vitro fertilization and embryo
fertilized ovum does not implant in the endometrium until 6 to replacement), which more clearly defines what actually occurs.
8 days after conception, the luteal phase is critical to maintain Both GIFT and ZIFT are relatively expensive procedures
the blood-rich lining long enough for implantation to occur. and may or may not be covered by health insurance. For many
A low progesterone level during the luteal phase may result in couples, these are final efforts to conceive.
spontaneous abortion (ending a pregnancy before the age of
viability) of the fertilized ovum before implantation. Diagnostic Pharmacological
tests that may be ordered include the following:
Several medications are used in the treatment of infertility
• Endometrial biopsy to detect tissue responses during both disorders, and most are focused on hormone imbalances or
phases of the enstrual cycle deficiencies. Clomiphene citrate (Clomid) stimulates release of
• Semen analysis, including sperm count, motility, and follicle-stimulating hormone (FSH) and luteinizing hormone
morphology (LH), and is used to induce ovulation. Clomid is administered
• Testicular biopsy (done when sperm are absent from the orally beginning on the fifth day of the menstrual cycle. If ovula-
semen) to ascertain the presence of sperm tion does not occur, the dosage will be increased for 5 days in the

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474 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

next cycle. If ovulation does not occur by the time the dose has associated with primary and secondary infertility caused by
been increased 4 or 5 times, it may be considered a Clomid fail- decreased pituitary function. This condition may resolve
ure. There is some chance of multiple gestation while the client is spontaneously, or medications may be required to stimulate
taking Clomid, and she should be so informed. Most often it is a ovulation in order to conceive.
twin pregnancy, but occasionally triplets may be conceived. Multiple sexual partners have also been associated with
Menotropins (Pergonal) mimics FSH and LH, causing an increased risk of sexually transmitted disease, infections,
follicular growth and maturation. It is administered by intra- and cervical cancer.
muscular injection. Although Pergonal is an expensive drug,
it has been shown to increase the possibility for ovulation in
clients who have not responded to other medications. ■ CONTRACEPTION

C
Human chorionic gonadotropin (Pregnyl) may also be
administered with the Clomid or Pergonal therapy to help main- ontraception, or prevention of pregnancy, has been
tain the endometrial lining for implantation. It stimulates the accomplished by many methods over the centuries. In
production of progesterone from the ovary until the fertilized weighing the options, safety, ease of use, effectiveness, and
ovum implants and the placenta begins to function. Progesterone cost should be considered. Both partners’ wishes should be
suppositories may be used vaginally two times per day to help considered in this decision-making process.
correct a luteal phase defect by lengthening the time from ovula- Contraception may be accomplished by natural means or
tion until the onset of the menses or through implantation and medical interventions. This section of the chapter discusses a
pregnancy. Some clients continue with the progesterone supposi- basic overview of the types of contraceptive methods currently
tories throughout the first few weeks of the pregnancy to ensure available, the advantages and disadvantages, the effectiveness of
that the endometrium remains intact. If the sperm count or motil- each kind, the mechanisms by which they work, and the client
ity is low, testosterone or thyroid extracts may be prescribed. education that should accompany the methods (Table 13-2).

Health Promotion NATURAL METHOD

Seeking prompt medical treatment for infections that involve Natural methods of contraception may include what is called
the reproductive system is an essential means of preventing the “rhythm method.” During the woman’s fertile period of the
infertility problems, especially with STIs and PID. PID causes month, usually lasting 7 days (3 days before ovulation to 3 days
scarring of the outside of the fallopian tubes, and gonorrhea after), the couple should abstain from intercourse. The deter-
can result in scarring or strictures of the internal fallopian tube. mination of the fertile period is based on the time of ovulation.
Either cause can result in an ectopic pregnancy when the fertil- Sperm can live up to 72 hours after ejaculation, and it is possible
ized ovum cannot pass through the tube. for sperm to still be in the cervix or uterus if the couple had
Other considerations may include wise choices in con- intercourse 3 days before ovulation. The couple may also decide
traceptive methods. The use of oral contraceptives has been to maintain a basal body temperature chart to more accurately

Table 13-2 Contraception Methods: Effectiveness and Concerns

EFFECTIVENESS POSSIBLE
METHOD RATE RISKS SIDE EFFECTS OTHER ADVANTAGES
Abstinence 100% None known Psychological reactions Prevents infections including HIV
Hormonal
Oral 97% Cardiovascular Possible nausea, Protects against PID, decreases
contraceptives complications headaches, dizziness, risk of ovarian and endometrial
such as stroke, spotting, weight gain, cancer, decreases menstrual blood
blood clots, high breast tenderness, loss and dysmenorrhea (cramps),
blood pressure, chloasma, cramping decreases benign breast disease,
and heart regulates irregular menses,
attacks with protects bone density, decreases
the higher-dose risk of atherosclerosis, lessens
combined oral the risk of rheumatoid arthritis,
contraceptive decreases uterine fibroids, and
decreases ovarian cysts
Depo-Provera 98% Pulmonary Headache, depression, Effective to treat obstructive
embolism hypertension, edema, sleep apnea
nausea
Lunelle 99% None known Breast tenderness, None known
weight gain

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 CHAPTER 13 Reproductive System 475

Table 13-2 Contraception Methods: Effectiveness and Concerns (Continued)

EFFECTIVENESS POSSIBLE
METHOD RATE RISKS SIDE EFFECTS OTHER ADVANTAGES
Mirena 99.8% None known Headache, acne, Decreases menstrual blood loss,
breast tenderness first may protect against endometrial
few months cancer
Transdermal 99% None known Skin reaction at None known
patch application site
Vaginal ring 97% None known Vaginal infections or None known
irritation, headache,
weight gain, nausea
Nonhormonal
IUD 94% Pelvic Menstrual cramping, None known
inflammatory spotting, increased
disease, uterine bleeding
perforation,
anemia
Barriers
Diaphragm 84% Mechanical Pelvic pressure, Protects to some degree against
Cervical cap 73−92% irritation, vaginal cervical erosion, sexually transmitted infections
infections, toxic vaginal discharges if
Spermicide 79% shock syndrome left in too long
Condoms 86% None known Decreased sensation, Protects against sexually
allergy to latex, transmitted infections, including
less spontaneity in AIDS; delays premature

COURTESY OF DELMAR CENGAGE LEARNING

lovemaking ejaculation

Sterilization
Female 99.6% Infection Pain at surgical site, None known
Male 99.8% psychological reaction
with subsequent regret

pinpoint ovulation each month. Another method to determine suppressing ovulation. In a sense, the body thinks it is preg-
the approaching ovulation is to monitor the stretchiness of the nant when the pill is used. Some oral contraceptives contain
cervical mucus. This is called “spinnbarkeit.” As the woman estrogen and progesterone; others contain only progestins.
nears ovulation, estrogen causes the cervical mucus to become In response to the pseudopregnancy state, the client may
clear, thin, and stretchy. This type of mucus provides a favorable experience mild side effects and discomforts often associated
environment for the sperm and helps their motility toward the with pregnancy such as nausea, headache, breast tenderness,
ova. Immediately after ovulation, the cervical mucus becomes or weight gain. Major side effects from oral contraceptives
hostile to sperm. It becomes thick, cloudy, and more acidic. It may include cardiovascular accidents or thrombophlebitis.
also loses its stretchiness. Kits are available for purchase from the There is approximately a 1 in 200 chance of becoming
local drug store or pharmacy that react to chemicals in the cervi- pregnant while taking the oral contraceptive. If the woman
cal mucus and predict the time of ovulation. The kits are inex- thinks that she might be pregnant, she should stop the pill
pensive and simple to use, much like home pregnancy tests. immediately and contact her physician. When the woman and
her partner decide that it is time for a pregnancy, she should
discontinue the oral contraceptive for at least 2 to 3 cycles
HORMONAL METHODS before having unprotected intercourse. This “rest period” will
The many forms of hormonal contraceptives are discussed lessen the possibility that pill effects will remain in her system
following. and will allow her body to return to its own natural rhythm.
Some women find that they experience primary or secondary
Oral Contraceptives infertility problems after being on the pill for several years
because of pituitary suppression. The remedy is often fertility
The “pill” has been available as a contraceptive method for drugs such as clomiphene citrate (Clomid). Women who have
many years. Since its earliest form, it has been refined and never established a regular pattern of menstruation may not
the level of hormones reduced. Oral contraceptives work by be good candidates for oral contraceptives, except as being

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476 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

used to regulate the cycle by artificial means. Other clients have had children because the cervix has been dilated. This
who should not take oral contraceptives include women with allows for easier insertion of the device. The IUD is inserted
a history of hypertension, diabetes, cardiovascular disease, or or removed by a clinician while the client is having her period
thrombophlebitis. Some physicians may consider oral contra- because there is slight dilation of the cervix at that time. A string
ceptives in the newer low-dose combinations for clients who attached to the distal end of the device hangs out of the cervix
were previously in this high-risk group. into the vagina. The client is instructed to check the string each
month after the menstrual period to make sure the device has
Depo-Provera not been expelled. Some women with an IUD experience more
dysmenorrhea and a heavier menstrual flow. The IUD lasts
The medroxyprogesterone acetate (Depo-Provera) injection is 10 years. Fertility returns immediately upon removal.
administered intramuscularly (IM) every 12 weeks. It works like
oral contraceptives to suppress ovulation. The client may experi-
ence breakthrough bleeding after the first injection, but this is Barriers
not an indication that the hormone is not working. It usually Methods of barrier contraception include male and female
requires about 3 weeks after the first injection before the contra- condoms, the diaphragm, and the cervical cap. Barrier devices
ceptive is effective, so the client should be advised to use a bar- work by blocking the pathway of the sperm through the cervix
rier contraceptive method during that period. The client must into the uterus. This type of contraceptive requires some pre-
receive the injections at regular intervals to ensure effectiveness. planning on the part of one or both of the partners and may
Depo-Provera is a good option for the client who is approaching reduce the spontaneity of the sex act.
her forties or who smokes because it contains only progestins,
which decreases the risk of cardiovascular problems. Spermicides
Lunelle Spermicides contain a chemical, nonoxynol-9, that kills sperm
on contact. If used alone, spermicidal agents have a lower effi-
The combination of estradiol cypionate and medroxyproges- cacy rate than if used with a condom. The nurse should advise
terone acetate (Lunelle) is administered by IM injection every the couple to use a spermicidal gel, foam suppository, or film
28 to 30 days. It suppresses ovulation, thickens cervical mucus, in addition to another barrier method for the greatest effective-
and thins the endometrial lining. Monthly clinic visits are nec- ness. Foam should not be used with the diaphragm because it
essary, or the client must learn self-injection (Akert, 2003). can result in deterioration of the latex. These agents must be
placed in the vagina at least 15 minutes before intercourse to
Mirena promote the spermicidal reaction. This method is safe and
Mirena, a levonorgestrol-releasing intrauterine system device, inexpensive but requires a high level of compliance each time
is placed in the uterus, providing contraception for 5 years. or the effectiveness of the method drops significantly.
The small, soft T-shaped polyethylene frame has a hormone
reservoir on the vertical stem that slowly releases the hor-
mone. Cervical mucus thickens, sperm migration is inhibited, STERILIZATION METHOD
and endometrial growth is reduced. Mirena must be placed Sterilization is considered a permanent and very effective method
and removed by a health care provider (Akert, 2003). of contraception. In a rare incident, a woman will become preg-
nant after a tubal ligation or after her partner has had a vasec-
Transdermal Patch tomy. The female procedure interrupts the pathway through the
This first contraceptive patch, called OrthoEvra, contains fallopian tube. Sterilization may be performed on an outpatient
norelgestromin and ethinyl estradiol. A new patch is applied basis in a surgical clinic or the outpatient department at the
every 7 days for 3 weeks. No patch is worn for the fourth week. hospital. The tubal ligation is done under a general or epidural
Skin reactions are possible at the application site. The patch anesthetic with laparoscopy. The procedure takes about 30 to 60
adheres during exercise, swimming, and hot tub/whirlpool minutes. The abdomen is distended with a gas to permit better
use. It may not be as effective if the client weighs more than visualization of the pelvic structures during the procedure.
198 pounds (Akert, 2003). The male sterilization, vasectomy (surgical resection of
the vas deferens), is usually performed with local anesthesia
Vaginal Ring on an outpatient basis. Rest, with ice to the scrotum, for 4
hours should follow. The client should not engage in strenu-
The NuvaRing contains etonogestrel and ethinyl estradiol in ous activity or exercise for 1 week.
a nonbiodegradable, flexible, transparent ring and provides It may take up to 6 weeks for the semen to be clear of
constant delivery of hormones. It is inserted into the vagina sperm. The client is instructed to return to the clinic for a
and left for 3 weeks and then removed for 1 week. Precise ring sperm count after 20 ejaculations. If he is sexually active, dur-
position is not critical (Akert, 2003). ing those ejaculations he should use a condom or some other
form of contraception. At 6 months, a sperm count should be
NONHORMONAL METHODS repeated and then monitored annually thereafter.
The female sterilization is more expensive and, because it
Intrauterine Device requires more anesthesia, carries a slightly higher risk than the
male procedure.
The intrauterine device (IUD) has been used for many years Refined microsurgical techniques have made it possible to
and has undergone several changes. The IUD is a T-shaped reverse sterilization procedures. The reversals are not always
device wrapped with copper wire, which acts like a spermicide. successful, and the couple need to consider the odds of success
The intrauterine device is recommended for women who before venturing into the expense of this type of surgery.

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 CHAPTER 13 Reproductive System 477

CASE STUDY
M.A. is a 70-year-old Caucasian man with a diagnosis of benign prostatic hyperplasia. Before his hospital admission
for a TURP, he had been in good health. He returned from surgery 3 hours ago with a three-way Foley catheter
and continuous bladder irrigation. His vital signs 1 hour ago were as follows: temperature 98.9°F, apical pulse 68,
blood pressure 130/84, and respirations 18. When the nurse enters his room to take another set of vitals, M.A. is
restless and moaning and has cool, moist skin; his catheter is not draining properly. His pulse is now 120 and blood
pressure is 88/50. The nurse calls the physician to report the change in M.A.’s condition. The physician orders a STAT
hematocrit and a bleeding and clotting time. An increase in the IV fluid drip rate is also ordered. The doctor is
planning to arrive at the hospital within the next hour.
The following questions will guide your development of a nursing care plan for the case study.
1. List symptoms and clinical manifestations, other than M.A.’s, that a client may experience after a TURP.
2. List reasons why the doctor has ordered the STAT blood work and the IV changes.
3. List other diagnostic tests that may have been ordered for M.A.
4. Mentally do a head-to-toe or functional assessment on M.A. List subjective and objective data a nurse would
want to obtain.
5. Write three individualized nursing diagnoses and goals for M.A.
6. Upon assessing M.A., the doctor decides to inject additional fluid into the balloon that anchors the indwelling
catheter and apply increased traction to the catheter. List pertinent nursing actions a nurse would do following
these medical interventions.
• Medications
• Comfort/rest
• Cardiac output
• Intake and output
• Activity
• Teaching
7. List resources within the medical center and the local area that could assist M.A. with his postoperative
recovery.
8. List teaching that M.A. will need before his discharge.
9. List at least three successful outcomes for M.A.

SUMMARY
• Potential complications from PID may include sterility or • Male cancers related to the reproductive system involve
infertility from scarring of fallopian tubes. the prostate, testes, breast, and penis. Emphasis should be
• Toxic shock syndrome occurs during the menses, and a placed on testicular self-examination and regular physical
strong correlation exists between the onset and use of examinations in order to facilitate early diagnosis and
super-absorbent tampons. treatment.
• Common male reproductive system inflammatory • Menstrual disorders are often associated with hormonal
disorders include epididymitis, orchitis, and prostatitis. imbalances, increased or decreased function of the
Bilateral epididymitis and orchitis can lead to sterility. endocrine glands, or neoplasms.
Treatment includes antibiotic therapy. • Menopause is a normal, gradual decline in the ovarian
• A BSE is an important method for detecting breast production of female hormones that occurs around
changes and should be practiced each month. Breast age 50.
cancer is the most common female cancer in the United • Infertility affects at least 1 in every 8 couples in the United
States. States and is caused by hormonal imbalances and
• Benign prostatic hyperplasia is a common disorder in structural or physiologic abnormalities in both male and
males older than age 50. Early symptoms include female clients.
hesitancy, decreased force of stream, urinary frequency, • Women who smoke and are older than age 40 are at
and nocturia. greater risk for major complications while using oral
• Cervical cancer is most common in women with multiple contraceptives. Major health risks include cardiovascular
sexual partners. accidents and deep vein thrombosis.
• Endometrial cancer often produces symptoms only after it • Impotence may be caused by emotional or physical factors.
is widespread. Any unusual vaginal bleeding should be Treatment includes counseling, medications, circulatory
investigated, especially if it occurs after menopause. aids, and surgery.

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478 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

REVIEW QUESTIONS
1. A postoperative prostatectomy client has a three- 2. “During the time I am ovulating is when I should
way indwelling catheter for continuous bladder do a BSE.”
irrigation. During second shift, 2,700 mL of 3. “I should do a BSE right after my menstrual
irrigation solution was instilled. At the end of period.”
the shift, 3,250 mL of fluid was drained from the 4. “I can perform a BSE anytime of the month.”
catheter collection bag. The total urine output for 7. Which nursing intervention must be included in
the shift is: a care plan for a 12-day post radical mastectomy
1. 6,250 mL client?
2. 3,250 mL 1. Maintain NPO status for 24 hours.
3. 2,700 mL 2. Place client on complete bed rest for 24 hours.
4. 550 mL 3. Place commode at bedside.
2. A client complains of pain and discomfort in the lower 4. Elevate operative arm for 24 hours.
abdominal area after a suprapubic prostatectomy. The 8. A 21-year-old female client makes an appointment
initial nursing action should be to: with her physician to ask about beginning oral
1. administer the intravenous antibiotic as ordered. contraceptives. Which of the following questions
2. inspect the drainage tube for occlusion. asked by the nurse would determine if oral
3. increase the intravenous rate. contraceptives are an appropriate method of
4. administer oxygen at 2 liter per minute per nasal contraception for this client?
cannula. 1. “Have you ever had a blood clot or deep vein
3. The nurse is teaching a female client about thrombosis?”
fibrocystic breast changes. Which of the following 2. “Do you exercise every day?”
should be included in the teaching plan? 3. “Are you married?”
1. Breast self-examination should not be performed 4. “Have you been pregnant before?”
because it will aggravate fibrocystic breasts. 9. What information should be included in a
2. Caffeine and sodium intake should be limited. teaching plan for a women’s health program to
3. Wearing a bra will increase breast discomfort. raise awareness of toxic shock syndrome? (Select
4. Take hot showers to promote comfort. all that apply.)
4. The nurse is teaching a 20-year-old man how to 1. Most often caused by Streptococcus group A.
perform a testicular self-examination. Which of the 2. Hypothermia occurs due to inflammatory
following is an abnormal finding? process.
1. The right testes is larger than the left testes. 3. There is a strong relationship with the use of
2. The testes are slightly sensitive to compression. tampons.
3. The testes are oval shape and movable. 4. A macular erythematous rash may develop.
4. The left testes hangs lower than the right testes. 5. Bed rest is usually prescribed.
5. A client has been informed that her sister has been 6. Hypertensive crisis is a common complication.
diagnosed with ovarian cancer. The client asks the 10. A 45-year-old male client asks the nurse why he
nurse if she is at risk of developing this type of cancer. is experiencing impotence since he started taking
The nurse informs the client that risk factors associated antihypertensive medication. The best response
with ovarian cancer include: (Select all that apply.) from the nurse is:
1. nulliparity. 1. “Antihypertensive medication lowers blood
2. infertility. pressure to penile arteries leading to failure
3. low-fat diet. of the penis to fill sufficiently to achieve
4. smoking. erection.”
5. family history. 2. “You should not be experiencing impotence and
6. multiparity. need to notify your physician immediately.”
6. The nurse is teaching a female client about breast 3. “Impotence is only a temporary side effect
self-examination (BSE). Which of the following and will go away within 3 weeks of taking the
statements indicates that the client correctly medication.”
understands when she should perform a BSE? 4. “Antihypertensive medication only causes
1. “I should perform a BSE a few days before my impotence in diabetic men that smoke.”
menstrual period begins.”

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 CHAPTER 13 Reproductive System 479

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Akert, J. (2003). A new generation of contraceptives. RN, 66(2), 54–61. Estes, M. (2010). Health assessment & physical examination.
American Cancer Society (ACS). (2003). Cancer facts & figures— (4th ed.). Clifton Park, NY: Delmar Cengage Learning.
2003. Retrieved from http://www.cancer.org/downloads/ STT/ Ficorelli, C., & Weeks, B. (2006). Facing up to prostate cancer.
CFF2003DUSSecured.pdf Nursing2006, 36(5), 66−68.
American Cancer Society. (2008). Breast cancer. Retrieved August 9, Fink, J. (2003). Beyond the shock of an abnormal Pap. RN, 66(6),
2009 from http://www.cancer.org/downloads/PRO/BreastCancer 56–61.
.pdf Fletcher, S., & Colditz, G. (2003). Editorial: Failure of estrogen plus
American Cancer Society. (2009a). Cancer statistics 2009 a presentation progestin therapy for prevention. Journal of the American Medical
from the American Cancer Society. Retrieved August 9, 2009 Association, 288(3). Available from http://jama.ama-assn.org/
from http://www.cancer.org/docroot/PRO/content/PRO_1_1_ issues/v288n3/ffull/jed20042.html
Cancer_Statistics_2009_Presentation.asp Fu, M., Ridner, S., & Armor, J. (2009). Post-breast cancer lymphedema.
American Cancer Society. (2009b). Detailed guide: Breast American Journal of Nursing, 109(7), 48–54.
cancer⎯how is breast cancer staged? Retrieved August 9, Gordon, S., Brenden, J., Wyble, J., & Ivey, C. (1997). When the Dx is
2009 from http://www.cancer.org/docroot/CRI/content/ penile cancer. RN, 60(3), 41–44.
CRI_2_4_3X_How_is_breast_cancer_staged_5.asp?sitearea= Harris, L. (2002). Ovarian cancer: Screening for early detection. AJN,
American Cancer Society. (2009c). Detailed guide: Cervical 102(10), 46–52.
cancer⎯what is cervical cancer? Retrieved August 9, 2009 from Held-Warmkessel, J. (2002). Prostate cancer. Nursing2002, 32(12),
http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X 36–42.
_What_is_cervical_cancer_8.asp?sitearea= Hurley, M. (2007). More evidence that race affects breast cancer
American Cancer Society. (2009d). Detailed guide: Ovarian survival. RN, 70(4).
cancer⎯chemotherapy. Retrieved August 9, 2009 from Hutti, M. (2003). New & emerging contraceptive methods. AWHONN
http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X Lifelines, 7(1), 32–39.
_Chemotherapy_33.asp?rnav=cri Katz, A. (2007a). ‘Not tonight, dear’: The elusive female libido.
American Cancer Society. (2009e). Detailed guide: Prostate American Journal of Nursing, 107(12), 32−34.
cancer⎯chemotherapy. Retrieved August 9, 2009 from http:// Katz, A. (2007b). When sex hurts: Menopause-related dyspareunia.
www.cancer.org/docroot/CRI/content/CRI_2_4_4X_ American Journal of Nursing, 107(7), 34−39.
Chemotherapy_36.asp?rnav=cri Katz, A. (2009). Fertility preservation in young cancer patients.
American Cancer Society. (2009f). Detailed guide: Prostate American Journal of Nursing, 109(4), 44−47.
cancer⎯what are the key statistics about prostate cancer? Retrieved Kessenich, C. (1999). Myths & facts about menopause. Nursing99,
August 9, 2009 from http://www.cancer.org/docroot/CRI/ 29(4), 67.
content/CRI_2_4_1X_What_are_the_key_statistics_for_ Kring, D. (2003). Benign prostatic hyperplasia. Nursing2003, 33(5),
prostate_cancer_36.asp?rnav=cri 44–45.
American Cancer Society. (2009g). Detailed guide: Testicular Lehman, M. (2007). Ovarian cancer it whispers so listen. RN, 70(10),
cancer⎯what are the key statistics about testicular cancer? 28–32.
Retrieved August 9, 2009 from http://www.cancer.org/docroot/ Machia, J. (2002). Breast cancer: Risk, prevention, & tamoxifen. AJN,
CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_ 101(4), 26–34.
testicular_cancer_41.asp?sitearea= Marchbanks, P., McDonald, J., Wilson, H., et al. (2002). Oral
Arbique, D., Carter, S., & Van Sell, S. (2008). Endometriosis can evade contraceptives and the risk of breast cancer. New England Journal of
diagnosis. RN, 71(9), 28−32. Medicine, 346(26), 2025.
Aschenbrenner, D. (2006). Over-the-counter access to emergency Marieb, E. (2003). Human anatomy and physiology (6th ed.). Redwood
contraception. American Journal of Nursing, 106(11), 34−36. City, CA: Benjamin/Cummings.
Baird, S., Donehower, M., Stalsbroten, V., & Ades, T. (Eds.). (1997). Martini, F. (2002). Fundamentals of anatomy & physiology (6th ed.).
A cancer source book for nurses (7th ed.). Atlanta: American Cancer Englewood Cliffs, NJ: Prentice Hall.
Society. Mayo Clinic. (2008a). Endometriosis treatments and drugs. Retrieved
Carroll, C. (2006). Sorting out breast biopsy options. Nursing2006, August 8, 2009 from http://www.mayoclinic.com/health/
36(3), 70−71. endometriosis/DS00289/DSECTION=treatments-and-drugs
Centers for Disease Control and Prevention. (2008). Pelvic Mayo Clinic. (2008b). Fibrocystic breasts lifestyle and home remedies.
inflammatory disease⎯CDC fact sheet. Retrieved August 8, 2009 Retrieved August 8, 2009 from http://www.mayoclinic.com/
from http://www.cdc.gov/std/PID/STDFact-PID.htm#What health/fibrocystic-breasts/DS01070/DSECTION=lifestyle-and-
Choma, K. (2003). ASC-US HPV testing. AJN, 103(2), 42–50. home-remedies
Conversations with Colleagues. (2003). Endometriosis sufferers risk McDaniel, C. (2007). Uterine fibroid embolism: the less invasive
other diseases. AWHONN Lifelines, 6(6), 502–504. alternative. Nursing2007, 37(7), 26−27.
Crandall, L. (1997). Menopause made easier. RN, 60(7), 46–50. Miller, K. (1999). Testicular torsion. AJN 99(6), 33.
D’Arcy, Y. (2002). What is postmastectomy pain syndrome? Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
Nursing2002, 32(11), 17. Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby.
Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic tests National Cancer Institute (NCI). (2002a). What you need to know
(2nd ed.). Clifton Park, NY: Delmar Cengage Learning. about breast cancer (NIH Publication No. 00-1556). Retrieved
Daniels, R., Nosek, L. & Nicoll, L. (2007). Contemporary medical- from http://www.nci.nihl.gov/cancerinfo/wyntk/ breast
surgical nursing. Clifton Park, NY: Delmar Cengage Learning. National Cancer Institute (NCI). (2002b). What you need to know
Dell, D. (2001). Regaining range of motion after breast surgery. about cancer of the cervix (NIH Publication No. 95-2047).
Nursing2001, 31(10), 50–52. Retrieved from http://www.nci.nih.gov/cancerinfo/wyntk/cervix

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480 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

National Cancer Institute (NCI). (2002c). What you need to know Resnick, B., & Belcher, A. (2002). Breast reconstruction. AJN, 102(4),
about cancer of the uterus (NIH Publication No. 01-1562). 26–33.
Retrieved from http://www.nci.nih.gov/cancerinfo/ wyntk/uterus Rizzo, D. (2010). Fundamentals of anatomy & physiology (3rd ed).
National Cancer Institute (NCI). (2002d). What you need to know Clifton Park, NY: Delmar Cengage Learning.
about ovarian cancer (NIH Publication No. 00-1561). Retrieved Sarvis, C. (2003). When lymphedema takes hold. RN, 66(9), 32–36.
from http://www.nci.nih.gov/cancerinfo/wyntk/ovary Spratto, G., & Woods, A. (2009). 2009 PDR nurse’s drug handbook.
National Institute of Diabetes, and Digestive and Kidney Disease Clifton Park, NY: Delmar Cengage Learning.
(NIDDK). (2002). Prostate enlargement: Benign prostatic The North American Menopause Society. (2009). Hormone products
hyperplasia. Retrieved from http://www.niddk.nih.gov/ health/ for postmenopausal use in the United States and Canada. Retrieved
urolog/pubs/prostate/index.htm August 9, 2009 from http://www.menopause.org/htcharts.pdf
National Institutes of Health. (2006). Prostate enlargement: benign U. S. Food and Drug Administration (FDA). (2002). Update
prostatic hyperplasia. Retrieved August 8, 2009 from http://kidney on advisory for Norplant contraception kits. Retrieved from
.niddk.nih.gov/kudiseases/pubs/prostateenlargement/index.htm http//:www.fda.gov/medwatch/safety/2002/norplant.htm
Neighbors, M., & Tannehill-Jones, R. (2006). Human disease (2nd ed). Wallace, M. (2008). Assessment of sexual health in older adults using
Clifton Park, NY: Delmar Cengage Learning. the PLISSIT model to talk about sex. American Journal of Nursing,
North American Nursing Diagnosis Association International. (2010). 108(7), 52−60.
NANDA-I nursing diagnoses: Definitions and classification 2009–2011. Walter, L., Bertenthal, D., et al. (2006). PSA screening among elderly
Ames, IA: Wiley-Blackwell. men with limited life expectancies. Journal of American Medical
Otto, S. (2001). Oncology nursing (4th ed.). St. Louis, MO: Mosby–Year Association, 296(19), 2336.
Book. Workman, L. (2002). Breast cancer. Nursing2002, 32(10), 58–63.
Pasacreta, J., Jacobs, L., & Cataldo, J. (2002). Genetic testing for breast Wynd, C. (2002). Testicular self-examination in young adult men.
and ovarian cancer risk: The psychosocial issues. AJN, 102(12), Journal of Nursing Scholarship, 34(3), 251–255.
40–47. Zaccognini, M. (1999). Prostate cancer, AJN, 99(4), 34–35.
Pickar, G., & Abernethy Pickar, A. (2008). Dosage calculations Zuckerman, D. (2002). The breast cancer information gap. RN, 65(2),
(8th ed.). Clifton Park, NY: Delmar Cengage Learning. 39–41.

RESOURCES
American Association of Sex Educators, Counselors, National Cancer Institute (NCI),
and Therapists, http://www.aasect.org http://www.cancer.gov
American Cancer Society, Inc., http://www.cancer.org National Ovarian Cancer Coalition,
American College of Obstetricians and Gynecologists http://www.ovarian.org
(ACOG), http://www.acog.org North American Menopause Society (NAMS),
American Society of Reproductive Medicine, http://www.menopause.org
http://www.asrm.org Older Women’s League, http://www.owl-national.org
Association of Women’s Health, Obstetric, and Ovarian Cancer National Alliance,
Neonatal Nurses (AWHONN), http://www.ovariancancer.org
http://www.awhonn.org RESOLVE: The National Infertility Association,
Breast Cancer Network of Strength, http://www.resolve.org
http://www.networkofstrength.org

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 14
Sexually Transmitted Infections

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of sexually transmitted
infections:
Adult Health Nursing
• Reproductive System
• Immune System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• List the most prevalent STIs, including causative agents.
• Describe currently used methods of prevention of STIs.
• Describe signs and symptoms, diagnostic aids, and treatment of the
common STIs.
• Utilize the nursing process to plan the care of a client with an STI.
• Demonstrate the ability to teach self-care and reinfection prevention
measures to the client with an STI.

KEY TERMS
abstinence chancre incidence
asymptomatic exposure incubation period

481

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482 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

The only 100% effective method of prevention of STIs is

INTRODUCTION abstinence (refraining from sexual intercourse or mucous
Sexually transmitted infections (STIs) are transmitted or membrane–to–mucous membrane contact altogether). Couples
passed from one person to another primarily through sexual who are mutually monogamous are also not at risk, unless
contact. The STIs covered in this chapter are chlamydia, gon- one of them was previously infected. The popularity of the
orrhea, syphilis, genital herpes, cytomegalovirus, genital warts, birth control pill has decreased consistent condom use. Most
trichomoniasis, and hepatitis B. Acquired immunodeficiency current methods of birth control are not effective in prevent-
syndrome (AIDS) is not solely an STI, although sexual activity ing the transmission of STIs. Only a barrier method, such as
is one of the primary modes of transmission. AIDS is discussed the latex condom, has been effective in preventing the spread
in detail in Chapter 16 and will be briefly discussed here. of STIs, although even this method provides only safer sex,
The incidence (frequency of disease occurrence) of not completely safe sex.
STIs has been increasing worldwide, with chlamydia and Once the diagnosis of an STI is made, identification of all
gonorrhea being the most widespread STIs today. Syphilis sexual contacts is important. Many people are reluctant to be
has been described as an STI for centuries. An estimated 19 candid regarding sexual activity and sexual contacts because
million Americans are diagnosed annually with an STI (CDC, this is an area of life considered to be extremely private. One
2007). Almost half of the newly diagnosed infections are of the most difficult aspects in dealing with STIs is that many
among young people who are 15 to 24 years of age. Chlamydia of the diseases are asymptomatic, especially in women. These
remains to be the most commonly reported STI with approxi- asymptomatic partners can both transmit the disease to new
mately 2.8 million new cases infecting Americans every year. partners and/or reinfect a treated partner, if they are not iden-
Gonorrhea is the second most commonly reported STI in the tified and treated.
United States, infecting an estimated 700,000 people (Mayo An overview of the STIs covered in this chapter is presented
Clinic, 2009a). Syphilis, although less common than either in Table 14-1.
chlamydia or gonorrhea, has seen a 17.5% increase from 2006
to 2007 in the United States (CDC, 2007a).
The development of antibiotic treatment for STIs in the ANATOMY AND PHYSIOLOGY
1940s caused a dramatic decrease in the prevalence of STIs,
and for awhile, it was predicted that STIs would be eradicated
REVIEW
completely. However, a variety of factors have contributed to The major system affected by STIs is the reproductive system.
the dramatic increase of STIs, such as casual sex, asymptomatic Males are generally more symptomatic than females and will
carriers of the disease, the use of nonbarrier methods of birth seek health care more readily because the signs of disease
control, and lack of knowledge of methods of preventing STIs. on the external genitalia are more visible. In females, the sex
Another factor that has contributed to the vast increase in organs are internal; females, therefore, are more likely to have
STIs in recent years is the increased consumption of alcohol complications and increased severity of symptoms by the time
and the use of illegal drugs. The sharing of needles among the disease is identified.
intravenous (IV) drug abusers is a factor in the increased In addition to the reproductive system, any area of sexual
incidence of STIs, as is the lessening of inhibitions that occurs contact, such as oral and rectal areas, may also exhibit signs
with drug and alcohol abuse. The trading of sex for drugs is and symptoms of the disease process.
also a factor in the spread of STIs.
Inadequate reporting of STIs may also cause statistics to
be inaccurate. There is no uniformity in reporting require- COMMON DIAGNOSTIC TESTS
ments for STIs. Regulations differ from state to state and from
disease to disease. Health-care providers are required to report Commonly used diagnostic tests for clients with symptoms of
new cases of chlamydia, gonorrhea, syphilis, and hepatitis to STIs are listed in Table 14-2.
state health departments and the CDC (Freedom Network,
2009). The Centers for Disease Control and Prevention
(CDC) keeps statistics on reportable diseases. ■ CHLAMYDIA

C
Public education regarding the causes, methods of
transmission, and methods of prevention of STIs is the hlamydia is caused by a spherical bacterial organism
most important weapon in the battle against STIs. Although known as Chlamydia trachomatis. Outside the body,
many STIs caused by bacterial infection are curable with the organism has difficulty surviving, but inside the body,
modern antibiotics, the viruses are not. The CDC (2007a) chlamydia reproduces rapidly. The mode of transmission in
estimates that STIs cost the U.S. health-care system $15.3 billion chlamydia must be through intimate body contact because the
annually. organism is so fragile that it cannot survive long when outside
Because sexual activity is beginning at earlier ages today, of the body.
sex education, including information about STIs, is being Because nearly 50% of chlamydia infections are asymp-
presented in elementary schools. Many schools have compre- tomatic, having no symptoms at all, it is known as the “silent
hensive education programs already in place to teach about STI” and usually goes untreated (Freedom Network, 2009).
STIs and recommendations to prevent the spread of STIs. If left untreated, chlamydial infections cause tissue inflam-
Television, especially educational programs, has been helpful mation, ulceration, and scar tissue formation in both women
in informing the public of the dangers of having sex without and men. Salpingitis (inflammation of the fallopian tubes)
protection against STIs. or pelvic inflammatory disease (PID) can lead to scarring
Many messages have been disseminated to the general of the delicate fallopian tubes, ectopic pregnancy, or even
public regarding the best methods of prevention of STIs. infertility.

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 CHAPTER 14 Sexually Transmitted Infections 483

Table 14-1 Sexually Transmitted Infections: An Overview

DISEASE CHARACTERISTICS NURSING IMPLICATIONS
Chlamydia Asymptomatic or may experience Instruct client to notify sexual partner(s) of past
purulent discharge 2 months of their need for treatment.
Painful urination Instruct client to avoid sexual activity or to use
Urethral discharge condoms until both client and partner(s) are
symptom free.
Note: If untreated, pelvic inflammatory
disease (PID) can develop Provide instruction regarding medications
prescribed.

Cytomegalovirus (CMV) Often asymptomatic, occasionally Implicated in some spontaneous abortions or

(Human herpesvirus type 5 fever, fatigue, and weakness mental retardation.
[HHV-5]) Generally acquired during childhood Congenital infection produces cytomegalic
or adolescence inclusion disease.
50% to 80% of adults have antibodies May be life threatening in a client with a poorly
to CMV by age 40 functioning immune system.

Genital Herpes: Herpes Vesicles on penis, vagina, labia, Refer sexual partner(s) for examination.
Simplex Virus 2 (HSV-2) perineum, or anus Teach that virus can be transmitted even when the
(Human herpes-virus Can progress to painful ulceration person experiences no symptoms.
type 2 [HHV-2])
Lesions may last up to 6 weeks Instruct in use of condoms.
Recurrence common Teach females of the need for annual Pap smears.
Note: May be asymptomatic Provide instruction regarding
medications prescribed.

Gonorrhea Male: Instruct client to return if symptoms persist.

Urethritis (inflammation of the Sexual partner(s) of past 60 days must be assessed.
urethra) Instruct client to avoid sexual activity until
Purulent discharge symptoms subside in both client and partner(s).
Urinary frequency Provide instruction regarding medications
Epididymitis (inflammation of the prescribed.
epididymis)
Female:
Often asymptomatic
May lead to PID or salpingitis
(inflammation of the fallopian
tube)
Can occlude the fallopian tubes,
resulting in sterility

Hepatitis B Virus (HBV) Varies greatly from asymptomatic Partner(s) should receive medical prophylaxis
state, to severe hepatitis, to cancer within 14 days after exposure.
For client and partner(s), recommend three-
dose immunization series when this episode has
abated.

Genital Warts (Human Fleshy, cauliflower-like growth on Inform and treat sexual partner(s).
Papillomavirus) (HPV) genitalia Provide instruction regarding medications
prescribed.
(Continues)

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484 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Table 14-1 Sexually Transmitted Infections: An Overview (Continued)

DISEASE CHARACTERISTICS NURSING IMPLICATIONS
Syphilis Disease consists of four stages with Interview client to identify sexual contacts.
distinct manifestations as follows:
Primary:
A painless papule on penis, vagina, or All those exposed to the disease should be given
cervix (chancre) penicillin or other antibiotic if allergic to penicillin.
Usually negative serologic blood test
Highly infectious during this stage
Secondary:
Rash, especially prevalent on palms Educate client and sexual contacts about the
and soles disease.
Low-grade fever Provide instruction regarding medications
Sore throat prescribed.

Headache
Early latency:
Possible infectious lesions, otherwise Counsel and educate client.
asymptomatic
Reactive serologic tests
Late latency:
Possible lesions in central nervous and Counsel and educate client.
cardiovascular systems
Noninfectious except to fetus of

COURTESY OF DELMAR CENGAGE LEARNING

pregnant woman

Trichomoniasis Petechial lesions Treat sexual partners simultaneously with

Profuse urethral or vaginal discharge metronidazole (Flagyl).
that is foul smelling, yellow, and foamy Provide instruction regarding medication
prescribed.

When symptoms of chlamydia appear in men, they It is important that all sexual partners are tested and treated
include dysuria; watery white, cloudy discharge from the ure- for chlamydia because reinfection is probable if only one
thra; and testicular pain and swelling. Women may have grayish partner is treated.
white mucopurulent vaginal drainage, bleeding between peri-
ods, dysuria, low abdominal pain, and bleeding or pain during
or after sexual intercourse. Health Promotion
Persons who have more than one sexual partner, especially
women less than 25 years old, should regularly be tested for
Medical–Surgical chlamydial infection even when there are no symptoms. The
Management current use of male latex condoms during sexual intercourse
may help reduce transmission.
Pharmacological
The treatment of choice is doxycycline (Vibramycin). If com-
pliance with an extended period of drug therapy is thought ■ GONORRHEA

G
to be a problem, azithromycin (Zithromax) can be given
orally in a single dose. Pregnant women may be treated with onorrheal infections are often seen in combination with
erythromycin estolate (Ilosone) or amoxicillin (Amoxil), but chlamydia. Gonorrhea is a serious bacterial infection,
they should be cultured again after treatment is completed to caused by the gram-negative bacterial organism Neisseria
confirm the absence of chlamydial infection. Retesting is not gonorrhea. In 2007, more than 350,000 cases occurred in
required after treatment with doxycycline or azithromycin. the United States (CDC, 2007a). The organism multiplies

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 CHAPTER 14 Sexually Transmitted Infections 485

Table 14-2 Common Diagnostic Tests

for STIs CLIENTTEACHING
Proper Use of Condoms
Blood Tests
• Enzyme immunoassay (EIA) (rapid test) No method of barrier birth control works perfectly to
protect against STIs. Therefore, the client should be
• Western Blot
educated regarding the proper use of both male and
• Venereal Disease Research Laboratories (VDRL) female condoms.
• Rapid plasma reagin (RPR) • Aside from abstinence, condoms provide the
• Fluorescent treponemal antibody-absorption test most protection against STIs by preventing
(FTA-ABS) mucous membrane contact.
• Clients should be advised to use condoms for
• Reiter test
every sexual encounter.
• Antigen test for HSV
• Latex sheaths are available to prevent oral-
Culture genital mucous membrane contact.
• Tissue: Male urethra, female endocervix • The client should be instructed to store con-
• Discharge—swab test doms in a cool, dry place, away from sunlight.
• A new condom must be used for each sexual
• Tzanck
encounter; condoms cannot be reused.
• Nucleic Acid Amplification Test (NAAT)
• Proper condom disposal includes holding the
Urine condom at the base of the penile shaft after
• Urine specimen ejaculation so that the condom does not slip out
of place.
• NAAT
COURTESY OF DELMAR CENGAGE LEARNING

Other
• Dark field examination of wart screenings
the same complications, such as infertility from salpingitis
• Microscopic examination and PID.
• OSOM Trichomonas rapid test Symptoms of infection may occur within 2 to 10 days
after exposure (contact with an infected person or agent).
• Immunofloresence testing
Men are more likely to exhibit symptoms such as white, yellow,
or green thick discharge from the tip of the penis (Figure
14-1), swelling of the testicles and prostate gland, dysuria, and
anal irritation and discharge. Many women are asymptomatic,
quickly in warm, moist areas of the body, including the but the remainder may have pain or burning on urination
oral cavity, reproductive tract, and rectum. Mouth-to-mouth and/or a yellow or bloody vaginal discharge.
kissing does not transmit gonorrhea. It is spread during If a woman is infected with gonorrhea when she gives
sexual intercourse—vaginal, oral, and anal. The cervix is the birth, the infection may be transmitted to the newborn’s eyes
usual site of infection in women. The disease progresses in as the baby travels through the birth canal. In the United
much the same manner as chlamydia and can cause many of States, all infants are treated with an antibiotic ophthalmic

CRITICAL THINKING

Chlamydia Treatment

1. Your client has been prescribed doxycycline for

treatment of chlamydia. What precautions will
the nurse include with the prescription?
2. The client asks you if she needs to continue
taking the medication even though she no lon-
ger has any STI symptoms. What will the nurse
tell her?
3. The client asks if she can continue to engage in
sexual activity with her boyfriend while she
is taking the antibiotic. What will the nurse
recommend? Figure 14-1 Male clients with gonorrhea exhibit purulent
discharge from the penis. (Courtesy of Centers for Disease Control
and Prevention.)

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486 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

CLIENTTEACHING
Reducing Your Risk
CULTURAL CONSIDERATIONS
• Practice abstinence or mutual monogamy.
• The best method is to use latex condoms at the Gonorrhea
beginning of vaginal and/or anal sex until there
is no longer skin contact. Traditionally, ethnic minorities in the United States
have had greater rates of reported gonorrhea and
• Water-based spermicides are not recommended
other STIs—in part, a reflection of limited access
for the prevention of gonorrhea.
to quality health care. African-American subjects
• Recent studies have shown that nonoxynol-9
are most widely affected by gonorrhea, with a rate
is not effective in preventing gonorrhea
of infection approximately 19 times greater than
(American Social Health Association [ASHA],
that of Caucasian subjects. American Indians/Alaska
2009).
Natives had the second highest gonorrhea rate in
• Do not share sex toys. 2007, followed by Hispanics. Asians/Pacific Islanders
• You cannot catch gonorrhea from sharing toilet had the lowest rates of gonorrhea (CDC, 2007b).
seats or sharing towels.
• Several barrier methods can be used to reduce
the risk of transmission of gonorrhea during Pharmacological
oral sex. A variety of antibiotics are effective against gonorrhea. One
• A nonlubricated condom can be used for of the most effective therapies includes a single dose of cip-
mouth-to-penis contact. rofloxacin (Cipro), followed by a 7-day course of oral doxy-
• A dental dam or food plastic wrap can be used cycline (Vibramycin). Because almost half of all clients with
during mouth-to vulva/vaginal or oral-anal gonorrhea also have chlamydia, doxycycline (Vibramycin)
(rimming) contact.
is an appropriate choice of drug therapy because it com-
bats both infections effectively. For pregnant clients, or those
(ASHA, 2009; Freedom Network, 2009) younger than 16 years of age, an injection of ceftriaxone sodium
(Rocephlin), followed by oral erythromycin estolate (Ilosone),
is recommended. Follow-up cultures to determine the success
of the course of treatment are recommended when the treat-
ointment at birth to prevent the gonorrheal-induced eye ment has been completed.
infection known as ophthalmia neonatorum.

Medical–Surgical ■ SYPHILIS
Management
Once the presence of gonorrhea has been confirmed,
both partners should be treated with a course of antibiotic
S yphilis, an STI that was almost eradicated after the discovery
of antibiotic therapy in the 1940s, is on the upswing again,
with 11,466 cases reported in 2007, a 15.2 % increase from 2006
therapy. Penicillin used to be the drug of choice when treating (CDC, 2007a). The causative organism of syphilis is a spiro-
gonorrhea, but because penicillin has been so widely used chete, a spiral-shaped bacterium known as Treponema pallidum,
against many types of infection, some strains of Neisseria gon- which was first identified in 1905. Transmission of syphilis is
orrhea have adapted and are no longer affected by penicillin. either through sexual contact or congenitally (mother to child).
The current practice is to treat all cases of gonorrhea as though Syphilis is often seen with human immunodeficiency virus
they were resistant to the traditional drug therapies. (HIV) infection, just as chlamydia is often seen with gonorrhea.
Syphilis has four stages. In primary stage syphilis, the
incubation period, time between exposure to an infectious
disease and the first appearance of symptoms, can be 10 to
90 days with the development of a chancre usually occurring
PROFESSIONALTIP within 2 to 6 weeks. A chancre is a clean, painless ulcer that
usually is present at the site of body contact (Figure 14-2).
Antibiotic Resistance There is usually just one chancre present, but multiple chan-
cres have been known to occur. Chancres may occur on the
In 2007, the CDC revised its gonorrhea treatment internal genitalia of women (e.g., the cervix) and thus not
guidelines based on data indicating widespread be noticed. The chancre will heal within a few weeks, even
drug resistance to fluoroquinolones, which were
without treatment, and either leave a thin scar or none at all.
If not identified and treated, about one-third will progress to
the leading antibiotic class to treat gonorrhea.
secondary syphilis.
Fluoroquinolones are no longer recommended In secondary syphilis, the client has a skin rash of penny-
to treat gonorrhea. Cephalosporins are now the sized brown sores that appear approximately 3 to 6 weeks after
antibiotic choice for treatment. the chancre. The rash may be on all or any part of the body but
almost always involves the palms of the hands and the soles of

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 CHAPTER 14 Sexually Transmitted Infections 487

CLIENTTEACHING
Testing for Syphilis
• According to the CDC (2007a), regular screening
of men who have sex with men (MSM), is an
important step toward preventing the spread of
syphilis.
• Pregnant women being screened at their first
prenatal visit is critical in protecting infants from
congenital syphilis complications such as blindness.

no cases of penicillin-resistant syphilis have been identified.

Figure 14-2 The primary stage of syphilis is usually marked All types of penicillin are effective, but penicillin G benzathine
by the appearance of a single sore called a chancre. (Courtesy of (Bicillin L-A) is often preferred. Antimicrobial therapy will
Centers for Disease Control and Prevention.) destroy Treponema pallidum at any stage, but any damage
done to body organs is irreversible. If the client has a demon-
the feet. Active bacteria are in the sores, so any contact, sexual strated allergy to penicillin, alternative medications may be
or nonsexual, with the broken skin of the infected person may administered, such as doxycycline (Vibramycin), tetracycline
spread the infection. The rash heals within several months. HCl (Achromycin V), or erythromycin estolate (Ilosone). For
Other symptoms, such as low-grade fever, fatigue, headache, pregnant women who are allergic to penicillin, erythromycin
sore throat, and generalized lymph node swelling, may occur. is recommended as the best alternative therapy.
Occasionally, a wart-like growth known as condyloma latum Clients being treated for syphilis must have periodic
may be present in the genital area of both men and women. blood tests to ensure that the infecting agent has been com-
Because this growth is so close in appearance to the condylo- pletely destroyed.
mata acuminata of human papillomavirus infection, it may be
confused with genital warts. Symptoms of secondary syphilis
may come and go for 1 or 2 years. Because many of these
symptoms are also common to many other diseases, syphilis ■ GENITAL HERPES

G
has often been called “the great imitator.”
enital herpes affects an estimated 45 million persons in
When not treated, syphilis enters into a latent period
the United States. (1 out of 5 adolescents and adults)
when no symptoms are present and the disease is no longer
(CDC, 2009). It is caused by the human herpesvirus type 2,
contagious. Only approximately one-third of those clients with
commonly called the herpes simplex virus (HSV-2). HSV-1
secondary syphilis will develop the symptoms of tertiary syph-
commonly causes sores on the lips (fever blisters, cold sores).
ilis, that is, when the bacteria damages the heart, eyes, brain,
HSV-2 causes genital sores. Either can infect the other area
nervous system, bones, joints, or any other part of the body.
following oral-genital sex. Genital herpes is usually acquired
Tertiary syphilis can last for years or decades and may result in
through sexual contact with an infected person. That person
heart disease, blindness, neurologic problems, and death.
may or may not be aware of having genital herpes.
Medical–Surgical
When symptoms occur in the first episode, they usually
appear in 2 to 10 days after infection and last an average of 2 to
Management 3 weeks. Itching or burning sensations; pain in the genital area,
legs, or buttocks; vaginal discharge; or abdominal pressure are
Pharmacological the early symptoms. Within a few days, lesions (sores) appear
Since the time that syphilis was first treated with antibiotic at the infection site (perianal area), in the vagina or on the
therapy, penicillin has remained the drug of choice because cervix of women, or in the urethra of women and men.
Small red bumps appear first, change into blisters
(Figure 14-3), and then become open sores that crust over in a
few days. Other symptoms with the first episode may include
MEMORYTRICK fever, muscle aches, headache, dysuria, vaginal discharge, and
swollen glands in the groin.
RASH With the first episode, the virus travels through the
sensory nerves and remains inactive in nerve cells until the
A useful memory trick to use when assessing a
virus travels back to the skin, causing a recurrence. The fre-
client for signs and symptoms of syphilis is RASH: quency of recurrences vary greatly (some only 1 or 2 a year),
R = Rash (on palms and soles) but new sores may or may not be apparent. Symptoms are
usually milder than the first episode and last approximately
A = A painless papule (on penis, vagina, or cervix) 1 week.
S = Sore throat The most accurate method of diagnosis is a viral cul-
ture, which takes several days. A blood test detecting HSV
H = Headache
antibodies only indicates that the person has been infected
at some time.

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488 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

contact. CMV is incurable; people are infected for life. The

inactive virus may reactivate from time to time.
Most people acquire CMV during childhood or adolescence
through contact with saliva and respiratory secretions and will
not notice any symptoms. Occasionally, a client will present
with fever, fatigue, and weakness. These symptoms may persist
for several weeks and may lead to a tentative diagnosis of infec-
tious mononucleosis, although the sore throat and swollen
lymph nodes of “mono” are not present with CMV.
CMV has been implicated in some complications of
pregnancy, such as spontaneous abortion or mental retarda-
tion of the neonate. Congenital infection of an infant produces
cytomegalic inclusion disease that ranges from an asymptom-
atic condition to a severely debilitating condition that may
even result in death. The central nervous system damage to
Figure 14-3 Chronic Mucocutaneous Perianal Herpes the infant may be profound, although it rarely occurs. An
Infection (Courtesy of Centers for Disease Control and estimated 8,000 children each year will suffer permanent dis-
Prevention.) abilities caused by CMV such as mental retardation, blindness,
deafness, or epilepsy (CDC, 2008a). CMV can also become a
Medical–Surgical life-threatening illness in a client who has a poorly functioning
Management immune system, such as a client with AIDS.
There is no antiviral agent specifically utilized for this
Pharmacological disorder because most of the population will not have any
symptoms.
There is no known cure for the herpes simplex virus at this
time. Treatment has been geared toward alleviating symptoms
of the disease. Acyclovir (Zovirax) has been used in the treat-
ment of herpes. A topical form may be applied to the lesions; ■ HUMAN PAPILLOMAVIRUS/
the drug may also be taken orally to shorten the duration of GENITAL WARTS

A
the lesions in a primary outbreak. When taken daily, it pre-
vents most recurrences. Famciclovir (Famivir) and valacyclovir nother virus that is sexually transmitted is the human papil-
(Valtrex) treat later episodes and prevent recurrences. lomavirus (HPV), which causes genital warts, also called
Cleansing the area of the lesions with mild soap and condylomata acuminata. Genital warts may occur in the urogen-
water, hydrogen peroxide, or Burow’s solution often helps ital, perineal, or anal areas and may be either external or inter-
reduce the discomfort of the lesions and decrease the chance nal. The population at risk seems to be teenage girls or young
of secondary infections. The area should be blown dry with a women in their twenties. In the United States, it is estimated that
hairdryer, and then the dry skin may be dusted with a corn- there are approximately 25,000 new cases of HPV identified
starch powder, which aids in decreasing client discomfort. every year, and at least 20 million people are already infected
(National Institutes of Health, 2008). The incubation period
for genital warts appears to be approximately 1 to 2 months but
■ CYTOMEGALOVIRUS may be up to 6 months. Unlike genital herpes, genital warts are
usually painless, soft fleshy growths appearing most commonly

A nother virus in the herpes virus family is cytomegalovirus

(CMV). Unlike the more commonly recognized herpes
viruses, CMV rarely produces noticeable clinical symptoms.
in the genital area. Sometimes many warts may grow together to
form a large cauliflower-shaped growth (Figure 14-4).

CMV is primarily transmitted from person to person

through contact with body fluids such as saliva, breast milk,
urine, and blood. The virus has been identified in semen,
vaginal fluids, and cervical mucus, so it can be spread by sexual

PROFESSIONALTIP
Client Support
The client may need emotional support, since the
diagnosis of herpes means lifelong management.
The disease will not be cured after a course of anti-
viral medication, and the client must thoroughly
understand this fact. The client may be referred to
Figure 14-4 Genital warts (Condylomata acuminate) are
a counselor or to a support group such as HELP at caused by human papillomavirus (HPV), which presents as
the Herpes Resource Center (ASHA, 2009a). bumps or warts on the genitalia and within the perineal region.
(Courtesy of Centers for Disease Control and Prevention.)

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 CHAPTER 14 Sexually Transmitted Infections 489

The greatest health threat that HPV poses to a female cli-

ent is the potential development of cervical cancer. Although ■ AIDS

A
there are more than 100 different types of HPV, only 30 types
are spread through sexual contact, and some of these can cause IDS, or acquired immunodeficiency syndrome, is not
cervical cancer. Cigarette smoking has been linked to the truly an STI, but it needs to be discussed briefly here
development of cancerous cervical changes in women with because sexual contact is one of the primary modes of its trans-
HPV. Women who have HPV should be advised not to smoke. mission. AIDS is the end stage of the disease process caused
HPV appears to play a role in the development of cervical can- by the human immunodeficiency virus (HIV) (Chapter 16).
cer, along with many other factors. An abnormal Pap test may Similar to the viruses previously discussed in this chapter,
be the first indication of HPV. AIDS is not curable. Unlike the other viruses, herpes genitalis
Genital warts are less common in men. If seen, they are and genital warts, AIDS is ultimately fatal. AIDS results in a
usually on the tip of the penis or anal area. severe disorder of the body’s immune system, leading to an
inability of the body to fight off disease.
Medical–Surgical Persons at risk are those who have multiple sexual part-
ners, IV drug users who share needles, and persons with
Management hemophilia. There are three basic modes of transmission: sex-
ual, bloodborne, and from mother to baby either prenatally,
Because genital warts are caused by a virus, there is no cure
during the birth process, or when breastfeeding. When first
for the disease. The focus is on preventing the spread of the
identified in 1981, HIV infection was primarily found among
disease to sexual partners and reducing the possibility of
homosexual men, but by 1990, the disease was moving into
cancer. Use of a condom during sexual intercourse may pro-
heterosexual populations with great rapidity. By the mid-
vide some protection. Once the genital warts disappear, the
1990s, cases of AIDS were occurring more frequently among
disease may lie dormant for many years until there is a recur-
women than among men. The greatest growth in AIDS rates
rence of the outbreak.
among women occurred in African-American and Hispanic
women. Teenagers also have one of the fastest growing rates
Surgical of HIV infection.
The warts may be removed under local anesthesia. This is The CDC’s HIV/AIDS surveillance system is the nation’s
especially recommended if the warts have formed a large, source for current information and statistics, tracking the
fleshy cauliflower-like growth. Freezing the warts off with epidemic, and collecting, analyzing, interpreting, and evalu-
cryosurgery, surgical use of extreme cold, is the treatment of ating data regarding HIV/AIDS. The CDC also conducts
choice for small warts. The warts may also be removed with research studies to find new treatment options and poten-
laser surgery or cauterized. Whatever treatment is recom- tial vaccines (Figure 14-5). It is estimated that 1.1 million
mended, it must be remembered that the treatment will not
cure HPV, but only provide a palliative effect. The warts may
recur after any treatment.

Pharmacological
A topical solution of podophyllum resin (Poddoen) may be
applied to the genital warts. It is only recommended for treat-
ment of one or two lesions at a time because it can be toxic if
applied to too large an area at one time. Most people report
experiencing a good deal of pain from the treatment. After the
solution has been in contact with the genital warts for a period
of 4 to 6 hours, it is then washed off with soap and water. If
not thoroughly washed off, podophyllum may cause chemical
burns that heal very slowly and are very painful. This therapy
must not be used on a diabetic client, a client with poor circu-
lation, or a pregnant client.
A cream, imiquimod (Aldara), is applied before bedtime
and washed off in the morning. It can be used 3 times a week
for 16 weeks or less.

Health Promotion
There is currently a vaccine (Gardasil) available that can
protect females from the four types of HPV that cause the
majority of cervical cancers and genital warts. The vaccine is
recommended for females 11 to 26 years of age. The immu-
nization schedule for the vaccine includes a series of three
intramuscular injections. There are no vaccines available at Figure 14-5 Since the beginning of the AIDS epidemic,
this time for males. Studies are currently being conducted the CDC has been at the forefront of HIV investigation and lab
to find out if the vaccine is safe for females and effective in research. (Courtesy of Centers for Disease Control and
males. Prevention.)

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490 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Americans are living with HIV and 33.2 million persons nal cramping. CNS effects such as headache or dizziness may
worldwide. Two-thirds of HIV infections are in sub-Saharan also be seen.
Africa (CDC, 2008c; WHO, 2009).

■ HEPATITIS B
■ TRICHOMONIASIS

T richomoniasis is caused by a parasitic protozoan called

Trichomonas vaginalis. Trichomoniasis is a very common
H epatitis B, caused by the hepatitis B virus, is now rec-
ognized as an STI. Today, it is primarily transmitted
through direct contact with blood, vaginal secretions, and
STI with an incidence of approximately 8 million new cases semen. In 2006, approximately 46,000 people were newly
a year (CDC, 2008b). It is seen frequently in combination infected with HBV. An estimated 800,000 to 1.4 million
with gonorrhea. The most common method of transmission Americans have chronic HBV infection (CDC, 2008e).
is sexual, although the protozoa can survive for a period of Clients with hepatitis B experience inflammation of the
time in water, so other modes of transmission are possible. liver, anorexia, vague abdominal discomfort, nausea, vomit-
The incubation period after initial exposure to ing, fatigue, and jaundice. Fever may be mild or absent. Symp-
trichomoniasis ranges from approximately 4 to 20 days. toms may progress to chronic liver disease, hepatic cancer,
About 25% of women infected with trichomoniasis will hepatic failure, and death.
have no symptoms, and men almost never have symptoms.
In these clients, the Trichomonas organisms may remain
dormant for years without becoming an active infection. Medical–Surgical
Precipitating factors that may encourage the growth of
Trichomonas include pregnancy, sexual intercourse, men-
Management
struation, or illness. Vulval and vaginal pruritus are the most
common symptoms, with a vaginal discharge of a frothy, Medical
copious yellow-green mucus. Only 10% of women will pres- There is no specific treatment for acute HBV infection. Treat-
ent with the classic symptoms of a Trichomonas infection: ment is based on relieving symptoms. Several antiviral medi-
severe itching of the vulva, redness, swelling of the vulva, cations are available to treat chronic HBV infection including
pain on intercourse and urination, urinary frequency, a gray- adefovir dipivoxil (Hepsera), peginterferon (Pegasys), lamivu-
ish, malodorous discharge, and the appearance of a “straw- dine (Epivir), and entecavir (Baraclude). Interferon, another
berry cervix” caused by hemorrhages with accompanying antiviral agent, helps to stop the replication of HBV.
papules and vesicles. Men most often have a watery, whitish
discharge and difficult or painful urination, but they may Health Promotion
also have urethritis and an accompanying inflammation. In Hepatitis B has two single-antigen vaccines and three combina-
men, Trichomonas in the dormant state are usually harbored tion vaccines currently available for administration in the United
in the prostate or urethra. States. The immunization schedule most commonly followed
consists of a series of three intramuscular injections. Recom-
Medical–Surgical mendations for immunization include all newborns, health-care
Management workers, and high-risk groups of all ages (CDC, 2008e).

Pharmacological Nursing Management

Both partners should be treated with metronidazole (Flagyl Follow proper hand hygiene technique. Teach the client hand
or Protostat) given either orally in a single dose or for a hygiene to be followed after using the bathroom and every
period of approximately 1 week. Metronidazole is effec- time the penis, vagina, or perineal areas are touched. Provide
tive against both protozoal and bacterial infections. If given nonjudgmental support to all clients. Encourage clients to
vaginally, metronidazole (Flagyl) is not as effective. Pregnant notify past and present sexual partners of the diagnosis and
women are usually treated after the first trimester to avoid the the need to seek medical care. Advise client to wear loose-
possibility of birth defects, because metronidazole is known fitting clothes and cotton underwear for comfort.
to cross the placenta.
Adverse effects occur in about 10% of clients taking
metronidazole (Flagyl) and usually affect the gastrointestinal
system in the form of nausea, vomiting, diarrhea, and abdomi- NURSING PROCESS
The following is a general nursing process for the client with
an STI.
CLIENTTEACHING
Metronidazole (Flagyl or Protostat)
Assessment
Subjective Data
No alcohol should be consumed when taking this
Data to be gathered from a client who presents with a sus-
drug because it causes severe nausea and vomit-
pected STI are very similar, regardless of the actual STI. A
ing, flushing, palpitations, abdominal cramps, and thorough history must be obtained. A relaxed, nonjudgmen-
headache (Cleveland Clinic, 2009). tal attitude will help to elicit accurate information from the
client. Confidentiality and privacy are extremely important

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 CHAPTER 14 Sexually Transmitted Infections 491

CRITICAL THINKING
Table 14-3 Health History Questions:
Multiple Sexual Partners STIs
Questions for Women and Men
What should a client who has multiple sexual partners • Can you share with me your sexual orientation
be taught about STIs? Make a teaching plan while (homosexual, heterosexual, bisexual)?
keeping in mind the sensitivity of the information to
• Have you been diagnosed with an STI in the past?
be shared and the client’s receptivity.
• If so, which STI(s) have you been diagnosed with?
• Have you been diagnosed with more than one STI?
If so, which disease(s)?
when dealing with both the history and physical examination
• How many sexual partners have you had in the past
for STIs. Gather pertinent information regarding the client’s
sexual orientation (homosexual, heterosexual, bisexual), any 6 months?
prior treatment for an STI, and the number of sexual partners • How many sexual partners have you had since you
that the client has had in the last 6 months. became sexually active?
Ask women about symptoms such as vulval or vaginal • Do you have any skin rashes or itching? If so, where
itching, vaginal discharge, pain or discomfort, skin rashes or
on your body?
pruritus, and any changes in the menstrual periods or other
abnormal bleeding. Question men regarding the presence of • Does it burn or hurt when you urinate?
symptoms such as pain or burning on urination, abnormal • Are you urinating more frequently than usual?
penile discharges, skin rashes or itching, or lesions on external
genitalia. Ask both men and women about urinary frequency • Have you been more tired than usual?
or discomfort and systemic symptoms such as fatigue, malaise, • Do you have a sore throat?
or sore throat. Ask homosexual men about rectal symptoms • Have you had any sores or lesions on your lips,
such as abnormal discharge, itching, lesions, or pain on defeca- tongue, or in your mouth?
tion (Table 14-3).
• Have you noticed any anal discharge or tenderness?
Objective Data Questions for Women
Carefully assess the reproductive, gastrointestinal, and integ- • Have you experienced vaginal itching? Vaginal pain
umentary systems. Determine the presence or absence of or discomfort?
skin rashes or lesions and abnormal discharges. Females
need a speculum examination of the vagina and cervix to • Are you experiencing any changes in your
closely observe internal organs for changes consistent with menstrual cycle?
STIs. Examine the rectal area to look for any abnormal dis- • Do you have any abnormal vaginal bleeding or
charge, lesions, or tenderness. Palpate inguinal lymph nodes discharge?
to look for signs of infection.
Questions for Men
• Do you have any sores or lesions in your pubic

COURTESY OF DELMAR CENGAGE LEARNING

LIFE SPAN CONSIDERATIONS area?
• Do you have any sores or lesions on your penis?
Sexual Activity in Older Adults • Are you experiencing any discharge from the tip of
Many young nurses find it difficult to think of older your penis?
adults as sexual beings. As the “baby boomers” age, • Are your testicles swollen or tender?
however, they are becoming very assertive about
living life to the fullest, which includes continuing
to enjoy an active sex life. An older adult who is sin-
gle may still be sexually active and engage in high-
risk sexual activities. A tactful, respectful approach
will allow the nurse to obtain an accurate sexual
history if symptoms seem to indicate the likelihood
of an STI.

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492 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

Nursing diagnoses for the client with an STI include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to unknown pro- The client will verbalize a lack of Provide a relaxed, nonjudgmental
cedures, embarrassment, or other knowledge and embarrassment. attitude which will aid in reducing
factors (relates to nearly every client client anxiety. Listen actively to both
who presents with an STI) the spoken and unspoken concerns
of the client.
The nurse must examine own at-
titudes toward STIs and the clients
who suffer from them.

Deficient Knowledge related to mode The client will accurately discuss the Teach mode of transmission, preven-
of transmission of the STI, preven- mode of transmission of an STI and tion of further infection, and risk for
tion methods, and risk for spread of list appropriate measures to avoid spread.
the STI reinfection or future infection. Take time to make sure the client has
a thorough understanding of all nec-
essary aspects of the disease.

Risk for Infection related to incom- The client will state the need for hav- Discuss the need for all sexual
plete treatment or lack of precautions ing all sexual partners notified and partners to be notified and treated.
with untreated, infected partners treated. Discuss the importance of complet-
The client will state understanding of ing treatment regimen.
the treatment regimen and of the Teach the importance of abstain-
importance of completing treatment. ing from sexual intercourse until
The client will explain appropriate the infection is resolved, or of using
use of latex condoms, including how appropriate measures, such as latex
and when to apply and remove the condoms, to prevent reinfection.
device.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Genital Herpes

J.B. is a single woman in her middle twenties who has been coming to the clinic for annual Pap smears
and birth control for several years. She is a well-nourished, healthy-appearing young woman of medium
height. She rescheduled her annual Pap smear to come into the clinic early because she noticed a cluster
of small blisters on the inside of her left thigh that also involves the labia majora. She also reports that
she has just gotten the flu as evidenced by headache, fever, and general achiness.
J.B. has used birth control pills in the past and reports satisfaction with this method of birth control.
She reports that she and her new boyfriend became intimate about 2 weeks ago, so she wants to renew
her birth control pill prescription. She also states that intercourse has been uncomfortable since the
appearance of the lesions and that she does not feel comfortable with sexual activity while the lesions
are present because they make her feel “ugly.”
The assessment determines the presence of a cluster of small blisters as well as swollen, tender inguinal
lymph nodes. A Tzanck smear test is obtained. J.B.’s test results come back positive for genital herpes.

NURSING DIAGNOSIS 1 Ineffective Sexuality Pattern related to lesions as evidenced by her com-
ment that intercourse has been uncomfortable since the appearance of the lesions
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Psychosocial Adjustment: Life Change Sexual Counseling

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 CHAPTER 14 Sexually Transmitted Infections 493

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
J.B. will express her feelings about Provide a nonjudgmental atmo- Demonstrates the caregiver’s
potential changes in her sexual sphere to encourage J.B. to express positive feelings toward J.B. and
behavior before leaving the clinic. her feelings about this perceived concerns she may have regarding
change in her sexual identity. her future sexuality.
Provide privacy and an Shows respect and conveys
uninterrupted amount of time to reassurance in discussing sexuality
talk with J.B. issues and concerns with her.
Provide accurate information to Helps J.B. focus on specific,
J.B. about genital herpes and necessary information and
include literature or videos for encourages her to ask questions.
her to share with her boyfriend.
Offer the names of local support Provides J.B. with resources for
groups such as HELP (Herpetics support once she has returned
Engaged in Living Productively) home and the reality of her
or other support persons who diagnosis has set in.
can provide information and
group support to J.B.

EVALUATION
J.B. states that she is still in shock but thinks that she will be able to deal with her diagnosis. She also
states that she will call back to the clinic in a few days with more questions after she has assimilated some
of the information.

NURSING DIAGNOSIS 2 Anxiety related to threatened sexual identity, as evidenced by her comment
that she is not comfortable with sexual activity while the lesions are present because they make her feel
“ugly”
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Acceptance: Health Status Teaching: Individual

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

J.B. will be able to express feelings Explain any procedures clearly and Helps alleviate anxiety.
of anxiety and identify support sys- concisely before performing them.
tems to help her cope with these
feelings before leaving the clinic.
Listen attentively to concerns or Helps identify anxious behaviors
expressions of anxiety from J.B. and source of her anxiety.
Include J.B. in as many decisions May reduce her feelings of anxiety
related to her care and follow-up and gives her some control.
as is possible.

EVALUATION
J.B. expresses feelings of anxiety about the diagnosis. States she has a cousin with herpes whom she will
use as a resource person. Also states that she has a secure relationship with her boyfriend and will talk to
him about herpes. Agrees to call the clinic for any further support or information that she may need.
(Continues)

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494 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 3 Risk for Infection related to break in skin integrity as evidenced by the pres-
ence of blisters
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Risk Control: Sexually Transmitted Infections (STI) Teaching: Disease Process
Teaching: Sexuality

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

J.B.’s herpes blisters will heal Wear gloves when examining Prevents secondary infection in
without secondary infection perineal area and when handling herpes blisters from caregiver’s
within 10 days. exudate from herpes lesions. hands and protects caregiver when
dealing with wound exudate.
Teach J.B. how to wash hands Prevents spread of herpes infection
very thoroughly after using from genital area to other areas of
the toilet or handling the area J.B.’s body or to another person.
around the herpes lesions.
Instruct J.B. in the importance of Helps prevent the occurrence of
keeping the herpes lesions clean a secondary infection that may
and dry until they heal. delay healing for up to 6 weeks.
Instruct J.B. to wear cotton Provides air circulation to
underwear and loose-fitting promote healing and reduce
clothing during herpes outbreaks. further local irritation.

EVALUATION
J.B. has been taught to keep blisters clean and dry and states that she will contact the clinic if the lesions
develop any signs of a secondary infection. She makes an appointment to return to the clinic in 10 days
for a follow-up evaluation.

CASE STUDY
N.L., a 17-year-old student, has come to your clinic seeking treatment. N.L. is complaining of pain and burning on
urination, as well as pain during intercourse. She states that she is infrequently sexually active with her 17-year-old
boyfriend and is also seeking a form of birth control. She has not used any form of birth control in the past and
neither has her boyfriend. She also complains of a yellowish vaginal discharge and has been wearing a panty liner
to deal with this. Upon examination, N.L. complains of some abdominal tenderness but denies that she has had
any tenderness before this time. N.L. is screened for chlamydia and gonorrhea. She denies having had sex with any
other partners but does admit that she and her boyfriend had a fight and broke up temporarily about a month
ago. They went back together about a week later. She does not know if he had any other sexual contacts during
their period of separation. N.L. is concerned that she has contracted an STI and states, “I’ll die of embarrassment!”
The following questions will guide your development of a nursing care plan for the case study.
1. What other information should be elicited from N.L.?
2. What other STIs will N.L. most likely be tested for in addition to chlamydia and gonorrhea?
3. Write three nursing diagnoses and goals for N.L.
4. List the medications that N.L. will be most likely to receive to treat a chlamydial infection.
5. List some complications that N.L. may experience if she does not receive treatment for an active chlamydial or
gonorrheal infection.
6. What information will you include when you counsel N.L. regarding sexual activity and forms of birth control?
(See the chapter on Reproductive Systems for additional information.)

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 CHAPTER 14 Sexually Transmitted Infections 495

SUMMARY
• STIs are among the most common infections occurring in • Many STIs, such as gonorrhea, syphilis, and chlamydia, are
the United States today. treatable with antibiotics, but many others are caused by
• Despite massive education efforts, the number of new STI viruses and are not curable.
cases identified each year continues to grow. • Identification of groups at risk for STIs and appropriate
• Early, intensive education regarding STIs is being used to prevention teaching are the most effective weapons in the
help combat the high incidence of STIs, which virtually are ongoing battle against STIs.
an epidemic among young, urban-dwelling populations.

REVIEW QUESTIONS
1. A female client comes to the health clinic because 3. An injection of ceftriaxone sodium (Rocephin)
her boyfriend was recently diagnosed with chla- followed by oral erythromycin estolate (Ilosone).
mydia. She asks the nurse what would have hap- 4. Abstain from mouth-to-mouth kissing.
pened to her if she had not found out and had gone 5. An antibiotic ophthalmic ointment is adminis-
without treatment. The nurse explains to her that tered in both eyes.
lack of treatment could result in: 6. Administer mild analgesics as ordered to mini-
1. development of a chancre. mize dysuria.
2. heart disease and blindness. 5. A 22-year-old male has recently been diagnosed with
3. scar tissue formation. syphilis and presents with a skin rash, sore throat,
4. nervous system damage. headache, and small papules on the tip of his penis.
2. A nursing diagnosis for a client with an STI is Risk The nursing assessment data indicates that the client
for Infection related to incomplete treatment and lack of is in which stage of syphilis?
precautions with an infected partner. Which of the fol- 1. Primary.
lowing are desired outcomes for the client? (Select 2. Secondary.
all that apply.) 3. Tertiary.
1. The client will state the need for having all sexual 4. Latent.
partners notified and treated. 6. The nurse is teaching a classroom of college students
2. The client will maintain adequate tissue perfu- the proper use of condoms to protect against STIs.
sion as manifested by stable vital signs. Which of the following statements made by a stu-
3. The client will maintain adequate fluid balance. dent indicates that further teaching is needed?
4. The client will state understanding of the treat- 1. “I always wear a condom and use a water based
ment regimen and of the importance of complet- lubricant when having sex with my girlfriend.”
ing treatment. 2. “I never reuse a condom.”
5. The client will explain appropriate use of con- 3. “I keep extra condoms in the glove compartment
doms, including how and when to apply and of my car so I am always prepared.”
remove the device. 4. “I prefer lambskin condoms because they fit the best.”
6. The client will maintain skin integrity and vagina 7. The nurse knows that which of the following is the
will not be dry. best method for reducing the risk of acquiring an STI?
3. A male client informs the nurse that his girlfriend 1. Always wear a condom during sexual intercourse.
is being treated for cytomegalovirus (CMV). What 2. Do not share sex toys.
common symptoms of cytomegalovirus (CMV) will 3. Use a barrier method when engaging in oral sex.
the nurse assess for in a male client? 4. Abstinence.
1. Urethritis, purulent drainage, and epididymitis. 8. The client has been diagnosed with trichomonas
2. Often asymptomatic, occasionally fever, fatigue, and is prescribed the medication Flagyl for treat-
and weakness. ment. Which of the following is the most important
3. Fleshy cauliflower like growth on genitalia. information for the nurse to teach the client regard-
4. Rash on palms and soles. ing the administration of Flagyl?
4. A 29-year-old male client is diagnosed with gonor- 1. Do not drink alcoholic beverages while taking
rhea. Which of the following treatments are included this medication.
in his plan of care? (Select all that apply.) 2. Take with food.
1. A single dose of ciprofloxacin (Cipro) followed by 3. Do not drink grapefruit juice while taking this
a 7-day course of oral doxycycline (Vibramycin). medication.
2. Follow-up cultures to determine the success of 4. Do not take use an antacid one hour before or
the course of treatment. after taking the medication.
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496 UNIT 5 Nursing Care of the Client: Reproductive and Sexual Health

9. When conducting a health history, which of the asks the nurse why she has to be tested and treated
following questions is inappropriate to ask a client as well, since she does not have any symptoms. The
suspected of having an STI? best explanation by the nurse is:
1. Have you been diagnosed with a STI in the past? 1. “It is important that all sexual partners be tested
2. How many sexual partners have you had in the and treated, because reinfection can occur if only
past 6 months? one partner is treated.”
3. Have you noticed any anal discharge or tenderness? 2. “The doctor requires that spouses be tested and
4. Why didn’t you use a condom when having sex treated even if they do not have any symptoms.”
with your partner? 3. “Because chlamydia is a silent disease with no
10. A 45-year-old male client has been recently diag- symptoms.”
nosed with chlamydia. His wife is in the room and 4. “It is something that all doctors require.”

REFERENCES/SUGGESTED READINGS
American Social Health Association (ASHA). (2009). Gonorrhea: Cleveland Clinic. (2009). Sexually transmitted diseases: an overview.
questions & answers. Retrieved January 17, 2009 from http:// Retrieved January 18, 2009 from my.clevelandclinic.org/disorders/
www.ashastd.org/learn/learn_gonorrhea.cfm Sexually_Transmitted_Disease_STD/hic_Sexually_Transmitted_
American Social Health Association (ASHA). (2009a). Herpes resource Diseases_An_Overview.aspx
center: overview. Retrieved January 17, 2009 from http:// Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic tests
www.ashastd.org/herpes/herpes_aboutcenter.cfm (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.
Apoola, A. & Radcliffe, K. (2004). Antiviral treatment of genital Ehreth, J. (2005). The economics of vaccination from a global
herpes. International Journal of STD & AIDS, 15(7), 429−433. perspective: present and future. 2-3 December, 2004, Vaccines: all
Ballard, R. & Morse, S. (2003). Chancroid. In: Atlas of sexually things considered. Expert Rev. Vaccines, 4, 19−21.
transmitted diseases and AIDS (3rd ed.). Edinburgh: Mosby. Estes, M. (2010). Health assessment & physical examination
Baseman, J. & Koutsky, L. (2005). The epidemiology of human (4th ed.). Clifton Park, NY: Delmar Cengage Learning.
papillomavirus infections. Journal of Clinical Virology, 32(Suppl. 1), Freedom Network. (2009). Facts about STD. Retrieved January 17,
S16−S24. 2009 from http://std-gov.org/
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. Keck, J. (2005). Ulcerative lesions. Clinical Family Practice, 7(1),
(2008). Nursing Interventions Classification (NIC) (5th ed.). 13−30.
St. Louis, MO: Mosby/Elsevier. Mayo Clinic. (2009a). Gonorrhea: definition. Retrieved January
Centers for Disease Control and Prevention. (2007a). Trends in 16, 2009 from http://www.mayoclinic.com/print/gonorrhea/
reportable sexually transmitted disease in the United States, 2007: DS00180/DSECTION=all&method=print
national surveillance data for chlamydia, gonorrhea, and syphilis. Mayo Clinic. (2009b). HIV/AIDS. Retrieved January 18, 2009 from
Retrieved January 17, 2009 from http://www.cdc.gov/std/stats07/ http://www.who.int/features/qa/71/en/index.html
trends.htm Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
Centers for Disease Control and Prevention. (2007b). Sexually Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby.
transmitted disease surveillance, 2007: gonorrhea. Retrieved January National Institutes of Health. (2008). U.S. reported 25,000 cases of
17, 2009 from http://www.cdc.gov/std/stats07/gonorrhea.htm HPV-related cancers annually. Retrieved January 18, 2009 from
Centers for Disease Control and Prevention. (2008a). About CMV: http://www.nlm.nih.gov/medlineplus/news/fullstory_71187.html
general information. Retrieved July 8, 2009 from http://www.cdc National Institutes of Health. (2009). Sexually transmitted diseases.
.gov/cmv/facts.htm Retrieved January 18, 2009 from http://www.nlm.nih.gov/
Centers for Disease Control and Prevention. (2008b). Division of medlineplus/sexuallytransmitteddiseases.html
parasitic diseases: trichomonas infection fact sheet. Retrieved North American Nursing Diagnosis Association International. (2010).
January 18, 2009 from http://www.cdc.gov/ncidod/dpd/parasites/ NANDA-I nursing diagnoses: Definitions and classification 2009–2011.
trichomonas/factsht_trichomonas.htm Ames, IA: Wiley-Blackwell.
Centers for Disease Control and Prevention. (2008c). HIV transmission Ohio Department of Health. (2007). Genital warts. Retrieved January
rates in the United States. Retrieved January 18, 2009 from http:// 18, 2009 from http://www.odh.ohio.gov/pdf/idcm/genwart.pdf
www.cdc.gov/hiv/topics/surveillance/resources/factsheets/ Roden, R., Ling, M., & Wu, T. (2004). Vaccination to prevent and treat
transmission.htm cervical cancer. Human Pathology, 35, 971−982.
Centers for Disease Control and Prevention. (2008d). Vaccines and Rural Center for AIDS/STD Prevention. (2006). Rural
Preventable Diseases: HPV vaccination. Retrieved January 17, 2009 methamphetamine use and HIV/STD risk. Fact sheet No. 18.
from http://www.cdc.gov/vaccines/vpd-vac/hpv/default.htm Retrieved January 15, 2009 from http://www.indiana.edu/~aids/
Centers for Disease Control and Prevention. (2008e). Viral hepatitis: factsheets18.pdf
FAQs for health professionals. Retrieved January 17, 2009 from Spratto, G., & Woods, A. (2009). 2009 edition Delmar nurse’s drug
http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm#overview handbook. Clifton Park, NY: Delmar Cengage Learning.
Centers for Disease Control and Prevention. (2009). Genital herpes— World Health Organization (WHO). (2009). HIV surveillance,
CDC fact sheet. Retrieved January 17, 2009 from http://www.cdc estimates, monitoring and evaluation. Retrieved July 8, 2009 from
.gov/std/Herpes/STDFact-Herpes.htm http://www.who.int/hiv/topics/me/en/index.html

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 14 Sexually Transmitted Infections 497

RESOURCES
American College of Obstetricians and Gynecologists National Institute of Allergy and Infectious Diseases,
(ACOG), http://www.acog.org http://www.niaid. nih.gov
American Public Health Association (APHA), Planned Parenthood Federation of America, Inc.,
http://www.apha.org http://www.plannedparenthood.org
American Social Health Association (ASHA), U.S. Department of Health and Human Services
http://www.ashastd.org (USDHHS), http://www.hhs.gov
Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), http://www.who.int
http://www.cdc.gov
National Foundation for Infectious Diseases,
http://www.nfid.org

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 Nursing Care of the Client:
UNIT 6
Body Defenses
Chapter 15 Integumentary System / 500

Chapter 16 Immune System / 543

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 CHAPTER 15
Integumentary System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the integumentary system:
Adult Health Nursing
• Oncology • The Older Adult
• Immune System

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe common disorders of the integumentary system.
• Relate the pathophysiology of each skin disorder.
• Discuss the common diagnostic tests used to differentiate skin disorders.
• State the usual treatment for each skin disorder.
• Assess the nursing care needs of a client with a disorder of the integument.
• Plan and implement effective nursing care.

KEY TERMS
alopecia hemorrhagic exudate pallor
angiogenesis hemostasis petechiae
angioma hyperthermia purulent exudate
blanching hypothermia sanguineous exudate
cyanosis inflammation sebaceous cyst
debride ischemia sebum
ecchymosis jaundice serosanguineous exudate
erythema keloid serous exudate
eschar keratin shearing
exudate lipoma telangiectasia
friction melanin vitiligo
granulation tissue nevi wound

500

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 CHAPTER 15 Integumentary System 501

The epidermis also contains specialized cells called

INTRODUCTION melanocytes. These cells produce melanin, the pigment
As an old adage asserts, the health of the skin mirrors the that gives the skin its color. The more melanin present, the
health of the body. Many systemic diseases have skin mani- darker the skin color. Exposure to ultraviolet light (sun)
festations. Psychological stress can affect the condition of causes an increase in the production of melanin, which dark-
the skin, and skin rashes can be a complication of drug ens (tans) the skin and provides some protection against
therapy. As the largest and the most visible system in the the harmful effects of suntanning. Moles and birthmarks
body, the integumentary system (skin, hair, scalp, nails, and (nevi), pigmented areas in the skin, are aggregations of
mucous membranes) is vulnerable to injury and susceptible melanocytes. In vitiligo, melanocytes are destroyed, caus-
to several primary diseases. Although the outward appear- ing milk-white patches of depigmented skin surrounded by
ance of the skin is important for psychological well-being, normal skin.
the healthy, intact status of the skin is also essential for physi-
ologic well-being. Maintaining this status of the integumen-
tary system is, therefore, an important independent nursing Dermis
function. The focus of this chapter is to describe common The dermis is dense, irregular connective tissue composed of
skin disorders, identify the usual treatment modalities for collagen and elastic fibers, blood and lymph vessels, nerves,
these disorders, and discuss measures that nurses can imple- sweat and sebaceous glands, and hair roots. The sebaceous
ment to provide effective nursing care for clients with disor- glands secrete an oily substance called sebum that lubricates
ders of the integument. the skin, helping to keep it soft and pliable. Sweat (eccrine)
glands are found in the skin over most of the body surface.
Another type of sweat gland, apocrine glands, is concentrated
in the axillae, anal region, scrotum, and labia majora. These
ANATOMY AND PHYSIOLOGY glands secrete an organic substance that is odorless at first but
REVIEW is quickly metabolized by skin bacteria, causing the character-
istic odor commonly referred to as body odor (Tate, 2008).
As the external covering of the body, the skin performs the Intradermal injections, such as the TB skin test, are given in
vital function of protecting internal body structures from the dermis.
harmful microorganisms and substances. The skin is continu-
ous with mucous membranes at external body openings of
the respiratory tract, the digestive system, and the urogenital Subcutaneous Tissue
tract. As appendages of the skin, the hair and nails also have The subcutaneous tissue is primarily connective and adipose
protective functions. In addition to its vital protective role, (fatty) tissue. Here the skin is anchored to muscles and bones.
the skin also plays other roles in the normal functioning of An individual’s nutritional status and genetic makeup dic-
the human organism. These roles include participating in tate the amount of subcutaneous tissue present. Emaciated
the regulation of body temperature, functioning as a sensory persons have very little subcutaneous tissue, whereas obese
organ, helping to maintain fluid and electrolyte balance, pro- persons may have several inches of subcutaneous tissue. The
ducing vitamin D, and excreting certain waste products from amount of subcutaneous tissue is an important factor in body
the body. temperature regulation.

Structure of the Skin Functions of the Skin

The skin is composed of three layers: the epidermis, the der-
mis, and the subcutaneous fatty tissue (Figure 15-1). Understanding the functions of the skin and contiguous mucous
membranes guides the nurse in planning and implementing
appropriate nursing care. Because intact, healthy skin and
Epidermis mucous membranes serve as the first line of defense against
The epidermis is a layer of squamous epithelial cells. Most of harmful agents, maintaining skin integrity is one of the most impor-
the cells are keratinocytes that produce a tough, fibrous protein tant independent functions of the nurse. Nursing interventions
called keratin. As new cells are produced in the deep layers of such as providing daily hygiene care and regularly turning and
the epidermis, old cells are pushed to the surface of the skin. repositioning dependent clients are aimed at preventing skin
As these cells move from the deeper epidermal layers to the breakdown.
surface, they undergo a process of keratinization in which they
become filled with keratin, thus hardening the outer layer of
epidermal cells. The keratin creates a barrier that repels bacte- Protection
ria and foreign matter and is impermeable to most substances. The first and most important function of the skin is protection.
The epidermal cells on the palms of the hands and soles of the As long as the skin is intact and healthy, it is a barrier against
feet, areas of the body subjected to increased friction and pres- microorganisms and numerous substances that could be
sure, contain larger amounts of keratin, resulting in thickened harmful to the individual. Not only is the skin a barrier to keep
skin and callouses. harmful substances out, it is also a barrier to keep essential

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502 UNIT 6 Nursing Care of the Client: Body Defenses

Dermal papilla Hair shaft

Sensory nerve Sweat pore
Arrector pili muscle ending for touch

Epidermis

Dermis

Subcutaneous
fatty tissue
(hypodermis)

COURTESY OF DELMAR CENGAGE LEARNING

Sweat gland
(eccrine) Hair follicle

Artery Sebaceous (oil) gland

Vein Papilla of hair

Nerve

Figure 15-1 Cross Section of the Skin

substances such as water and electrolytes inside the body. It help protect the body from environmental dangers as well as
also cushions internal organs. provide sensations of comfort and pleasure. The brain then
processes the information and causes a response.
Temperature Regulation
The body produces heat as a result of metabolism of food. Fluid and Electrolyte Balance
Exercise, fever, or a hot environment can raise body tem- The skin helps maintain the stability of the internal environ-
perature. Through several mechanisms, the skin can either ment by preventing loss of body fluids and electrolytes and by
release or conserve body heat to maintain normal body preventing subcutaneous tissues from drying out. Skin dam-
temperature. Radiation is the primary means of heat loss. As age, such as that occurring with severe burns, results in rapid
body heat increases, arterioles in the dermis dilate, bringing loss of large quantities of fluid and electrolytes. This can lead
body heat to the skin surface. By the process of radiation, to shock, circulatory collapse, and death.
waves of heat from uncovered body surfaces are released to
the environment. Layering clothes in winter, for example,
helps prevent excess loss of body heat by radiation. Heat Structure and Function
is also lost by conduction. In conduction, heat is trans-
ferred from warmer surfaces to cooler ones. Placing a cool of Hair
washcloth on a client’s forehead is an example of using the Hair is composed of dead epidermal cells that begin to grow
principle of conduction. The washcloth becomes warmer, and divide in the base of the hair follicle. As the cells are
the forehead cooler. Evaporation is another way in which pushed toward the skin surface, they become keratinized and
excess body heat is lost. As moisture on the skin—either die. Hair color is genetically determined.
from perspiration or from a tepid sponge bath—dries, the Scalp hair grows for 2 to 5 years, then the follicle
body is cooled. To conserve (prevent excess loss) body becomes inactive. When the growth cycle begins again, a
heat, arterioles in the dermis contract to decrease the flow of new hair is produced and the old hair is pushed out. Approxi-
blood to the skin surface, thus decreasing heat lost by radia- mately 50 hairs are lost each day. Sustained hair loss of more
tion. The phenomenon of “goose flesh” is another method than 100 hairs each day usually indicates that something is
of conserving body heat. Tiny hairs standing on end create wrong.
a layer of air insulation decreasing loss of body heat to the There are 5 million hairs covering the entire human body
environment. except for the lips, palmar and plantar surfaces, nipples, and
the glans penis. The amount and texture of hair vary with age,
sex, race, and body part.
Sensory Perception Hair on the head protects the scalp from the ultraviolet
The skin contains receptors for pain, touch, pressure, and rays from the sun and cushions blows to the head. Eyelashes
temperature. The sensory receptors pick up information to help prevent foreign particles from entering the eyes just as the

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 CHAPTER 15 Integumentary System 503

hairs in the nostrils and external ear canals help keep particles
from entering the nose and ears. LIFE SPAN CONSIDERATIONS

Structure and Function Effects of Aging on the Skin

of Nails • Skin vascularity and the number of sweat

and sebaceous glands decrease, affecting
Nail production occurs in the nail root, an epithelial fold that thermoregulation.
cannot be seen from the surface (Figure 15-2). The nail plate
covers the nail bed. The blood vessels under the nail bed give • Inflammatory response and pain perception
the nails their pink color. diminish, increasing the risk of adverse effects
The nails protect the ends of the fingers and toes. from noxious stimuli.
• A thinning epidermis and prolonged wound

Structure and Function healing make the elderly more prone to injury
and skin infections.
of Mucous Membranes • Skin cancer is more common among the elderly.
Mucous membranes have epithelium overlying a layer of loose • Use of skin lotions containing alcohol can cause
connective tissue. Specialized cells within the mucous mem- drying of the skin, increasing the risk of injury.
brane secrete mucus. Moisture-enhancing products should be used
The cavities and tubes that open to the outside of the instead.
body are lined with mucous membranes. These include the
oral and nasal cavities and the tubes of the respiratory, gastro-
intestinal, urinary, and reproductive systems. Mucous mem-
branes perform absorptive or secretory functions depending
on their placement. and eventually comatose. Each summer many elderly persons
die from the effects of hyperthermia. Winter puts older adults
at risk for hypothermia, a condition in which the core body
Effects of Aging temperature drops below 95°F (35°C). The hypothermic cli-
ent may become confused and disoriented. As the core body
With advancing years, the blood flow to the skin is reduced. temperature continues to drop, the person becomes comatose.
The skin becomes thinner and is more easily injured. Older Each winter some older adults die from severe hypothermia
skin breaks down easily from prolonged pressure. The long- (Tate, 2008).
accepted rule of thumb is to turn clients every 2 hours, but On the hands and face, melanocytes increase in number,
for the ill older client, every 2 hours may not be often enough. causing the age spots commonly seen in older adults. Gray
Significant skin damage can occur in just 1 hour of unrelieved pres- hair occurs from a lack of melanin production. Skin exposed
sure. Preventing skin breakdown in the elderly client depends to sunlight ages faster.
on an accurate assessment of both the client’s skin condition
and mobility status.
Loss of subcutaneous tissue causes skin sagging and wrin-
kling. The activity of sebaceous and sweat glands diminishes, ASSESSMENT
resulting in dry skin and a decreased ability to adapt to changes Assessing clients with disorders of the integument includes
in environmental temperature. Extremes in temperature pose obtaining a health history and performing a physical assess-
hazards for older adults. In very hot weather, they are susceptible ment of the skin, hair, nails, and mucous membranes. The
to hyperthermia, a condition in which the core body tempera- nurse’s assessment skills, along with an understanding of
ture reaches 106°F (41.1°C). In hyperthermia, the hypothala- the anatomy and physiology of the integumentary system,
mus no longer functions appropriately. Sweating stops, the skin ensure a complete, factual database from which to plan and
becomes dry and flushed, and the person becomes confused implement appropriate nursing care. Box 15-1 contains a list
of questions to ask and observations to make in obtaining a
health history.
Eponychium
Nail body
Lunula
Assessment of Skin
Phalanx
Nail plate Nail root (bone of fingertip)
Hyponychium
Seven parameters should be examined when performing a
physical assessment of the skin. They are integrity, color,
temperature and moisture, texture, turgor and mobility,
COURTESY OF DELMAR CENGAGE LEARNING

sensation, and vascularity. Table 15-1 outlines these param-

eters with the normal and abnormal findings. Inspection
and palpation are the two assessment techniques used when
examining the skin. Good lighting is essential for accurate
assessment.
Any skin lesions should be identified according to type
and described regarding color, size, and location. Describe the
amount, color, odor, and appearance of any drainage that might
Figure 15-2 Structures of the Fingernail be present. Document assessment findings clearly, concisely,

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504 UNIT 6 Nursing Care of the Client: Body Defenses

BOX 15-1: QUESTIONS TO ASK AND OBSERVATIONS TO MAKE WHEN COLLECTING DATA
Subjective Data Objective Data
• When did you first notice this problem? • Check vital signs.
• Where did the first symptom appear? • Inspect color and integrity of skin.
• What did the rash/lesion look like when it first appeared? • Observe skin for rashes, lesions, moles, calluses,
• Describe what happened in the days/weeks after the tattoos, scars, and piercings.
first symptom appeared. • Inspect skin folds and creases.
• Are the symptoms worse at any particular time? Season? • Inspect skin for edema.
• Have you experienced any itching or burning sensa- • Observe for signs of bleeding and ecchymosis.
tions? • Observe hair distribution, quality, and texture.
• Are the lesions painful? • Inspect scalp for dryness and lesions.
• What do you think might have caused this problem? • Inspect nail curvature, color, thickness.
• Have you ever had a skin problem like this before? • Palpate skin for temperature, moisture, and
• Has anyone in your family ever had a problem like this? texture.
• What have you been doing to treat this problem? • Assess skin turgor.
• What kind of skin care products do you normally use? • Palpate the skin for pitting edema.
• Have you changed any of your usual products/ • Note any skin odor.
habits/routines? • Report diagnostic test results.
• Is there anything else you would like to tell me about
this problem?

Table 15-1 Skin Assessment Parameters

PARAMETER NORMAL ABNORMAL
Integrity Skin intact; no diseased or injured Broken skin; open areas such as fissures, ulcers, excoriations.
tissue Rash or lesions such as papules, nodules, vesicles, pustules,
wheals, scales (Figures 15-3 and 15-4).

Color Varies with skin type and race: pink, Pallor—pale skin, especially in face, conjunctiva, nail beds, and
tanned, olive, brown oral mucous membranes. Cyanosis—bluish discoloration noticed
in lips, earlobes, and nail beds. Jaundice—a yellowing of the
skin, mucous membranes, and sclera. Erythema—reddish hue to
the skin as in sunburn and inflammation or increased blood flow.

Temperature Usually warm and dry, depending Cool, cold, moist, clammy, or warmer than normal
and moisture on environmental temperature

Texture Smooth, soft. Thickness varies in Loose, wrinkled, rough, thickened, thin, oily, flaking, scaling
different areas.

Turgor and An assessment of skin hydration. Taut with edema; slack with dehydration; rigid in some diseases
mobility Normally skin moves freely. A such as scleroderma
pinched fold of skin returns
immediately to normal position
(Figure 15-5).
COURTESY OF DELMAR CENGAGE LEARNING

Sensation Distinguishes hot and cold, sharp Numbness, tingling, insensitive to pressure and sharp objects
and dull

Vascularity Clear; no discoloration Telangiectasia—permanent dilation of groups of superficial

capillaries and venules. Petechiae—pinpoint hemorrhagic spots.
Ecchymosis—large, irregular, hemorrhagic areas (Figure 15-6).

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 CHAPTER 15 Integumentary System 505

NONPALPABLE
A B

Macule: Patch:
Localized changes in skin Localized changes in skin
color of less than 1 cm color of greater than 1 cm
in diameter in diameter
Example: Example:
Freckle Vitiligo, stage 1 of pressure
ulcer

PALPABLE
C D
Papule:
Solid, elevated lesion less Plaque:
than 0.5 cm in diameter Solid, elevated lesion
Example: greater than 0.5 cm
Warts, elevated nevi, in diameter
seborrheic keratosis Example:
Psoriasis, eczema

E F
Nodules: Tumor:
Solid and elevated; however, The same as a nodule only
they extend deeper than greater than 2 cm
papules into the dermis or
subcutaneous tissues, 0.5–2 cm Example:
Example: Carcinoma (such as advanced
Lipoma, erythema nodosum, breast carcinoma); not basal cell
cyst, melamoma, hemangioma or squamous cell of the skin

G
Wheal:
Localized edema in the
epidermis causing irregular
elevation that may be red
or pale
Example:
Insect bite, hive, angioedema

FLUID-FILLED CAVITIES WITHIN THE SKIN

H I

Vesicle: Bullae:
Accumulation of fluid between Same as a vesicle only
the upper layers of the skin; greater than 0.5 cm
elevated mass containing Example:
serous fluid; less than 0.5 cm Contact dermatitis, large
Example: second-degree burns,
Herpes simplex, herpes bullous impetigo, pemphigus
zoster, chickenpox, scabies

J K
Pustule:
COURTESY OF DELMAR CENGAGE LEARNING

Vesicle or bullae that Cyst:

becomes filled with pus, Encapsulated fluid-filled or
usually described as less semi-solid mass in the
than 0.5 cm in diameter subcutaneous tissue or
Example: dermis
Acne, impetigo, furuncles, Example:
carbuncles, folliculitis Sebaceous cyst, epidermoid
cyst

Figure 15-3 Types of Primary Skin Lesions

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506 UNIT 6 Nursing Care of the Client: Body Defenses

ABOVE THE SKIN SURFACE

A B

Lichenification:
Scales:
Layers of skin become
Flaking of the skin's surface
thickened and rough as a
Example:
result of rubbing over a
Dandruff, psoriasis, xerosis
prolonged period of time
Example:
Chronic contact dermatitis

C D
Crust: Atrophy:
Dried serum, blood, or pus Thinning of the skin surface
on the surface of the skin and loss of markings
Example: Example:
Impetigo, acute Striae, aged skin
eczematous inflammation

BELOW THE SKIN SURFACE

E F

Erosion: Fissure:
Loss of epidermis Linear crack in the epidermis
Example: that can extend into the dermis
Ruptured chickenpox vesicle Example:
Chapped hands or lips,
athlete's foot

G H
Ulcer: Scar:
A depressed lesion of Fibrous tissue that replaces
the epidermis and upper dermal tissue after injury
papillary layer of the dermis Example:
Example: Surgical incision
Stage 2 pressure ulcer

COURTESY OF DELMAR CENGAGE LEARNING

I J
Keloid:
Enlarging of a scar past Excoriation:
wound edges due to excess Loss of epidermal layers
collagen formation (more exposing the dermis
prevalent in dark skinned Example:
persons) Abrasion
Example:
Burn scar

Figure 15-4 Types of Secondary Skin Lesions

and completely. The intent of nursing care is to maintain the Nails should be pink, smooth, and shiny and feel firm yet
integrity of intact skin and to restore damaged skin or mucous flexible when palpated. An angle of approximately 160° should
membranes to an intact state. Aging changes skin texture, be present between the nail body and the eponychium. Early
moisture, and mobility, requiring increased nursing vigilance clubbing is a nail angle of at least 180°. Clubbing occurs when
to maintain skin integrity. Daily hygiene products should be long-standing hypoxia is present, particularly with cyanotic
selected to meet the client’s individual skin care needs. heart disease and advanced chronic obstructed pulmonary
disease. Koilonychia, also known as “spoon nails,” is a sign of
Assessment of Hair, Nails, iron deficiency anemia, malnutrition, or trauma of the nail
and Mucous Membranes bed. The nails are thin and concave. Beau’s lines are white lines
across the nail seen with acute severe illness, malnutrition, or
Hair should be smooth, shiny, and resilient. Excess hair loss trauma. Paronychia is an infection of the nail caused by bacte-
can result from drugs, radiation, dietary or hormonal factors, ria or Candida albicans (Figure 15-7).
stress, and high fever. Mucous membranes normally appear pink and moist.

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 CHAPTER 15 Integumentary System 507

COURTESY OF DELMAR CENGAGE LEARNING

Figure 15-5 Assessment of Skin Turgor

COMMON DIAGNOSTIC TESTS

Commonly used diagnostic tests for clients with integumen-
tary disorders are listed in Table 15-2.

COURTESY OF DELMAR CENGAGE LEARNING

WOUNDS
A disruption in the integrity of body tissue is called a wound.

Physiology of Wound Healing

When an injury is sustained, a complex set of responses is set Figure 15-6 A, Telangiectasis (Spider Veins);
into motion, and the body begins a three-phase process of B, Ecchymosis (Bruise)
wound healing. Understanding these physiological responses
will assist the nurse in caring for clients with impaired skin in the affected area. Platelets, activated by the injury, aggregate
integrity and promoting optimal wound healing. to form a platelet plug and stop the bleeding. Activation of
the clotting cascade results in the eventual formation of fibrin
Defensive (Inflammatory) Phase and a fibrinous meshwork, which further entraps platelets and
The defensive phase occurs immediately after injury and lasts other cells. The result is fibrin clot formation, which provides
about 3 to 4 days. The major events that occur in this phase initial wound closure, prevents excessive loss of blood and
are hemostasis and inflammation. Hemostasis, or cessation body fluids, and inhibits contamination of the wound by
of bleeding, occurs by vasoconstriction of large blood vessels microorganisms.

Normal Nail Angle Clubbing

160°

Paronychia

Beau’s Lines
Koilonychia

Figure 15-7 Nail Variations (Photos of clubbing and Beau’s line courtesy of Robert A. Silverman, MD, Clinical Associate Professor,
Department of Pediatrics, Georgetown University; all other images courtesy of Delmar Cengage Learning.)

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508 UNIT 6 Nursing Care of the Client: Body Defenses

the same function as neutrophils but remain for a longer time.

Table 15-2 Common Diagnostic Tests In addition to being the primary phagocyte of debridement,
for Integumentary Disorders macrophages are important cells in wound healing because
they secrete several factors, including fibroblast activating
Biopsy (punch, incisional, excisional, shave) factor (FAF) and angiogenesis factor (AGF). FAF attracts
Patch testing fibroblasts, which form collagen or collagen precursors. AGF
stimulates the formation of new blood vessels. The develop-

COURTESY OF DELMAR CENGAGE LEARNING

Tzanck smear ment of this new microcirculation supports and sustains the
Immunofluorescence (IF testing) wound and the healing process.
Wood’s light examination
Skin scrapings
Reconstructive (Proliferative) Phase
The reconstructive phase begins on the third or fourth day
Culture and sensitivity after injury and lasts for 2 to 3 weeks. This phase contains the
process of collagen deposition, angiogenesis, granulation tis-
Inflammation is a nonspecific cellular response to tis- sue development, and wound contraction.
sue injury and involves both vascular and cellular responses. Fibroblasts, normally found in connective tissue, migrate
During the vascular response, tissue injury and activation of into the wound because of various cellular mediators. They are
plasma protein systems stimulate the release of various chemi- the most important cells in this phase because they synthesize
cal mediators, such as histamine (from mast cells), serotonin and secrete collagen. Collagen is the most abundant protein in
(from platelets), complement, and kinins. These vasoactive the body and is the material of tissue repair. Initially, collagen
substances cause blood vessels to dilate and become more per- is gel-like, but within several months it cross-links to form
meable, resulting in increased blood flow and leakage of serous collagen fibrils and adds tensile strength to the wound. As the
fluid into the surrounding tissues. The increased blood supply wound gains strength, the risk of wound separation or rupture
carries nutrients and oxygen, which are essential for wound is less likely. The wound can resist normal stress such as ten-
healing, and transports leukocytes to the area to participate sion or twisting after 15 to 20 days. During this time, a raised
in phagocytosis, or the envelopment and disposal of microor- “healing ridge” may be visible under the injury or suture line.
ganisms. The increased blood supply also removes the “debris Angiogenesis (formation of new blood vessels) begins
of battle,” which includes dead cells, bacteria, and exudate within hours after the injury. The endothelial cells in pre-
(material, fluid, and cells slowly discharged from cells or blood existing vessels begin to produce enzymes that break down
vessels). The area is red, edematous, and warm to touch, and it the basement membrane. The membrane opens, and new
has varying amounts of exudate. endothelial cells build a new vessel. These capillaries grow
During the cellular response, leukocytes move out of the across the wound, increasing blood flow, which increases the
blood vessel into the interstitial space. Neutrophils are the supply of nutrients and oxygen needed for wound healing.
first cells to arrive at the injured site and begin phagocytosis. Repair begins as granulation tissue, or new tissue, grows
They subsequently die and are replaced by macrophages, inward from surrounding healthy connective tissue. Granula-
which arise from blood monocytes. Macrophages perform tion tissue is filled with new capillaries that are fragile and
bleed easily, thus giving the healing area a red, translucent,
granular appearance. As granulation tissue is formed, epitheli-
alization, or growth of epithelial tissue, begins. Epithelial cells
migrate into the wound from the wound margins. Eventually,
PROFESSIONALTIP the migrating cells contact similar cells that have migrated
from the outer edges. Contact stops migration. The cells then
Possible Signs of Physical Abuse begin to differentiate into the various cells that comprise the
different layers of epidermis.
Areas of ecchymosis are one sign of trauma that Wound contraction is the final step of the reconstructive
could be the result of physical abuse. Injuries noted phase of wound healing. Contraction is noticeable 6 to 12 days
at the base of the skull or on the face, buttocks, after injury and is necessary for closure of all wounds. The
breasts, abdomen, or any area such as the top edges of the wound are drawn together by the action of myo-
of the back that the client could not reach, are fibroblasts, specialized cells that contain bundles of parallel
suspicious for abuse. Unusual marks on the skin
fibers in their cytoplasm. These myofibroblasts bridge across
a wound and then contract to pull the wound closed.
such as cigarette burns and belt buckle or bite
marks may also be signs of abuse. Injuries that are
inconsistent with the client’s story may also be the Maturation Phase
result of abuse. Maturation, the final stage of healing, begins about the 21st
Institutional policies generally relate to reporting
day and may continue for up to 2 years or more, depending
on the depth and extent of the wound. During this phase, the
and to whom to report when the situation of
scar tissue is remodeled (reshaped or reconstructed by col-
possible physical abuse is encountered. This is lagen deposition and lysis and debridement of wound edges).
usually based on state laws about reporting Although the scar tissue continues to gain strength, it remains
physical abuse. Nurses must know the reporting weaker than the tissue it replaces. Capillaries eventually disap-
laws of the state in which they are employed. pear, leaving an avascular scar (a scar that is white because it
lacks a blood supply).

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 CHAPTER 15 Integumentary System 509

Types of Healing Factors Affecting Wound

Tissue may heal by one of three methods, which are charac-
terized by the degree of tissue loss. Primary intention healing
Healing
occurs in wounds that have minimal tissue loss and edges Wound healing depends on multiple influences, both intrinsic
that are well-approximated (closed). If there are no complica- and extrinsic. Wounds may fail to heal or may require a longer
tions, such as infection, necrosis, or abnormal scar formation, healing period when unfavorable conditions exist. Factors that
wound healing occurs with minimal granulation tissue and may negatively influence healing include age, oxygenation,
scarring. smoking, drug therapy, and diseases such as diabetes. Such
Secondary intention healing is seen in wounds with exten- factors reduce local blood supply and impair wound healing.
sive tissue loss and wounds in which the edges cannot be Nutrition and diet can also affect the healing process.
approximated. The wound is left open, and granulation tis-
sue gradually fills in the deficit. Repair time is longer, tissue Hemorrhage
replacement and scarring are greater, and the susceptibility to Some bleeding from a wound is normal during and immediately
infection is increased because of the lack of an epidermal bar- after initial trauma and surgery, but hemostasis usually occurs
rier to microorganisms. within a few minutes. Hemorrhage is abnormal and may indicate
Tertiary intention healing, also known as delayed or sec- a slipped surgical suture, a dislodged clot, or erosion of a blood
ondary closure, is indicated when primary closure of a wound vessel. Swelling in the area around the wound or affected body
is undesirable. Conditions in which healing by tertiary inten- part and the presence of sanguineous, bloody, drainage from the
tion may occur include poor circulation or infection. Suturing surgical drain may indicate internal bleeding. Other evidence
of the wound is delayed until the problems resolve and more of bleeding may include the signs and symptoms seen in hypo-
favorable conditions exist for wound healing. volemic shock (decreased blood pressure, rapid thready pulse,
increased respiratory rate, diaphoresis, restlessness, and cool
clammy skin). A hematoma (localized collection of blood under-
Kinds of Wound Drainage neath the tissues) may also be seen and appears as a reddish-blue
Chemical mediators released during the inflammatory swelling or mass. External hemorrhaging is detected when the
response cause vascular changes and exudation of fluid and surgical dressing becomes saturated with sanguineous drainage.
cells from blood vessels into tissues. Exudates may vary in It is also important to assess the linen under the client’s wound
composition, but all have similar functions. These functions site because it is possible for the blood to seep out from under the
include the following: sides of the dressing and pool under the client. The risk for hem-
orrhage is greatest during the first 24 to 48 hours after surgery.
• Dilution of toxins produced by bacteria and dying cells
• Transport of leukocytes and plasma proteins, including
antibodies, to the site
Infection
• Transport of bacterial toxins, dead cells, debris, and other Bacterial wound contamination is one of the most com-
products of inflammation away from the site mon causes of altered wound healing. A wound can become
infected with microorganisms preoperatively, intraoperatively,
The nature and amount of exudate vary depending on the or postoperatively. During the preoperative period, the wound
tissue involved, the intensity and duration of the inflamma- may become exposed to pathogens because of the manner in
tion, and the presence and type of microorganisms. which the wound was inflicted, such as in traumatic injuries.
Serous exudate is composed primarily of serum (the Nicks or abrasions created during preoperative shaving may
clear portion of blood), is watery in appearance, and has a low also be a source of pathogens. The risk for intraoperative expo-
protein level. This type of exudate is seen with mild inflamma- sure to pathogens increases when the respiratory, gastrointes-
tion, resulting in minimal capillary permeability changes and tinal, genitourinary, and oropharyngeal tracts are opened.
minimal protein molecule escape (e.g., seen in blister forma- If the amount of bacteria in the wound is sufficient or the
tion after a burn). client’s immune defenses are compromised, clinical infection
Purulent exudate is also called pus. It generally occurs may result and become apparent 2 to 11 days postoperatively.
with severe inflammation accompanied by infection. Purulent Infection slows healing by prolonging the inflammatory phase
exudate is thicker than serous exudate because of the presence of healing, competing for nutrients, and producing chemicals
of leukocytes (particularly neutrophils), liquefied dead tissue and enzymes that are damaging to the tissues.
debris, and dead and living bacteria. The process of pus forma-
tion is called suppuration, and bacteria that produce pus are
referred to as pyogenic bacteria. Purulent exudates may vary in Wound Classification
color (e.g., yellow, green, brown) depending on the causative Many different classification systems are used to describe
organism. wounds. These systems describe either how the wound was
Hemorrhagic exudate or sanguineous exudate has a acquired, how clean it is, or which tissue layers are involved.
large component of red blood cells (RBCs) because of capil- A classification system will assist the nurse in planning wound
lary damage, which allows RBCs to escape. This type of exu- care management. The following are commonly used classifi-
date is usually present with severe inflammation. The color of cation systems.
the exudate (bright red versus dark red) reflects whether the
bleeding is fresh or old.
Mixed types of exudates may also be seen, depending on Cause of Wound
the type of wound. For example, a serosanguineous exu- Intentional wounds occur during treatment or therapy. These
date is clear with some blood tinge and is seen with surgical wounds are usually made under aseptic conditions. Examples
incisions. include surgical incisions and venipunctures.

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510 UNIT 6 Nursing Care of the Client: Body Defenses

Unintentional wounds are unanticipated and are often Size

the result of trauma or an accident. These wounds are created
in an unsterile environment and therefore pose a greater risk The length (head to toe), width (side to side), and depth of a
of infection. wound are measured in centimeters. Single-use measurement
guides (tape measures) often come with dressing supplies.
To determine the depth of a wound, a sterile cotton swab,
Cleanliness of Wound moistened with 0.9% saline solution, is inserted into the deep-
This classification system ranks the wound according to its est point of the wound and marked at the skin surface level.
contamination by bacteria and risk for infection (Brunicardi, Then the swab can be measured and the wound depth in cen-
Anderson, Billiar, & Dunn, 2005). timeters documented. Tunneling, also called undermining,
• Clean wounds are intentional wounds that were created can be measured by using a cotton swab to gently probe the
under conditions in which no inflammation was wound margins. If tunneling is noted, the location and depth
encountered and the respiratory, alimentary, genitourinary, are documented. For clarity in describing the location of the
and oropharyngeal tracts were not entered. tunneling, the hands of the clock can be used as a guide, with
• Clean-contaminated wounds are intentional wounds that 12 o’clock pointing at the client’s head. Example: “Tunneling
were created by entry into the alimentary, respiratory, occurs at 1 o’clock and its depth is 2 cm.”
genitourinary, or oropharyngeal tract under controlled
conditions. General Appearance and Drainage
• Contaminated wounds are open, traumatic wounds or A general description of the color of the wound and surround-
intentional wounds in which there was a major break ing area helps determine the wound’s present phase of heal-
in aseptic technique, spillage from the gastrointestinal ing. Gently palpate the edges of the wound for swelling, and
tract, or incision into infected urinary or biliary tracts. document the amount, color, location, odor, and consistency
These wounds have acute nonpurulent inflammation of any drainage.
present.
• Dirty and infected wounds are traumatic wounds with Pain
retained dead tissue or foreign material or intentional Document and notify the physician of any pain or tenderness
wounds created in situations where purulent drainage was at the wound site. Pain may indicate infection or bleeding. It
present. is normal to experience pain in a surgical incision wound for
approximately 3 days. Report any sudden increase in pain
Depth of Wound accompanied by changes in the appearance of the wound to
The third classification system is based on the depth of the the physician immediately.
wound, taking into account the skin layers involved.
• Superficial wounds are confined to the epidermis layer, Laboratory Data
which comprises the four outermost layers of skin. Cultures of wound drainage are used to determine the pres-
• Partial-thickness wounds involve the epidermis and part ence of infection and the identity of the causative organism.
of the dermis, which is the layer of skin beneath the The sensitivity results list the antibiotics that will effectively
epidermis. treat the infection. An elevated WBC count indicates an
• Full-thickness wounds involve the entire epidermis and infectious process. A decreased leukocyte count may indicate
dermis. Deeper structures such as fascia, muscle, and bone that the client is at increased risk for developing an infec-
may be involved. tion related to decreased defense mechanisms. Albumin is
a measure of the client’s protein reserves; if the albumin is
decreased, the client will have decreased resources of protein
Assessment for wound healing.
Nurses are confronted with wounds that are extremely diverse.
The wound may have occurred traumatically just before the Nursing Diagnoses
client presents to the emergency room, or the wound may Nursing diagnoses for clients with wounds focus on preven-
be a slow-healing chronic ulcer. Approach wound assessment tion of complications and promotion of the healing process
systematically, evaluating the wound’s stage in the healing pro- through proper wound care and client teaching. Following
cess. Show sensitivity to the client’s pain and tolerance levels are NANDA-approved nursing diagnoses with a partial list of
during assessment and always follow Standard Precautions to related factors:
prevent transfer of pathogens. Following are some basic crite-
ria for wound assessment. • Impaired Tissue Integrity related to surgical incision,
pressure, shearing forces, decreased blood flow,
immobility, mechanical irritants
Location
• Risk for Infection related to malnutrition, decreased defense
Assessment begins with a description of the anatomical loca- mechanisms
tion of the wound (e.g., “5-inch suture line on the right lower
quadrant of the abdomen”). This task often becomes difficult • Acute Pain related to inflammation, infection
if the client has multiple wounds close to each other, as is • Disturbed Body Image related to changes in body appearance
common in burn or multiple-trauma victims. Use of a skin secondary to scars, drains, removal of body parts
documentation form that incorporates drawings of the body • Deficient Knowledge (Wound Care) related to lack of
allows the nurse to number the location of the various wounds exposure to information, misinterpretation, lack of interest
and then describe them. in learning

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 CHAPTER 15 Integumentary System 511

Planning/Outcome granulation tissue as possible. Choice of cleansing agent depends

on the physician’s prescription as well as agency protocol. It is
Identification recommended that isotonic solutions such as normal saline or
After identifying the nursing diagnoses, establish targeted lactated Ringer’s be used to preserve healthy tissue.
outcomes for wound healing based on the client’s identified
needs and individualized to the client’s condition. Changes Dressing the Wound
in the health care delivery system have brought about early A dressing serves several purposes:
discharge from the hospital, so clients are often sent home
with wounds that need continued care; the goals for clients 1. To protect the wound from bacterial contamination
with wounds generally focus on promoting wound healing, 2. To promote homeostasis
preventing infection, and educating the client. 3. To provide a moist environment to enhance epithelial-
ization
Implementation 4. To support healing by absorbing drainage
5. To enhance debridement of the wound
Nursing interventions to promote wound healing and prevent
infection include emergency measures to maintain homeosta- 6. To provide thermal insulation of the wound
sis (state of internal constancy of the body), and cleansing and 7. To provide splinting or support of the wound site
dressing of the wound. 8. To shield the client from seeing the wound when
perceived as unpleasant
Emergency Measures Keeping these purposes in mind, determine an appropriate
Assess the type and extent of injury that the client has sus- dressing for the client’s wound. There are thousands of different
tained. If hemorrhage is detected, apply sterile dressings and wound care products on the market. The physician may pre-
pressure to stop the bleeding, and notify the physician imme- scribe a specific dressing, or follow agency policy. Remember
diately. Always implement Standard Precautions. Monitor the that dressing plans must be modified as the wound changes.
client’s vital signs frequently.
When dehiscence or evisceration occurs, instruct the client Monitoring Drainage of Wounds
to remain quiet and avoid coughing or straining. Position the cli- During the inflammatory response, exudates develop within
ent to prevent further stress on the wound. Use sterile dressings, a wound. When excessive drainage accumulates in the wound
such as ABD pads soaked with sterile normal saline, to cover the bed, tissue healing is delayed. If the outer surface is allowed to
wound and internal contents. This reduces the risk of bacterial heal while the drainage remains entrapped within the wound,
contamination and drying of the viscera. Notify the surgeon infection and abscess may form. To facilitate drainage of any
immediately and prepare the client for surgical repair of the area. excess fluid, the physician may insert a tube or drain.

Cleansing the Wound Other Therapies

The goal of cleansing the wound is to remove debris and bac- Negative-pressure wound therapy, also called vacuum-assisted
teria from the wound bed with as little trauma to the healthy closure (VAC), increases healing rates. It supports the wound-
healing efforts of the body by increasing cellular proliferation,
reducing edema around the wound, and providing a moist,
protected wound bed.
PROFESSIONALTIP Biodebridement or maggot debridement therapy (MDT)
is mainly used for chronic wounds. Maggots ingest and digest
Wound Cleansing bacteria and dead tissue, thus they debride and disinfect the
wound. This decreases wound odor. Maggots excrete a vari-
Following are the major principles to keep in mind ety of substances, such as calcium carbonate and urea that
when cleansing a wound: promotes granulation tissue formation. The Food and Drug
• Use Standard Precautions at all times. Administration regulates MDT since only certain types of
• When using a swab or gauze to cleanse a maggots are therapeutic. The first intentional use occurred
wound, work from the clean area out toward during the Civil War (Hunter, Langemo, Thompson, Hanson,
the dirtier area. For example, when cleaning a & Anderson, 2009). Unintentional use can occur if flies are
surgical incision, start over the incision line, and allowed to land on open wounds.
swab downward from top to bottom. Change
Electrical stimulation helps speed healing by increasing
capillary density and perfusion, improving wound oxygen-
the swab and proceed again on either side of
ation, and encouraging fibroblast activity and granulation.
the incision, using a new swab each time. Placement of the electrodes varies with the stage of healing. A
• When irrigating a wound, warm the solution physical therapist determines electrode placement and polar-
to room temperature, preferably to body ity (Ramadan & Zyada, 2008).
temperature, to prevent lowering of the
tissue temperature. Be sure to allow the
irrigant to flow from the cleanest area to
Evaluation
Evaluate the client’s achievement of the goals established during
the contaminated area to avoid spreading the planning phase to achieve or maintain skin integrity. Goals
pathogens. for clients with wounds generally focus on wound healing, pre-
vention of infection, and client education. If the goals are not

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512 UNIT 6 Nursing Care of the Client: Body Defenses

achieved, examine the nursing interventions and strategies that are partial-thickness (within the epidermis/dermis) burns.
were employed and revise the nursing care plan accordingly. First-degree burns involve only the epidermis. The skin is hot,
Review techniques and procedures, especially those performed red, and painful. Sunburn is an example of a first-degree burn.
by the client or other caregivers in the client’s support system. First-degree burns heal in about a week without scarring. Sec-
ond-degree burns damage the dermis and the epidermis. The
skin is red, hot, and painful; blisters form and tissue around
BURNS the burn is edematous. An example of a second-degree burn

B
is spilling boiling water on the skin. Usually, second-degree
urns are among the most devastating injuries an individual burns heal in about 2 weeks without scarring; however, if deep
can suffer. Burns can be painful and disfiguring, requiring layers of the dermis are involved, healing might take months
long hospitalizations. Many are fatal. Most burns occur in the and scarring can occur. Second-degree burns involving deep
home and are preventable. Often, the burn injury is the result layers of the dermis may appear white, tan, or red in color.
of the individual’s own action. Feelings of anger and guilt can When the dermis and epidermis are completely destroyed
complicate recovery. Often, the individual suffers self-image and deeper tissues are involved, burns are classified as full-
disturbances, and family relationships can be strained. thickness burns. Third-degree and fourth-degree burns are
full-thickness burns. In third-degree burns all dermal structures
Major Causes are destroyed and cannot be regenerated. Subcutaneous tissue
is also damaged. Full-thickness burns can be white, tan, brown,
There are many different causes for burns to the skin. A major
source of burn injury for all ages is overexposure to the sun. black, charred, or bright red in color. Fourth-degree burns,
Most burn injuries to adults are associated with cigarette which extend to the underlying muscles and bones, appear
smoking and cooking. The elderly are more likely to spill hot white to black or charred with dark networks of thrombosed
liquid on themselves or catch their clothes on fire as they cook capillaries visible inside the wound. Fourth-degree burns
or smoke. Young children are especially prone to burn injuries result from fires, explosions, and nuclear radiation. Figure 15-8
from spilling scalding liquids on themselves and playing with depicts the various layers of skin involved in burn injuries.
matches or cigarette lighters. Industrial accidents account for a Severely burned individuals generally have both partial-
significant number of burn injuries in young adults. thickness and full-thickness burns. Whereas first- and second-
degree burns are painful, third- and fourth-degree burns are
Severity not painful because sensory nerve endings are destroyed. The
client, however, will still be in severe pain. Body movement
Burns are classified according to the depth of the burn and the causes pain in areas of first- and second-degree burns that
extent of skin surface involved. First- and second-degree burns often surround the full-thickness burns. Skin can regenerate

A B C D
Epidermis
Dermis
Epidermis Epidermis Epidermis
Dermis Dermis Subcutaneous
tissue
Subcutaneous
Muscle
tissue
and bone

Charring; skin white to black

with networks of thrombosed
Skin red, dry Blistered; skin moist, pink or red Charring; skin black, brown, red capillaries

First degree, Second degree, Third degree, Fourth degree,

superficial partial thickness full thickness full thickness

Figure 15-8 Skin Layers Involved in Burn Injuries; A, First-Degree Burn; B, Second-Degree Burn; C, Third-Degree Burn;
D, Fourth-Degree Burn (Photos courtesy of the Phoenix Society of Burn Survivors, Inc.)

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 15 Integumentary System 513

only from the edges of full-thickness burns. Scarring is inevita- For years, documenting the extent of burn injuries was
ble. Skin grafting is necessary to promote healing because the done by using the Rule-of-Nines method to estimate the body
section of skin destroyed by the burn cannot regenerate itself. surface area burned for adults. The body is divided into areas
Prognosis in burn cases depends on the severity of the that are about 9% (or multiples of 9%). The head comprises
burn, the surface area of the body burned, and the preinjury 9% (4.5% anterior and 4.5% posterior). Each arm is 9% (4.5%
health status of the individual. Local tissue injury response anterior and 4.5% posterior). The anterior trunk and posterior
from burns becomes systemic when more than 20 percent of trunk are each 18%. Each leg is 18% (9% anterior and 9% pos-
the body is involved. These clients have an increased suscepti- terior). The genitalia comprise the remaining 1%.
bility to multiple organ failure and sepsis. The most frequent More recently, Milner (2001), inventor of the “Burn
burn related problem is inhalation injury, and it has the most Wheel” (Figure 15-9), incorporated a chart similar to the
significant effect on survival (Grunwald & Warren, 2008). Rule-of-Nines. His chart has a specific percentage for the
Elderly burn victims whose physiologic reserves are already upper and lower parts of the arms and legs and for the hands
reduced as an effect of aging will have an extended recovery and feet, making a more accurate assessment. One side is for
period and a greater risk of complications. infants and children; the other side is for adults.

Adult 8
mls
9000

WEIGHT BURNS
7 7875
HOURS
FLUID
6 6750
5 5625
Kg SINCE 4 4500
%
90
BURN 3
2
3375
2250 DEFICIT 50

1 1125
0–8 1125 CONTINUATION
9–24 565
FLUIDS
FOR USE ONLY WITH RINGERS LACTATE

THE BURN WHEEL

INSTRUCTIONS CHART FOR ESTIMATING
SURFACE AREA OF BURN
WEIGHT
1. ESTIMATE/MEASURE THE PATIENT’S WEIGHT
Kg
TO THE NEAREST 10Kg (1lb = 0.45Kg).
41/2 41/2
BURNS
2. ESTIMATE TOTAL BURN AREA (TO THE NEAREST 10%) %
USING THE CHART SHOWN.

3. ALIGN WHEEL SO THAT THE CORRECT VALUES APPEAR 2 13 2 2 13 2

IN THE BOXES MARKED “WEIGHT” AND “BURNS”.
11/2 11/2
11/2 11/2
4. ADMINISTER THE VOLUME OF FLUID IN THE DEFICIT
DEFICIT
COLUMN FOR THE TIME ELAPSED SINCE BURN. 1 21/2 21/2
mls 11/4 11/4
DEDUCTING ANY FLUID ALREADY GIVEN. 11/4 11/4
(THIS SHOULD BE GIVEN WITHIN A MAXIMUM OF TWO HOURS.) 43/4 43/4
43/4 43/4
5. AT THE SAME TIME START TO ADMINISTER THE
CONTINUATION
AMOUNT OF FLUID GIVEN IN THE CONTINUATION
COLUMN EACH HOUR. mls 31/2 31/2 31/2 31/2
(NOTE THAT THE AMOUNT OF HOURLY FLUID INFUSION CHANGES
BETWEEN THE PERIODS OF 0–8 HOURS AND 9–24 HOURS POST BURN)

13/4 13/4
NAME 13/4 13/4

TIME OF TYPE
FLUID ALREADY GIVEN:
BURN VOLUME mls IGNORE SIMPLE ERYTHEMA

ADULT CHART

Burn Concepts, Inc.

P.O. Box 1049
Galveston, TX 77553
Phone / Fax (409) 762-4004
This device is designed for initial fluid resuscitation in emergency situations.
IMPORTANT: Please contact a specialist as soon as possible.
This device uses fluid calculations based on standard burn formulas. © 1994 STEPHEN M. MILNER, PATENT PENDING

Figure 15-9 Burn Wheel (Invented by Stephen M. Milner.)

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514 UNIT 6 Nursing Care of the Client: Body Defenses

Complications Medical–Surgical
Destruction of the skin renders it unable to fulfill its func- Management
tions. Vast amounts of internal fluids and electrolytes are lost.
The ability to maintain body temperature is altered, and the Medical
individual is susceptible to serious infections. Initially, the Immediate Care Initially, medical management of the client
complications that are the most life threatening are respiratory involves keeping an open airway, maintaining an adequate level
failure and massive loss of body fluids. of oxygenation, replacing body fluids and electrolytes, monitor-
ing kidney function, controlling pain, and protecting the burns
Smoke Inhalation and Carbon Monoxide with sterile dressings to minimize the loss of body temperature
Poisoning and the risk of infection. In cases of severe burns, the client
usually requires endotracheal intubation and administration of
Heat and smoke can cause serious damage to the respiratory 100% humidified oxygen. A multiport central venous catheter or
tract. Signs and symptoms of potential respiratory tract dam- two large-bore peripheral venous catheters are needed for fluid
age include facial burns, singed nasal hairs, changes in voice, and electrolyte replacement. A Foley catheter is inserted and
difficulty breathing, wheezing, coughing, and carbon-tinged urine output measured hourly to help monitor kidney function.
sputum (National Institutes of Health, 2008a). Inhaling heat Pain is controlled with small intravenous doses of mor-
and smoke in a closed-space fire causes airway inflammation phine. Emotional and psychological trauma can intensify pain
and edema of the respiratory mucosa. The carbon-monoxide perception. The client will be anxious about survival, physical
that is inhaled along with the heat and smoke attaches to hemo- appearance, and the effect this injury will have on the family.
globin, forming the compound carboxyhemoglobin. A high Prophylactically, the client is given tetanus toxoid.
level of carboxyhemoglobin in the blood means that oxygen
is not being delivered to vital body tissues. The client may be Stabilized Care Once the client’s condition has been stabi-
stuporous because of cerebral anoxia. Keeping an open airway lized, care focuses on promoting healing, preventing compli-
and administering 100% humidified oxygen are essential for cations, controlling pain, and restoring function. Preventing
treating these two conditions. Intubation is often necessary. infection is an important priority. Burn wounds may require
daily cleansing and dressing changes. Because of the nature
Shock of the injury, burn wounds contain a large amount of dead
Severely burned clients may experience both hypovolemic tissue along with fluids and proteins, making them highly
shock (a life-threatening condition caused by massive loss susceptible to infection even with the best of care. Antibiot-
of blood and circulating fluids) and neurogenic shock (a ics and strict aseptic technique are essential. The dead tissue
form of shock that occurs when peripheral vascular dilation of full-thickness burns forms a dry, dark leathery eschar
occurs causing hypotension). Fluids and electrolytes must be (a scab of denatured protein) within 48 to 72 hours. Infection
replaced as fast as they are being lost. Tremendous amounts can often begin under the eschar, causing tissue sloughing.
of fluids are lost through the burn wounds themselves as well Loose eschar must be debrided before skin grafting can occur.
as into surrounding tissues in the form of edema. The fluid Debriding, removing dead and damaged tissue or foreign mate-
loss shock that results can lead to circulatory collapse and rial within the burn wound, can sometimes be done mechani-
renal shutdown. The Burn Wheel was developed for use in cally by hydrotherapy. Burn wounds may require surgical
hospitals and emergency departments (EDs) because the first debridement. The base of the wound must be free of infection
24 hours after a burn injury are crucial (Milner, 2001). The and necrotic tissue before it can be covered with skin grafts.
Burn Wheel uses the client’s weight (in Kg) along with the Use of specialty beds, such as fluidized or alternating
percentage of area burned to identify the amount of Ringer’s air-filled mattresses, minimizes pressure on skin surfaces, thus
lactate solution to be given IV within 2 hours and the amount promoting comfort. Limiting movement and maintaining
to be continued for 24 hours. Use of the wheel takes seconds normal body alignment with the use of splints can also help
to determine fluid replacement, whereas remembering and alleviate client discomfort.
figuring formulae may take much longer and mistakes can be
easily made. At least two large-bore venous catheters are used Surgical
to give large volumes of fluid rapidly. Skin grafts cover the burn wound to promote healing. Four
types of skin grafts might be used:
Infection 1. Autograft—the client’s own skin that is removed from
Once the client has been stabilized, infection poses a serious risk. an unburned area and applied to the wound
Staphylococcus aureus, an ever-present organism in the environ- 2. Homograft—skin obtained from a cadaver within 6 to
ment, is a common cause of infections. Of grave concern is an 24 hours after death
infection caused by methicillin-resistant Staphylococcus aureus
(MRSA) because this strain of staphylococcus is resistant to all 3. Heterograft—skin obtained from an animal, such as a pig
antibiotics except vancomycin hydrochloride (Vancocin). This
antibiotic has serious side effects, especially to the otic nerve
and to the liver, and is used only when other antibiotics fail. INFECTION CONTROL
All persons coming into contact with the burn client must
wear gowns, gloves, masks, and caps to help prevent the intro- Debridement
duction of organisms such as S. aureus, Pseudomonas aeruginosa,
or coliform bacilli, into burn wounds. Sterile technique is used Strict aseptic techniques must be followed dur-
for wound care and dressing changes. Care in special burn units ing burn debridement procedures.
reduces the chance of infection because of stringent infection
control precautions and a carefully controlled environment.
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 CHAPTER 15 Integumentary System 515

4. Synthetic skin substitute—a manmade product that has effective against S. aureus. It is not absorbed systemically and
properties similar to skin (Fritsch & Yurko, 2003) has a low incidence of sensitivity.
Homografts, heterografts, and synthetic skin substitutes Antibiotic ointments are used to decrease infection.
are temporary grafts that facilitate healing. These grafts pre- Neomycin sulfate (Myciguent) and gentamicin sulfate (Garamy-
vent water, electrolyte, and protein loss. They decrease pain cin) can be absorbed systemically and have serious side effects
and allow more freedom of movement for the client. When the of ototoxicity and nephrotoxicity. Bacitracin (Baciguent) has
client’s condition is stable and the wound beds have healthy minimal antimicrobial activity, but it is especially useful to pre-
granulation tissue (delicate connective tissue consisting of vent drying of the wound. Topical agents must be applied in a
fibroblasts, collagen, and capillaries), permanent closure of thin layer with a sterile glove. The wound may be left open to
the burn wounds is done with autographs. Granulation tissue air or covered with a gauze dressing, depending on the proper-
is red and provides a base for healing (Tate, 2008). ties of the medication and the physician’s orders. Application
Autografts are taken from areas of healthy skin. They may be of these medications can be painful because of manipulation of
either split-thickness grafts or full-thickness grafts. Split-thickness the burned tissue. Administration of pain medication may be
grafts include the epidermis and part of the dermis. They are not necessary before providing wound care. The surrounding skin
so deep as to prevent regeneration of skin at the donor site. should be assessed for any allergic rashes.
The application of pressure dressings during the reha-
bilitative phase reduces the development of hypertrophic Diet
scarring, a condition in which the scar becomes elevated and After experiencing a moderate to severe burn, the client’s need
has a “Swiss cheese” appearance. Pressure dressings, which for calories and protein increases. Actual protein loss occurs
may be elastic wraps, stockinettes, or custom-made pressure with the burn injury itself, and some protein is metabolized to
garments, must be worn constantly and are to be removed meet the increased energy requirements brought on by stress.
only for daily hygiene care. Full maturation of the burn scar For tissue repair and healing, daily protein needs of the client
may take 1 to 2 years. As the physical wounds heal, so do the increase significantly. Twice the normal caloric requirement
emotional and psychological wounds. The client’s ability to may be needed to meet the body’s energy needs. Supplemen-
cope with daily stresses and resume social and work activities tal vitamins and minerals are given.
typically coincides with the physical healing process. Initially, the client’s daily nutritional needs may be met
with total parenteral nutrition (TPN) because of a paralytic
Pharmacological ileus and gastric dilation. Following a severe burn, decreased
Dressing changes, wound debridement, as well as any movement enteric circulation leads to slowed or stopped peristalsis. Food
or manipulation, are extremely painful for clients. Many clients and fluids cannot be given orally or by tube feeding until peri-
become extremely anxious, fearing pain as well as permanent stalsis is restored. Hearing active bowel sounds is one indica-
disfiguration and loss of function. Intravenous narcotics, usually tion of peristaltic activity in the bowel. Immobility, stress, and
morphine, may be administered 10 to 15 minutes before proce- the negative nitrogen balance brought on by protein catabo-
dures. By decreasing anxiety and fear, daily doses of psychotropic lism depress appetite. Curling’s ulcer may develop. Meeting
drugs can enhance the effectiveness of pain medications and help the client’s nutritional needs can be a challenge. Six to eight
the client cope with the prospect of long-term rehabilitation. small feedings daily and high-protein milkshakes or protein
Treatment of the burn wound with topical agents can supplements can help meet daily nutritional needs. Involving
decrease infection and promote healing. Common topical the family in bringing in favorite foods can also stimulate the
agents used are mafenide acetate (Sulfamylon); silver sulfadi- client’s appetite.
azine (Silvadene); povidone-iodine (Betadine); nitrofurazone
(Furacin); and antibiotic agents such as neomycin sulfate Activity
(Myciguent), bacitracin (Baciguent), and gentamicin sulfate Contractures, among the most serious complications of
(Garamycin). Mafenide acetate (Sulfamylon) can penetrate severe burns, can be prevented with a program of positioning,
thick eschar and is effective against gram-negative and gram-
positive organisms, including P. aeruginosa. Silver sulfadiaz-
ine (Silvadene) is effective against many gram-positive and
gram-negative organisms as well as Candida organisms. It is PROFESSIONALTIP
painless and somewhat soothing but may cause a skin rash.
Povidone-iodine (Betadine) has broad-spectrum microbial Serving Meals
action against a wide variety of bacteria, fungi, yeasts, viruses,
and protozoa. Application of povidone-iodine (Betadine) to Serve foods attractively and put an occasional
large open areas could lead to elevated serum iodine levels. small “surprise” on the tray (e.g., a flower, a small,
Nitrofurazone (Furacin) has broad-spectrum activity and is brightly colored seasonal decoration, a funny card)
so that the client will look forward to meals.

INFECTION CONTROL
CRITICAL THINKING
Skin Grafts
Burns and Self-Image
Follow strict aseptic care of both the donor sites
and the newly grafted burn wounds to prevent
How might a person’s self-image be affected when
infection.
the person has burns on the face, arms, or legs?

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516 UNIT 6 Nursing Care of the Client: Body Defenses

or enteral tube feedings, monitor client’s reaction to feedings.

LIFE SPAN CONSIDERATIONS Assess abdomen for bowel sounds. Use pillows and splints,
if ordered, to keep client’s body in good alignment and turn
Burn Injuries in the Elderly and reposition every 2 hours. Perform passive ROM exercises
when able. Explain the healing process to the client and fam-
• Normal physiologic changes that occur with ily. Provide opportunities for the client to express feelings.
aging delay recovery and put the older adult at Listen actively. Encourage the client to look at the wounds to
greater risk for complications following a burn see evidence of healing. Maintain an open, honest approach
injury. with the client and family. Assist client and family to prepare
• As a person ages, the physiologic reserves of for discharge.
organ systems decrease.
• While the older person may have
adequate pulmonary and cardiac functions
at rest, the stress of a severe burn can leave
NURSING PROCESS
the body unable to cope with demands
for increased oxygen and increased cardiac
Assessment
output. Subjective Data
• Renal changes that occur with aging, such as Observe for emotional reactions such as anger, self-conscious-
decreased renal blood flow, fewer nephrons, ness, embarrassment, or isolation. Clients with burns are likely
and a decreased glomerular filtration rate, put
to be frightened and anxious. Feelings of guilt, anger, and
depression are also common following burns. Ask the client
the older adult at higher risk for kidney failure
to describe the pain according to location, intensity, and dura-
after a severe burn. tion, and also to rate the pain on a scale of 0 to 10. Hypoxia
• With loss of subcutaneous tissue and decreased or fluid and electrolyte imbalances can cause confusion, dis-
secretion of sebum, the older person’s skin is orientation, and decreased level of consciousness. The client
normally more fragile. may be nauseated.
• Circulation, especially in the lower extremities,
may already be compromised, so healing will be
delayed. Objective Data
• Skin-grafting procedures may not be successful Assess vital signs, level of consciousness, and breath sounds.
because of impaired circulation and impaired If the client has a productive cough, the amount, consistency,
tissue nutrition. and color of sputum should be noted. Black/gray sputum indi-
cates smoke inhalation. Clients with smoke inhalation may
also have crackles, wheezing, or diminished breath sounds.
Observe burn wounds for signs of infection such as redness,
swelling, purulent drainage, and a foul odor. Measure urine
splinting, exercising, and ambulating. When repositioning, the output hourly. Monitor intake and output and daily weight.
client’s body must be kept in correct alignment. Use pillows Routinely check for bowel sounds. As rehabilitation pro-
to keep limbs in alignment and splints on limbs to prevent gresses, continue to assess wounds for signs of healing, such as
contractures or to immobilize joints following skin grafting. a moist, clean, red wound base and decrease in the size of the
Range-of-motion exercises maintain joint mobility. Whenever wound. Note the client’s mobility status and degree of involve-
possible, encourage active rather than passive range-of-motion ment in care. Assess daily dietary intake. Monitor laboratory
exercises. Active exercise increases circulation, maintains joint test results for the following:
flexibility, and improves muscle tone. As the client recovers, • Red blood cell count and hemoglobin level give
activities of daily living can be increased and ambulation can information about the body’s ability to meet oxygen
be initiated. demands of body tissues and organs.
• Creatinine and blood urea nitrogen as well as urine
Nursing Management
specific gravity give information about kidney
function.
Immediate care includes establishing an airway and adminis- • Total protein and albumin levels yield information about
tering oxygen. (The physician often inserts an endotracheal the ability to maintain the volume of circulating fluid as
tube). Initiate IV fluid therapy with Ringer’s lactate solution. well as information about nutritional status.
Insert a Foley catheter and monitor output, which should be • White blood cell count indicates the presence of infection
30 to 50 mL per hour. Administer analgesic IV as ordered. and the body’s ability to fight it.
Monitor vital signs, noting respiratory pattern, effort, and
breath sounds. Assess pulse oximetry, client’s color, and level • Wound culture and sensitivity data indicate the specific
of consciousness. Accurately record I&O. Monitor client’s organisms causing infection and the specific antibiotics
laboratory results, especially electrolytes. effective against these organisms.
When the client is stabilized, continue monitoring vital • Electrolytes yield information about the homeostasis of
signs, I&O, respiratory pattern, daily weight, and for pain. body fluids. Alterations in pH and electrolyte levels affect
Strictly follow Standard Precautions. Monitor wounds for cell function in every body tissue, particularly vital body
signs of infection. Assess mental status. If client is on TPN organs such as the heart and cerebrum.
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 CHAPTER 15 Integumentary System 517

Nursing diagnoses for a client with a burn injury include the following.
Initially, the greatest dangers to the client will be:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Gas Exchange The client will achieve a Monitor the client’s vital signs every 4 hours if stable; otherwise,
related to edema and regular respiratory pattern every 1 to 2 hours. Listen to breath sounds, especially noting
inflammation of the and oxygen saturation level respiratory pattern and effort.
respiratory tract >90%. If the client is on continuous oximetry, note the oxygen
saturation reading each time vital signs are assessed. Assess
the client’s color and level of consciousness.
Document assessments and keep the physician informed about
the client’s condition.
Elevate the head of the bed 30 degrees to facilitate full chest
expansion with each breath.

Deficient Fluid Volume The client will maintain Administer intravenous fluids at the ordered rate.
related to increased electrolytes within normal Monitor for signs and symptoms of fluid overload such as
capillary permeability limits and an hourly urine shortness of breath, crackles auscultated in lung bases,
with loss of large output >30 mL per hour. changes in heart rate and/or heart sounds, changes in blood
amounts of fluid through pressure, increased anxiety, or changes in mental status.
open burn wounds Measure urine output hourly, report outputs below 30 mL to the
physician. Record intake and output. Involve the client and family
in keeping a bedside record of fluid intake.
Weigh client daily, preferably before breakfast, and in the same
type of clothing each day.
When the client can tolerate oral fluids, set a fluid intake goal
for each shift (e.g., 1,200 mL during the day; 800 mL during the
evening; 500 mL during the night).
Explain to the client and family the reasons for a high fluid
intake. Involve family members in helping the client achieve the
fluid maintenance goal. Keep fluids available at the bedside,
including, within dietary restrictions, the client’s favorite fluids.
Monitor for signs and symptoms of electrolyte imbalances
such as increased muscle weakness, muscle cramps, cardiac
arrhythmias, fatigue, nausea, dizziness.
Monitor the client’s laboratory results.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

During the stabilization and recovery period after a burn, the nursing
diagnoses include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Infection The client’s burn wounds Wash hands with an antibacterial skin cleanser before and
related to risk factors will exhibit signs of healing after gloving. Wear clean gloves when giving client care.
of tissue destruction without serious or life- Wear an isolation gown over your uniform when giving client care.
and inadequate primary threatening infections. Whenever the client’s wounds are exposed, wear gown, cap,
defenses mask, and sterile gloves.
Use sterile technique for wound care and dressing changes.
Monitor wound daily for signs of infection: redness, swelling,
purulent drainage, pain.
Assess for signs of systemic infections.
Observe for increased pulse and respirations, decreased
blood pressure, fever, and any changes in mentation such as
disorientation and delirium.
(Continues)

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518 UNIT 6 Nursing Care of the Client: Body Defenses

During the stabilization and recovery period after a burn, the nursing
diagnoses include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Note urinary output and assess for hypoactive bowel sounds.
Monitor the client’s white blood cell count.
Assist client with personal hygiene, and keep noninjured areas
of the body clean.

Acute Pain related to The client will verbalize Assess for pain every 2 to 4 hours by asking client to rate pain
physical injury that pain is controlled at a level on a scale of 0 to 10. Observe for nonverbal signs of pain
tolerable level. such as grimacing or crying.
Administer pain medications as ordered, especially prior to
wound care or exercise and mobilization activities.
Monitor and document response to medications.
Implement comfort and diversional measures:
a. Reposition client; use pillows or foam supports to keep all
body parts in good alignment.
b. Teach client to use progressive relaxation exercises or to
use guided imagery.
c. Encourage the client to use diversionary activities of his
choice such as television or music, or place him so that
he can see into the hallway.

Imbalanced Nutrition: The client will ingest If the client is currently on TPN or enteral tube feedings,
Less than Body sufficient calories daily to administer the ordered nutrients at the correct rate and closely
Requirements, related meet increased metabolic monitor the client’s reaction.
to increased caloric needs. When oral intake is tolerated, encourage the client to eat 90%
requirements and to 100% of daily diet.
difficulty ingesting Provide oral hygiene before meals to stimulate salivation and
sufficient quantities of eliminate any bad taste in the client’s mouth.
food
Give 6 to 8 small feedings daily of the client’s favorite foods
within dietary restrictions and encourage family members to
bring in home-prepared foods and to eat with the client.
When permitted, encourage the client to sit up in a chair for
each meal.
Plan care so that painful procedures are not done immediately
before meals. A rest period of 20 to 30 minutes before meals
helps the client feel more like eating.
Determine the time of day when the client feels most like
eating and does indeed eat most of the meal, and serve the
highest calorie/protein nutrients at that time.

Impaired Physical The client will participate Perform passive ROM exercises 4 times a day by supporting
Mobility related to pain in daily activity to maintain the limb above and below the joint and performing exercises
and decreased muscle joint mobility and prevent slowly and smoothly.
strength contractures. As the client is able, have him perform active ROM exercises
every 3 to 4 hours.
Turn and reposition the client every 2 hours. Use small pillows
and foam supports to keep the client’s body in good alignment.
Use splints as ordered by the physician to keep hands, wrists,
feet, and ankles in natural alignment and explain the reason for
these activities to the client.
As healing and rehabilitation progress, encourage progressive
ambulation and self-care activities.

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 CHAPTER 15 Integumentary System 519

During the stabilization and recovery period after a burn, the nursing
diagnoses include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Gradually guide and assist the client to resume activities of
daily living (ADLs).
Encourage family members to participate in ADLs and provide
positive reinforcement as the client becomes involved in his care.

Disturbed Body Image The client will state Provide time for the client to express feelings (fear, anger,
related to change in realistic expectations for frustration, regret, and depression are commonly expressed by
physical appearance with recovery and participate in clients with burns) and practice active listening.
loss of body tissues or rehabilitation. Explain the healing process to the client. Give the client daily
body parts updates on the degree of wound healing and on his progress
in rehabilitation.
Encourage the client to look at the wounds to see evidence
of healing. Stress that wound healing following serious burn
injuries proceeds slowly and that complete healing with
improved skin appearance may take a year or more.

Interrupted Family The client and family Involve family members in the client’s care and encourage
Processes related to the members will verbalize daily visits.
shift in health status of a feelings to nurses and each Encourage family members to express their fears and
family member other and will participate in concerns, especially any feelings of anger, blame, or guilt.
client care. Guide family members in recognizing and reflecting to the
client small, step-by-step progress that is made.
Maintain an honest, open approach with the client and family
but do not give false reassurance.
Collaborate with counselor, social worker, and chaplain to help
the client and family cope with the condition.
Assist the family to appraise the situation and plan for
discharge. What is at stake? What is realistic for the future?
What can they expect during the rehabilitation phase? What
are their choices? Where can they get help?

Evaluation: Evaluate each outcome to determine how it has been met by the client.

NEOPLASMS: MALIGNANT ■ BASAL CELL CARCINOMA

S kin cancer is one of the most common malignant neo-

plasms in the United States and is the most preventable
cancer. In 2009, the American Cancer Society estimates
B asal cell carcinoma, the most frequent type of skin cancer,
arises from the basal cell layer of the epidermis. Prolonged
sun exposure, poor tanning ability, and previous therapy with
more than one million new diagnoses of basal cell carcinoma x-rays for facial acne are risk factors for basal cell carcinoma
(approximately 800,000–900,000) and squamous cell carci- (Figure 15-10). Metastasis is rare.
noma (approximately 200,000–300,000) in the United States It is generally found on the face and upper torso, and is
(American Cancer Society [ACS], 2008a). Approximately scaly in appearance. As the disease develops, it extends into
68,720 new diagnoses of melanomas are expected to occur in the dermis and may form an open ulcer. Surgical removal
2009 (ACS, 2008b). These are the three most common skin cures this type of cancer.
cancers.
Skin lymphoma is another type of malignancy. Exposure ■ SQUAMOUS CELL CARCINOMA

S
to the sun is the leading cause of skin cancer. Skin damage
from sun exposure is cumulative. The ability of skin to tan quamous cell carcinoma appears as a nodular lesion in the
is not fully developed until the teenage years, meaning that epidermis. It is much less common than basal cell carci-
most of the long-term skin damage from sun exposure occurs noma. Risk factors include prolonged sun exposure and expo-
during childhood. By age 20, most adults have already experi- sure to gamma radiation and x-rays. The sun-exposed lower lip
enced significant skin damage; however, it takes 10 to 20 years is a common site for squamous cell carcinoma. Without treat-
before unprotected sunbathing results in skin cancer. ment, it can extend into the dermis and ultimately metastasize

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520 UNIT 6 Nursing Care of the Client: Body Defenses

Figure 15-10 Basal Cell Carcinoma (Courtesy of Robert Figure 15-11 Squamous Cell Carcinoma (Courtesy of
A. Silverman, MD, Clinical Associate Professor, Department of Robert A. Silverman, MD, Clinical Associate Professor,
Pediatrics, Georgetown University.) Department of Pediatrics, Georgetown University.)

to other body tissues, causing death (Figure 15-11). Treatment, independent of mole existence. Any mole that looks signifi-
for squamous cell carcinoma may be by excision of lesion, cantly different from other moles present on the body whether
electrodesiccation (cautery) and curettage (scraping of lesion), or not it has always been present should be examined carefully,
cryosurgery (freezing with liquid nitrogen), Mohs surgery (a photographed, followed, and/or biopsied.
microscopic surgical procedure of removing layers of cancer- The incidence of malignant melanoma is increasing in
ous tissue with very high rates of success), radiation therapy, the United States as a result of increased sun exposure and use
lymph node dissection, and/or chemotherapy (ACS, 2008c). of artificial ultraviolet light (tanning lights/beds). Clearly, the
best hope of preventing skin cancer lies in education. Limiting
sun exposure (and artificial ultraviolet light) and using sun-
■ MALIGNANT MELANOMA screen at least SPF 15 on exposed skin markedly reduce dam-

I
age from ultraviolet rays and ultimately decrease the risk of
n malignant melanoma, atypical melanocytes are present in skin cancer. Figure 15-12 shows lentigo malignant melanoma.
both the dermis and epidermis. Malignant melanoma is the
most serious of the three types of skin cancers and may begin
in a preexisting mole (nevus). These moles have an irregular ■ CUTANEOUS T-CELL
shape. Contrasted to normal moles, they are larger than 6 mm
in diameter and do not have a uniform color (see ABCD rule). LYMPHOMA

C
Malignant melanoma can metastasize to every organ in the
body through the bloodstream and lymphatic system. utaneous T-cell lymphoma is also known as mycosis
Melanoma is more common in fair-skinned individuals fungoides and skin lymphoma. It is a malignant disease
and occurs most often on the trunk of males and the lower legs involving T-helper cells that has both skin manifestations and
on females, but can occur on any area of the body and in all multiple organ system manifestations. In the early stages, it
skin tones. Malignant melanomas can arise from a mole that resembles psoriasis or seborrheic dermatitis. Later, fissures
has been present for a client’s entire life as well as from skin and skin ulcers develop. Pruritus can be severe. Even if the

MEMORYTRICK

ABCD rule: Usual warning signs for melanoma

A = ASYMMETRICAL – Both halves of the mole or
birthmark do not match.
B = BORDER – Borders are irregular, blurred, or.
notched.
C = COLOR – Color is uneven, in different shades
of black, brown, or red, white or blue.
D = DIAMETER – Diameter is greater than
6 mm (¼ inch).

The most significant warning sign is a mole or

birthmark that is changing in size, shape, or color
Figure 15-12 Lentigo Malignant Melanoma (Courtesy of
over time (ACS, 2009e). Robert A. Silverman, MD, Clinical Associate Professor,
Department of Pediatrics, Georgetown University.)
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 CHAPTER 15 Integumentary System 521

skin condition can be improved with topical steroids and che-

motherapeutic agents, the disease is ultimately fatal because of NEOPLASMS: NONMALIGNANT

B
the involvement of vital organ systems. Clients with AIDS can
develop cutaneous T-cell lymphoma. enign tumors of the skin include a variety of lesions
such as skin tags, lipomas, keloids, sebaceous cysts, nevi
Medical–Surgical Management (moles), and angiomas. In general, they do not require medi-
cal or nursing intervention except for cosmetic reasons or
Surgical unless they are subject to continual irritation that might pre-
Treatment is determined by the size of the lesion, the type of dispose to a break in skin integrity and infection. Lipomas
neoplasm, and the stage of the disease. The primary treatment (benign, fatty tumors) or sebaceous cysts (distended seba-
is surgery: a simple excision or a wide excision (removing skin ceous glands filled with sebum) might cause pressure on sur-
in a large area around the lesion), amputation if on fingers rounding nerves or interfere with normal body function. In
or toes, and/or lymph node dissection if lymph nodes are these instances they would be surgically removed. A keloid is
enlarged or a sentinel node biopsy confirms the presence of abnormal growth of scar tissue that is elevated, rounded, and
malignant cells. If indicated, chemotherapy may be used either firm with irregular, clawlike margins. Surgical removal is not
systemically or directly into the affected extremity. By inject- always successful; healing following surgery can again result
ing chemo into an artery of the affected limb, high doses are in a keloid. Steroids or radiation have been helpful in some
targeted to the tumor area without affecting the entire body. conditions. Angiomas, commonly known as birthmarks, are
Radiation therapy may also be used (ACS, 2009d). With early vascular tumors involving skin and subcutaneous tissue. They
detection, melanoma can be successfully treated, but presently can be raised, bright red nodular lesions (strawberry birth-
there is no cure with advanced melanoma. Melanomas have a marks) or dark red/purple patches (port-wine angiomas).
rapid rate of metastasis. Cosmetics can be used to camouflage them. Laser treatments
are being used on some angiomas with some success.
Nursing Management
Careful assessment of the client’s skin can reveal suspicious INFECTIOUS DISORDERS
skin lesions. Clients with blue eyes, fair complexion, blonde or OF THE SKIN

G
red hair, and freckles have the greatest risk. Clients who have
had one skin cancer are likely to have more. Early referral and iven an accessible portal of entry and decreased host
prompt care can ensure a good prognosis. Because most skin resistance, virulent organisms can invade the skin, caus-
cancers are treated by excision, client teaching and follow-up ing inflammation, infection, itching, and pain. Bacteria, viruses,
care focus on proper wound care to promote healing and fungi, or parasites can cause infectious disorders of the skin
prevent infection. Many clients will experience body image (Figure 15-13). Treating the client’s disease is only one aspect
disturbance; the nurse can help the client cope with this. All of the treatment plan; preventing the spread of infection is
other nursing care should be focused on prevention. the other. Table 15-3 outlines several disease conditions and

A B C

D E F

Figure 15-13 Infectious Disorders of the Skin; A, Impetigo Contagiosa; B, Herpes Zoster (Shingles); C, Herpes Simplex Type 1;
D, Tinea Corporis (Ringworm); E, Scabies; F, Pediculosis (Head Lice) (Images A, B, C, D and E courtesy of Robert A. Silverman, MD,
Clinical Associate Professor, Department of Pediatrics, Georgetown University; image F courtesy of Hogil Pharmaceutical Corporation.)
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522 UNIT 6 Nursing Care of the Client: Body Defenses

Table 15-3 Infectious Disorders of the Skin

DISEASE ORGANISM CLINICAL MANIFESTATIONS MANAGEMENT
Bacterial Infections

Impetigo Staphylococcus Begins as a small vesicle; becomes Cleanse the affected area at least
contagiosa aureus weeping lesion; forms a light brown crust. 3 times a day. Apply an antibiotic
Usually on the face and upper trunk (Figure ointment. Occasionally, systemic
15-13A). More common in children. More antibiotics are needed.
common in spring and fall. Poor hygiene
coupled with warm weather facilitates the
spread of the disease.

Carbuncle Staphylococcus Begins as infected hair follicles in the dermis. Warm, moist soaks may help “bring
aureus Symptoms are redness, swelling, pain. the boil to a head.” Once the carbuncle
Yellow cores of pus develop. Carbuncles ruptures or is incised and drained,
usually occur on the nape of the neck and pain subsides. Carbuncles tend to
upper back. Obese or malnourished persons recur. The Staphylococcus organism
with poor hygiene as well as diabetics are may be resistant to topical antibiotics.
most susceptible to carbuncles. Systemic antibiotics may be needed.

Viral Infections

Herpes zoster V-Z (varicella- Clusters of small vesicles over the course Acyclovir (Zovirax), valacyclovir
(shingles) zoster) of a peripheral sensory nerve. Two-thirds (Valtrex), or famciclovir (Famvir) may
of clients have lesions just in the thoracic be given to clients in severe pain
region. Lesions can occur over the or to immunosuppressed clients.
trigeminal nerve, affecting the face, scalp, Analgesics help control the pain.
and eyes (Figure 15-13B). Crusts develop Narcotic analgesics are prescribed
in several days. Symptoms are mild to for severe pain. Antipruritic topical
severe pain, itching, fever, malaise. In older medications decrease the itching.
adults, pain can last for months or years. Shingles (herpes zoster) vaccine
Persons who have not had chickenpox is recommended for adults 60 and
risk contracting the disease if they care for older even if they have had shingles
herpes zoster clients with open lesions. in the past (Harvard Health Letter,
Persons who previously had chickenpox, 2008).
but developed only partial immunity to it,
may still be susceptible to herpes zoster.

Herpes simplex, Herpes simplex Type 1—a cluster of vesicles on an Topical use of antiviral agents
Type 1 (fever virus erythematous base occurring most such as acyclovir decreases
blisters, cold commonly at the corners of the mouth discomfort. Even with treatment,
sores) (Figure 15-13C) or at the edge of the nostrils. cold sores and fever blisters tend
Type 2 (genital) Type 2—lesions in the vagina or cervix of a to recur, especially with fever, upper
woman or on the penis of a man. The lesions respiratory infections, and stress.
itch, burn, and frequently break open, forming Oral administration of acyclovir helps
a crust. Healing occurs in about 10 days. prevent recurrence of genital herpes.

Warts Human Seen as small, painless round papules No treatment is indicated for painless
papillomavirus on hands, face, and neck. On the bottom warts; they tend to disappear
of the feet, warts grow inward from the eventually. Plantar warts may be
pressure and are painful (plantar warts). removed by cryosurgery or with locally
Warts in the anogenital region itch. Genital applied chemicals such as nitric acid.
warts increase the risk of cervical cancer. Warts are not highly contagious from
person to person but may be spread
on the person’s own body by rubbing
or scratching. Genital warts are
spread by sexual intercourse.

(Continues)

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 CHAPTER 15 Integumentary System 523

Table 15-3 Infectious Disorders of the Skin (Continued)

DISEASE ORGANISM CLINICAL MANIFESTATIONS MANAGEMENT
Fungal Infections

Tinea (ringworm) Microsporum Tinea is a superficial infection of the Treat mild infections with a topical
Tinea capitis audouini skin called ringworm because of its antifungal drug such as miconazole
(ringworm of the circumscribed appearance, typically round, nitrate (Micatin) or tolnaftate (Aftate).
scalp) and reddened with slight scaling (Figure Severe infections are treated with
15-13D). Lesions of tinea corporis have a oral administration of griseofulvin
Tinea corporis pale center. Itching is common with tinea microsize (Grisactin).
(ringworm of the cruris. Itching and burning occur with tinea
body) pedis. Tinea is spread easily. Jock itch and
Tinea cruris (jock athlete’s foot are more common among
itch) Tinea pedis men than women.
(athlete’s foot)

Parasitic Infections

Scabies Sarcoptes The itch mite burrows under the skin, lays Apply the scabicide, lindane (Kwell),
scabiei (female eggs, and deposits fecal material. Short, topically to the entire body at bedtime
itch mite) dark-red wavy lines may be seen on hands, so that the medication remains on
wrists, elbows, axillary folds, nipples, the skin 8 to 12 hours. Treat all family
waistline, and gluteal folds (Figure 15-13E). members even if they do not have
Pruritis is severe and can persist for up to symptoms. Wash all underclothing
3 months after treatment. Scratching leads and bed and bath linens in hot water
to secondary infection. Scabies is spread and dry in dryer. Change linens daily.
by prolonged contact and is frequently Items that cannot be washed should
seen in several members of a family. be dry cleaned.

Pediculosis (lice) Pediculus Eggs, or nits, of pediculosis capitis attach Lindane (Kwell) is applied topically
capitis (head themselves firmly to a hair shaft on the to the hair as a shampoo or to the
lice) head or in a beard (Figure 15-13F). Nits body as a cream or lotion. Repeat
Pediculus have a gray, pearly appearance. The pubic the treatment again in 8 to 10 days.

COURTESY OF DELMAR CENGAGE LEARNING

corporis (body louse resembles a tiny crab that attaches Wash or dry clean clothing and
lice) itself to pubic hair. Body lice live in the linens. Disinfect combs and brushes.
seams of clothing. The bite of the louse Vacuum carpets and furniture;
Phthirus Pubis causes severe pruritis. Scratching leads to then spray with a pediculicide. All
(pubic lice) secondary infection. nits must be removed to prevent
reinfection.

identifies the organism responsible, clinical manifestations, of not scratching lesions. Provide emotional support to client
and the management for each disorder. and family. Encourage expression of feelings.

Nursing Management
Teach the client and family about preventing the spread of NURSING PROCESS
infection. Follow Standard Precautions. Stress the importance
Assessment
Subjective Data
CRITICAL THINKING Ask the client how long the problem has existed, if there is
any itching or pain, and what treatment has been used. Clients
Preventing Spread of Skin with infectious disorders of the skin may feel shame or embar-
Infections rassment because of stigmas attached to some of these condi-
tions, so also note the client’s mood.
How can the spread of skin infections be pre-
vented? Prepare a teaching plan for a client with a
Objective Data
skin infection. A complete skin assessment is performed, describing the size,
appearance, and distribution of all lesions, as well as any drain-
age, itching, odor, or pain present.
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524 UNIT 6 Nursing Care of the Client: Body Defenses

CLIENTTEACHING
Herpes Zoster
• Take the full course of prescribed medications.
• Use topical measures along with NSAIDs for pain management.
• Avoid persons who have not had chickenpox, especially pregnant women, so they do not get chickenpox.
• When dark crusts form over pustules, the client is no longer contagious.
• In older adults, pain may last for months or years.

Nursing diagnoses for a client with an infectious disorder of the skin include
the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Skin Integrity The client will regain skin Wear gloves when caring for the client with skin lesions.
related to invasion of skin integrity. Cleanse the skin thoroughly, but gently. In the case of bacterial
structures by pathogenic infections or lesions with secondary infections, use an
organisms antibacterial soap. Gently remove crusts, scales, and traces
of old medication before applying fresh creams or lotions.
Administer prescribed medications; apply creams and lotions;
then monitor their effectiveness.
Explain what you are doing and why.

Acute Pain, related to The client will report less Instruct client to keep the environmental temperature cool
itching, burning, and pain. because warmth increases itching; also cleanse skin lesions
infection with tepid water, not hot.
Stress the importance of not scratching the lesions.

Disturbed Body Image The client will verbalize a Encourage client to ask questions and to talk about feelings.
related to unsightly positive body image. Provide positive reinforcement as the client learns to care for
skin lesions and the skin lesions. When possible, suggest ways to camouflage
embarrassment the lesions or minimize their appearance.
When there is no danger of spreading the infection, encourage
client to participate in social and work activities.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Scabies
E.E., 68, has had a skin rash for the past 2 weeks. The dark red lesions occur mainly on her hands, wrists, and el-
bows, around her nipples, at her waistline, and in her gluteal folds. The itching has become increasingly intense.
She states that she has been scratching the lesions, sometimes until they are open and bleeding. Upon examina-
tion, some of the lesions are open with small amounts of serosanguineous drainage. Other lesions are scabbed.
She lives with her daughter and two teenaged granddaughters. Because the lesions were getting steadily worse,
her daughter finally convinced her to seek medical attention. She was horrified when the doctor told her that
she had scabies. She had always associated “the itch” with “dirty people who didn’t take care of themselves.”

NURSING DIAGNOSIS 1 Impaired Skin Integrity related to scratching scabies lesions as evidenced
by open lesions draining serosanguineous fluid, scabbed lesions, and client statements of scratching the
lesions until they bleed
(Continues)

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 CHAPTER 15 Integumentary System 525

SAMPLE NURSING CARE PLAN (Continued)

Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Tissue Integrity: Skin & Mucous Membranes Skin Care: Topical Treatments
Self-Care: Hygiene Skin Surveillance

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

E.E. will follow the Instruct E.E. to cleanse lesions Reduces the number of microorganisms
prescribed treatment carefully using an antibacterial soap present and decreases the risk of infection.
protocol to promote and tepid water. The lesions can be Tepid water does not intensify itching as hot
healing of skin lesions cleaned 1 to 3 times daily. water does.
and regain skin integrity. Teach E.E. to apply antipruritic lotions as Lotions applied just after bathing help to
prescribed by the doctor after cleansing retain skin moisture.
the skin.
Instruct E.E. to keep fingernails short Less likely to break the skin if the client
with smooth edges. scratches.
Teach E.E. to press itching lesions, and Stimulates nerve endings and reduces the
not to scratch them. sensation of itching. Prevents breaks in the
skin, which would be portals of entry for
microorganisms.
Explain that itching can persist up to Skin reaction to the toxins and secretions of
3 months following treatment with the itch mite can persist for up to 3 months
the scabicide but persistent itching after the itch mites are killed by the
does not mean that treatment was scabicide.
ineffective.
Keep room temperature between Itching is intensified in hot, humid
68° and 72°F and humidity constant environments.
at 30% to 35%.

EVALUATION
E.E.’s lesions are still red, but none are open and draining. Some lesions are still scabbed. No new open
lesions have developed. E.E. states that the recommended measures “help,” but that the itching is still
“pretty bad.” Goal of promoting healing of skin lesions is being met. Encourage E.E. to continue outlined
protocols. Reassure her that itching will gradually subside as healing progresses.

NURSING DIAGNOSIS 2 Deficient Knowledge (infection control measures), related to lack of

familiarity with treatment and prevention protocols as evidenced by client’s inability to recognize the skin
lesions as infectious and by statements about scabies happening only to people with poor hygiene
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Knowledge: Infection Control Teaching: Disease Process
Teaching: Prescribed Medication

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

E.E. will apply the Assess E.E’s knowledge of scabies, Provides a frame of reference for
scabicide correctly and its treatment regimen and infection the client, helping her relate new
state ways to avoid control measures. Ask specific information and integrate it into her
spreading infection to questions. behavior.
others.
(Continues)

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526 UNIT 6 Nursing Care of the Client: Body Defenses

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Explain that scabies is transmitted Teaching that does not “talk down” to
by skin-to-skin contact or by the client communicates respect.
contact with articles freshly
contaminated by infected persons,
and affects persons of all social,
economic, and age levels.
Stress the importance of following Failure to apply the scabicide as directed
treatment protocol exactly. Review and/or failure to leave the lotion on the
salient points such as (1) shower skin for the prescribed length of time will
before applying the scabicide; not kill the itch mite.
(2) apply the scabicide to the
entire body surface, including skin
without scabies lesions; and (3)
apply the scabicide at bedtime so
that the medication remains on
the skin 8 to 12 hours.
Give E.E. step-by-step written Enhances compliance with the treatment
instructions. regimen.
Instruct E.E. to wash hands under Thorough handwashing is the single most
warm running water with plenty effective means of preventing the spread
of soap (preferably an antibacterial of infection. Large numbers of bacteria
soap) for at least 10 seconds reside under the fingernails.
after touching lesions and clean
carefully under fingernails while
washing hands.
Advise E.E. not to share washcloths, Disease-causing microorganisms can
towels, clothing, pillows, or bed be spread to well individuals indirectly
linens with other family members. when their skin comes into contact with
contaminated items.
Instruct E.E. to wash underclothing Soap reduces surface tension. When
and bed and bath linens in fat or protein substances that shield
detergent and hot water and dry organisms are broken down, the
outside in sunlight or in a dryer on organisms are exposed to the killing
the hot setting. effects of heat. Prolonged exposure
to heat or ultraviolet rays from direct
sunlight kills microorganisms.
Advise E.E. to shower daily, use an Reduces the number of microorganisms
antibacterial soap, rinse thoroughly, on the skin. Moisture encourages
and dry carefully, especially in skin the growth of microorganisms.
folds and between toes, using a Laundering the towel and washcloth
towel and washcloth only once after only one use prevents the indirect
before laundering it. transfer of the itch mite.

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 CHAPTER 15 Integumentary System 527

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Assess lesions daily for signs Increases the probability of effective
of healing. Report any signs treatment with fewer complications.
and symptoms of infection in
secondary lesions such as redness,
swelling, pain, drainage (describe
characteristics of the drainage) to
the physician or clinic.
Teach E.E. and family members Early recognition and treatment of
the early signs and symptoms scabies can minimize the severity of the
of scabies infection, such as any infection.
reddened papules with wavy,
threadlike lines visible on the skin
around the papules and severe
itching, especially at night.
Instruct them to assess their skin A daily examination allows treatment
daily. to begin as soon as the problem is
identified.

EVALUATION
E.E. and her family did apply the scabicide as prescribed. The client can describe how scabies are
transmitted but continues to express fear that she will give “this awful thing to somebody.” Goal of
correctly applying scabicide met. Although E.E. can state how scabies are transmitted, she still has doubts;
hence, the goal of stating ways to avoid spreading the infection to others has only been partially met.
Reinforce that even though red skin lesions are still visible, the itch mites were killed by treatment and
cannot be transmitted to others even if the client does shake hands, hug, or touch someone else.

NURSING DIAGNOSIS 3 Disturbed Body Image related to unsightly lesions and embarrassment as
evidenced by distribution of lesions on exposed skin areas and client statements of being horrified about
the diagnosis and associating scabies with “dirty people”
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Body Image Anxiety Reduction
Mutual Goal Setting

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

E.E. will assume self-care Explain that by using the scabicide, Reassurance that scabies can be cured
of lesions. lindane (Kwell), as directed and enhances the client’s self-image.
by following measures to prevent
secondary infection of the scabies
lesions, she can expect complete
healing of the lesions without any
visible scars within a few weeks.
E.E. will maintain Encourage E.E. to express her Brings feelings and opinions out into
relationships with family feelings about herself and her the open where they can be dealt with
and friends. opinions about scabies. appropriately.

(Continues)

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528 UNIT 6 Nursing Care of the Client: Body Defenses

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Provide information to correct any Accurate information dispels
misconceptions she might have. misconceptions.
Encourage E.E. to verbalize the A person perceiving derogatory opinions
perceptions she has about her of her is likely to socially isolate herself
family’s and friends’ feelings about from them.
persons with scabies.
Be alert to verbal and nonverbal Nonverbal messages give insight into
messages. the client’s real feelings. Identifying and
discussing feelings can lead to behavioral
changes.
Reassure her that she will not The client will be unlikely to avoid friends
infect friends and family members or make disparaging remarks about
by sitting beside them or being herself when she realizes that she is not a
in the same room with them for danger to them.
prolonged periods.
Share with E.E. that wearing long- Makes the client less self-conscious and
sleeved cotton blouses or dresses embarrassed. Cotton fabric allows good
will hide most of the visible lesions. air circulation. Cool skin itches less.

EVALUATION
The client has assumed self-care responsibilities. She does interact with her family but emphasizes that she
“doesn’t want to get too close to them until these things are completely gone.” She has refused to go to
church, social gatherings, or activities outside of the house.

Goal has been partially met in that the client does follow proper procedures when caring for her skin
lesions, but goal has not been met in so far as maintaining relationships is concerned. Encourage the client
to talk about her feelings, particularly feelings of embarrassment. Point out to her the evidence that her
lesions are healing. Emphasize that symptoms of intense itching, worsening of present skin lesions, and
signs of more skin lesions would be present if the itch mites were alive and still spreading. Encourage her
to go on at least one outing with her family during the coming week. Reevaluate in 1 week.

In some cases, application of a topical corticosteroid is all that

INFLAMMATORY DISORDERS is needed. Other types of this inflammatory disorder include
contact dermatitis and exfoliative dermatitis.
OF THE SKIN

I ncluded in this category are dermatitis and psoriasis.

ECZEMA
Eczema is an atopic dermatitis often associated with allergic
■ DERMATITIS rhinitis and asthma. It is a chronic superficial inflamma-

B
tion that evolves into pruritic, red, weeping, crusted lesions
y definition, dermatitis is an inflammatory condition of (Estes, 2010). See Figure 15-14. Mostly infants get eczema,
the skin. In current usage, eczema has almost become syn- but older children and adults may have it. The common aller-
onymous with dermatitis, although eczema tends to be used gens are chocolate, orange juice, wheat, and eggs. Heredity
most often to refer to chronic forms of dermatitis. Most clients is a major factor. Elimination of dietary substances is used
with dermatitis are treated as outpatients. Patch testing may to identify the client’s allergen(s). Tiny cracks in the skin
identify a specific allergen that is causing the dermatitis. Avoid- allow body fluid to escape, so skin hydration is the major
ing the allergenic substance may prevent future dermatitis. treatment.

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 CHAPTER 15 Integumentary System 529

Figure 15-15 Allergic Contact Dermatitis from Poison

Oak: Note Linear Pattern to Lesions (Courtesy of Centers for
Disease Control and Prevention.)

burning, and erythema. Often, a maculopapular rash or a

combination of papules and vesicles develops. Scratching the
lesions may spread the dermatitis as well as lead to secondary
infections of the skin (Figure 15-15).
Treatment of symptoms may include a corticosteroid
Figure 15-14 Eczema (Courtesy of Centers for Disease ointment and an oral antihistamine such as diphenhydramine
Control and Prevention.) hydrochloride (Benadryl).

Nursing Management
Nursing Management Assist the client in identifying the causative allergen. Use asep-
Nursing management is directed toward promoting heal- tic technique when caring for open lesions. Apply dressings
ing, providing comfort, preventing infection, and fostering wet with Burow’s solution as ordered. Advise the client that a
a positive attitude to help the client cope with an altered cool, moist environment reduces pruritis.
body image. Nursing diagnoses may include Impaired Skin
Integrity; Risk for Infection; Acute Pain; and Disturbed Body
Image. DERMATITIS VENENATA AND
Affected areas are soaked in warm water for 15 to
20 minutes and then an occlusive ointment is applied, as
MEDICAMENTOSA
directed, to retain the water. Following a bath or shower, pat Dermatitis venenata is a specific type of contact dermatitis
the skin dry and immediately apply the occlusive ointment. when the allergen is from a plant (e.g., poison ivy, poison oak).
Wet dressings may be ordered to maximize skin hydration. The first exposure sensitizes the client’s body to form antigens
Moisturizing lotions such as Curel or Lubriderm may be against the allergen. Later exposures lead to inflammation,
used as the lesions heal. Client teaching is focused on identi- pruritis, edema, and vesicle formation.
fying and avoiding substances that cause dermatitis, care for Dermatitis medicamentosa is a skin reaction to a medica-
the lesions, how to prevent infection, and how to cope with tion (e.g., penicillin, codeine). Symptoms range from mild to
the conditions. severe erythema and vesicle formation. Respiratory distress
may occur.

CONTACT DERMATITIS Nursing Management

In contact dermatitis the skin reacts to external irritants such For dermatitis venenata, wash the affected area immediately.
as (1) allergens like cosmetics, (2) harsh chemical substances Calamine lotion relieves the pruritis. Corticosteroids may be
like detergents or insecticides, (3) metals such as nickel, needed for more severe cases to decrease inflammation and
(4) mechanical irritation from wool or glass fibers, and (5) body itching.
substances like urine or feces. Symptoms include pruritus, For dermatitis medicamentosa, notify the physician
immediately so the medication can be discontinued and
treatment of symptoms initiated. Advise the client to wear a
LIFE SPAN CONSIDERATIONS Medic Alert bracelet or necklace and to notify all health care
members of the allergy.
Skin Integrity in the Older Adult
The thinning and drying of the skin due to aging
makes older adults more susceptible to irritants
EXFOLIATIVE DERMATITIS
that cause dermatitis. Restoring skin integrity in In exfoliative dermatitis, inflammation of the skin gradu-
older adults takes longer and requires persistent ally worsens. Localized symptoms include erythema, severe
nursing effort.
pruritus, extensive scaling, and skin sloughing. Exfoliative
dermatitis affects the entire body, not just the skin. Systemic
symptoms include chills, fever, and malaise. With the loss of

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530 UNIT 6 Nursing Care of the Client: Body Defenses

LIFE SPAN CONSIDERATIONS

Exfoliative Dermatitis
Older adults have a greater risk of fatal
complications from exfoliative dermatitis. As body
systems age, they are less able to respond quickly
and effectively to the stress of illness.

large areas of skin surface, the individual has difficulty main-

taining body temperature, loses body fluids and electrolytes,
and is susceptible to infection.
In most cases, the cause of exfoliative dermatitis is unknown.
Severe reactions to drugs such as penicillin may sometimes
cause exfoliative dermatitis. It may also be associated with other
types of dermatitis or lymphoma. Exfoliative dermatitis can be
fatal, primarily because of overwhelming systemic infections
and/or massive loss of body fluids and electrolytes.

Nursing Management
When clients are hospitalized with exfoliative dermatitis, man- Figure 15-16 Psoriasis (Courtesy of Robert A. Silverman,
agement is directed toward maintaining fluid balance, prevent- MD, Clinical Associate Professor, Department of Pediatrics,
ing infection, decreasing inflammation, and promoting comfort. Georgetown University.)
The client requires intravenous fluids to maintain the volume of
circulating fluid, corticosteroids to decrease inflammation, and Pharmacological
antibiotics to treat infection. Medicated baths, topical steroids, Keratolytic agents such as salicylic acid preparations and coal
and mild analgesics may be prescribed to ease the pruritus. tar preparations are applied topically to the lesions. Cortico-
steroids may also be used to reduce inflammation. Ultraviolet
■ PSORIASIS light and methotrexate (Mexate) inhibit DNA synthesis in the

P
epidermal cells, thus slowing the rate of cell division and the
soriasis, a chronic, inflammatory, noninfectious autoim- process of abnormal keratinization. Because of its toxicity to
mune disease of the skin, affects about 7.5 million Ameri- the liver, methotrexate is used only in severe cases of psoria-
cans, especially young adults. Psoriasis is more prevalent in sis that do not respond to any other form of treatment. The
Caucasians. The parts of the body most commonly affected are Goeckerman regimen, which combines the use of coal tar and
the scalp, elbows, palms, knees, lower back, and soles of the feet ultraviolet light, is one of the oldest effective treatments avail-
(National Psoriasis Foundation, 2009) (Figure 15-16). The able but is not offered in many centers in the United States
exact cause of psoriasis is unknown, although a genetic com- (American Academy of Dermatology [AAD], 2007).
ponent may be involved. Emotional stress, infections, trauma, Photochemotherapy is used for severe psoriasis. Photo-
and seasonal and hormonal changes trigger exacerbations of chemotherapy (psorafen and ultraviolet A-range, or PUVA)
psoriasis. It may improve for a while only to recur. This process combines the use of psorafen with ultraviolet A light waves.
of subsiding and recurring continues throughout the client’s life. Psorafen is a photosensitizing agent that reacts with ultravio-
Psoriasis is not curable. In psoriasis, the process of keratinization let A light waves to markedly reduce DNA synthesis, thereby
has gone awry. Instead of producing cells that provide a natural slowing cell division in psoriasis lesions and relieving symp-
barrier against harmful substances and microorganisms, abnor- toms. PUVA is effective in approximately 85% of cases, but
mal keratinization causes large, red patches covered with thick approximately 25 treatments occur over several months before
silvery scales in the outermost layer of the epidermis (Tate, clearing of psoriasis occurs. Continued treatments are needed
2008). If these scales are scraped away, bleeding occurs. When to maintain control over this disease (AAD, 2007).
fingernails are affected, pitting and yellow discoloration is seen. Etretinate (Tegison), a compound related to retinoic acid
vitamin A, is used in severe psoriasis not amenable to other
Medical–Surgical therapies. It may be used alone or in combination with ultra-
violet A light waves. Etretinate has numerous adverse effects,
Management including liver damage and severe birth defects. The client
must be monitored closely. Women of childbearing age must
Medical use effective contraception during treatment and for at least
Treatment is directed toward slowing down the rate of cell 1 month after treatment.
formation in the epidermis or toward altering the abnormal Alternative therapies, such as aloe vera, may decrease
process of keratinization. Treatment regimens can be effective itching, scaling, redness and inflammation. Capsaicin cream
in reducing the scaling and itching. The client must recognize may lessen itching, and Omega 3 fatty acids (fish oil) may
that psoriasis can only be controlled, not cured. Furthermore, reduce inflammation. These treatments are considered safe to
the client must be committed to lifetime therapy. use (Mayo Clinic, 2009).

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 CHAPTER 15 Integumentary System 531

Nursing Management Many clients tend to suffer self-esteem and body image
disturbances, and sometimes depression, because psoriasis
Assist the client to understand and comply with the treatment. requires lifelong treatment. The treatment can be time-
Teach the client proper hand hygiene. Listen to the client’s consuming, bothersome, and, from the client’s point of view,
feelings and frustrations. not completely effective. Encourage the client to verbalize
feelings. Ask about itching, burning, and discomfort, as well
as the client’s mood.
NURSING PROCESS
Assessment Objective Data
Subjective Data Check the skin carefully, noting the distribution, size, and
Psoriasis lesions are generally very visible and likely to appearance of lesions. Note signs of infection such as redness,
make the client feel self-conscious and uncomfortable. swelling, pain, or drainage.

Nursing diagnoses for a client with psoriasis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will discuss Help client gain an understanding of psoriasis and comply
related to psoriasis and condition and adhere to with the treatment regimen. Support and encourage the
its treatment treatment. client.
Explain the purpose of each medication.

Risk for Infection related The client will not get an Teach client how to prevent infections by proper hand
to open lesions infection. hygiene and not scratching the lesions.

Disturbed Body Image The client will identify positive Listen actively and encourage client to express feelings and
related to scaly lesions attributes about self. frustrations. Reinforce positive behavior.

Situational Low Self- The client will demonstrate Guide client in identifying effective coping techniques.
Esteem related to behaviors that promote Help client focus on personal attributes that contribute to
appearance self-esteem. effective functioning and a positive self-image.
Encourage work and social interactions.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Staphylococcus or Streptococcus. Healing is very slow. In an

ULCERS effort to decrease venous congestion and improve circulation,

T
varicose veins, if present, may be removed. Ulcers that do not
he two most common types of ulcers of the skin are heal may require surgery. If diagnostic testing reveals adequate
venous ulcers and pressure ulcers. circulation, skin grafting will result in the healing of large
venous ulcers. In cases that do not respond to treatment, the
affected leg has to be amputated.
■ VENOUS ULCERS

P oor venous circulation, especially in lower extremities,

can lead to a condition known as stasis dermatitis (Figure
15-17). The skin changes in texture, turgor, and color. The
Medical–Surgical
Management
skin develops a brownish discoloration and a brawny indura-
tion—that is, skin in the affected area becomes dry and looks Medical
rough; subcutaneous tissue atrophies; and it loses its usual Vacuum-assisted closure (VAC) therapy may be used for
resiliency and feels hard to the touch. Body hair is lost in this chronic open wounds such as venous ulcers. Applying nega-
area. Pruritus is common. Scratching or small injuries can lead tive pressure to the wound is painless for the client. The
to ulcer formation because of the poor circulation. negative pressure stretches or distorts the cells, causing the
Venous ulcers begin as small, tender, inflamed areas epithelial cells to multiply rapidly and form granulation tis-
above the ankle. Any slight trauma to the area causes an open sue. As the vacuum pulls fluid from the surrounding tissues,
area that develops into an ulcer. Some edema surrounds the reducing edema that compressed blood vessels, blood flow to
ulcer, which can easily become infected, most often with the wound is improved.

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532 UNIT 6 Nursing Care of the Client: Body Defenses

Diet
A diet high in protein and vitamin C is needed for tissue regen-
eration. If the client is anemic, lean meats, whole grains, and
green, leafy vegetables should be encouraged.

Nursing Management
Maintain peripheral tissue perfusion by encouraging the client
to elevate legs when sitting, wear support hose, and not cross
legs. Promote comfort by encouraging the client to keep legs
elevated, cleansing the venous ulcer as prescribed, and keep-
ing the area covered as ordered. Promote wound healing by
reviewing the client’s diet and encouraging foods high in iron,
protein, and vitamin C.

NURSING PROCESS
Assessment
Subjective Data
Figure 15-17 Venous Stasis Ulcer (Courtesy of Carrington
Ask the client to describe any pain and rate its severity on a
Laboratories, Inc., Irving, TX.) scale of 0 to 10. Note whether the pain is worse with the leg
in a dependent position or when the client is standing. Doc-
Elevation and compression are the keys to reducing ument measures used to relieve the pain. Note if the skin
edema of the leg and improving blood return to the heart. This around the ulcer itches, the length of time the client had
reduces venous hypertension and helps the venous ulcer heal. the ulcer before seeking care, and any palliative measures
The legs should be elevated 7 inches above the heart at night tried.
and for several hours during the day. Many types of compres-
sion therapy products are available, including Unna’s boot, Objective Data
elastic wraps, intermittent pneumatic or sequential compres- Describe the size and location of the ulcer, as well as the
sion stockings, compression pumps, and sustained graduated appearance of the ulcer and surrounding skin. Observe for
compression using an elastic, multilayered bandage system. necrotic tissue inside the ulcer. It may be yellow and look like
thin strands of fibers. The base of the ulcer may have a dark
Pharmacological red, “beefy” appearance. Document the color and appearance
For healing to occur, the ulcer must have adequate circulation and of the extremity in both a dependent and an elevated position
be free of infection and necrotic tissue. Usually, antibiotics are as well as any drainage, including its odor and characteristics.
prescribed. Enzyme preparations such as fibrinolysin and desoxy- Edema may be present, and the lower extremity may appear
ribonuclease (ELASE) or wet-to-dry dressings may be used to swollen. Hardened and indurated tissue may surround the
debride the ulcer. Normal saline is the solution most often used in ulcer. Tissue farther away from the ulcer may “pit” with firm
wet-to-dry dressings because it is not irritating to healthy tissue. pressure. Assess peripheral pulses.

Nursing diagnoses for a client with a venous ulcer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Tissue Client will follow prescribed Assess for edema.
Perfusion (Peripheral) measures to improve Encourage client to elevate legs while sitting or when in
related to edema and peripheral circulation. bed and to avoid standing for more than a few minutes at a
pooling of venous blood time.
Advise client to wear elastic stockings when walking and
that new stockings should be purchased every few months
because continual wear and laundering tend to decrease
the elasticity of the stockings. Instruct not to sit with legs
crossed.
Note the client’s hemoglobin level because anemic clients
will have difficulty meeting tissue demands for oxygen.

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 CHAPTER 15 Integumentary System 533

Nursing diagnoses for a client with a venous ulcer include

the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to Client will report decreased Assess for pain.
exposed sensory nerve pain after implementing Encourage client to elevate legs.
endings and edema recommended measures.
Cleanse ulcer with prescribed solutions. Keep ulcer covered
with prescribed medications and dressings.

Risk for Infection related Client will describe and Assess the ulcer daily for signs of healing.
to poorly nourished implement measures to Assess the client’s ability to care for the ulcer physically and
tissue in and around the minimize the risk of infection. financially. Review diet with the client and instruct in food
ulcer and to nonintact choices as needed. Encourage foods high in iron such as
skin fortified cereal, lean meats, whole grains, and leafy green
vegetables.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

blanches with fingertip pressure or if the redness disappears

■ PRESSURE ULCERS within an hour, no tissue damage is anticipated. If, however,

P
the redness persists and no blanching occurs, then tissue dam-
ressure ulcers, also known as bedsores or decubitus ulcers, age is present.
are localized areas of tissue necrosis that tend to develop Pressure ulcers are staged to classify the degree of tis-
when soft tissue is compressed between a bony prominence sue damage (Figure 15-18). The National Pressure Ulcer
and an external surface such as a mattress or chair seat for a Advisory Panel (NPUAP, 2008) recommends the following
prolonged period. Pressure ulcers are caused by ischemia, a staging system:
local and temporary decrease in blood supply, and commonly
occur in areas subject to high pressure from body weight on • Suspected Deep Tissue Injury: Discolored intact skin, either
bony prominences. maroon or purple, caused by shear or pressure resulting in
soft tissue damage to underlying tissue. This localized area
may be warmer or cooler, firmer or boggy in comparison
Physiology of Pressure to surrounding tissue.
Ulcers • Stage I: Nonblanchable erythema of intact skin; the
heralding lesion of skin ulceration. No blanching may be
A pressure ulcer occurs when pressure on the skin is sufficient noticeable in darkly pigmented skin. A change in color
to cause collapse of blood vessels in the area. Ischemia and usually occurs in comparison to surrounding tissue.
redness can occur at the site within 1 hour; when pressure • Stage II: Partial-thickness skin loss involving epidermis,
continues for more than 2 hours, necrosis (tissue death) may dermis, or both. The ulcer is superficial and presents
occur in the involved area. Bony prominences such as the clinically as an abrasion, blister, or shallow crater.
occipital skull, pinna of ears, sacrum, ischial tuberosities, tro- • Stage III: Full-thickness skin loss involving damage or
chanter area of hips, ankles, and heels are the areas most likely necrosis of subcutaneous tissue that may extend down
to develop a pressure ulcer. to, but not through, underlying fascia. The ulcer presents
Other forces acting in conjunction with pressure contrib- clinically as a deep crater with or without undermining
ute to pressure ulcer formation. Shearing is the force exerted and tunneling.
against the skin by movement or repositioning. The skin and
subcutaneous tissue tend to adhere to the bed surface and • Stage IV: Full-thickness skin loss with extensive
remain stationary while deeper underlying tissues pull away destruction, tissue necrosis, or damage to muscle, bone,
and slide in the direction of movement. This action results in or supporting structures. Undermining and tunneling may
stretching and tearing of blood vessels, reduced blood flow, also be associated with stage IV pressure ulcers.
and necrosis. • Unstageable: A full-thickness tissue loss where slough
Friction is the force of two surfaces moving across one (yellow, gray or tan) or eschar (black or brown) covers
another. When a client moves or is pulled up in bed, rubbing the base of the wound bed. This ulcer is unstageable until
of the skin against the sheets creates friction. Friction can debridement of the slough and/or eschar occurs.
remove the superficial layers of the skin, making it more prone The NPUAP (1999) has developed an assessment tool,
to breakdown. Pressure Ulcer Scale for Healing (PUSH Tool). It uses three
The reduction of blood flow causes blanching (white parameters: the surface area of the wound, amount of exudate,
color) of the skin when pressure is applied. When pres- and type of tissue present in the wound. The scores for each
sure is relieved, the skin takes on a brighter color (reactive parameter are added together and plotted to show wound
hyperemia) because of vasodilation, the body’s normal com- healing or worsening. This PUSH Tool is available on the
pensatory response to the absence of blood flow. If this area Internet (www.npuap.org/push3-0.htm).

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534 UNIT 6 Nursing Care of the Client: Body Defenses

Epidermis

Dermis

Adipose
Tissue

Muscle
Bone

Normal Suspected Stage 1

Deep Tissue Injury

Stage 2
Stage 3

Stage 4 Unstageable

Figure 15-18 Pressure Ulcers (Courtesy of the NPUAP. Reproduction of the National Pressure Ulcer Advisory Panel [NPUAP]
materials in this document does not imply endorsement by the NPUAP of any products, organizatons, companies, or any statements made by
any organization or company.)

The Braden Scale for Predicting Pressure Sore Risk reduced or eliminated. More than 2.5 million clients each year
(Table 15-4) is a research-based tool that estimates risk level have pressure ulcers, and most of these clients are in their 70s
for pressure ulcers and predicts those clients who are most and 80s (Institute for Healthcare Improvement, 2008). Both
likely to develop pressure ulcers. intrinsic and extrinsic factors may influence tissue response
to pressure. Intrinsic factors include impaired immobility,
Risk Factors for Pressure Ulcers incontinence, nutritional status, and altered level of conscious-
Pressure ulcers can be prevented if at-risk individuals are ness. Extrinsic factors include pressure, shearing, friction, and
identified and the specific factors placing them at risk are moisture. Any condition that decreases tissue perfusion, such

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 CHAPTER 15 Integumentary System 535

Text not available due to copyright restrictions

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536 UNIT 6 Nursing Care of the Client: Body Defenses

Text not available due to copyright restrictions

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 15 Integumentary System 537

as edema, anemia, or atherosclerosis, also increases the risk.

Other factors are decreased mental status, diminished sensa-
tion, and age-related changes.
Individuals should be assessed for pressure ulcer risk on
admission to acute care hospitals and at least every 48 hours,
long-term care facilities at least daily, and home health care at
every RN visit.

Medical–Surgical Management
Medical
Follow sterile technique in the care of all pressure ulcers to
prevent secondary infection. Cleanse the wound with nor-
mal saline or a noncytotoxic wound cleaner at each dressing
change. Such agents as povodine-iodine, iodophor, sodium
hypochlorite, hydrogen peroxide, or acetic acid should not be
used because they can damage the cells. A 35-mL syringe with
a 19-gauge needle or angiocatheter provides enough pressure
to cleanse the wound and enhance wound healing without
causing trauma to the tissue.
Debridement must be done as needed. Topical enzyme
agents may be applied or a mechanical method of wet-to-dry
dressings, or hydrotherapy, may be used. Refer to the discus-
sion of VAC therapy in the section on venous ulcers; this
therapy can also be used for pressure ulcers.
Figure 15-19 Clinitron® Air-Fluidized Therapy Unit
There are many commercial products available for treat-
Model C11 (Courtesy of Hill-Rom, Batesville, IN.)
ment and dressing of pressure ulcers. Whichever products the
physician prescribes, everyone should be taught how to use
them and have a commitment to use them properly.
Support Surfaces and Beds A variety of support surfaces
and beds are available to support the entire body and evenly
distribute pressure. These devices help reduce pressure, but
they are no substitute for frequent positioning.
In addition to pressure reduction or relief, many sup-

COURTESY OF DELMAR CENGAGE LEARNING

port surfaces reduce shear and friction and control moisture.
Pressure-reducing support surfaces include overlays filled
with foam, gel, or water.
• Egg-crate mattress: The egg-crate mattress is composed of
thick foam with a unique, egg-crate design. The purposes
of the egg-crate mattress include minimizing pressure and
shearing force. The open design of the mattress surface allows
air to circulate to dissipate heat and moisture. Egg-crate foam Figure 15-20 Kin Air Bed
is also used as wheelchair cushions, heel-ankle protectors,
wrist restraint cushioning pads, and ulnar protectors.
be adjusted in each of the sections for the client’s specific
• Air-filled mattresses: The air-filled mattress is placed over needs. Air flows from the mattress to eliminate moisture.
the mattress of the hospital bed for weight redistribution.
The bed frame can be adjusted for various positions such
Varieties of air-filled mattresses include some with a pump
and alternating bands of inflation and deflation and some as Fowler’s, Trendelenburg, prone, or supine. A trapeze can
that are inflated continuously with air. Mattresses are be connected to the bed frame (Figure 15-20).
covered with a sheet for client comfort. These types of • Roto Kinetic bed: A Roto Kinetic bed is a specialized bed
mattresses are frequently used in long-term care situations. that rocks slowly from side to side, thus relieving pressure
• Clinitron® bed: A Clinitron® bed (Figure 15-19) is a areas and countering the effects of immobility. The client
specialized bed that has a mattress filled with small glass is placed on the mattress, with dividers between the legs
sand particles. Moisture from urine, stool, or drainage and dividers between the trunk and arms. Clients can be
flows through the mattress, preventing moisture exposure maintained in traction while on this bed.
to the skin. Because warm air is circulating through the Regardless of the type of surface or bed on which the cli-
mattress, the accumulation of moisture next to the skin ent is lying, the 30-degree side-lying position prevents pressure
is inhibited. The mattress aids in positioning the client on the sacrum and trochanters. This position is illustrated in
because it is constructed to mold against the client’s body. Figure 15-21.
• Kin Air bed: A Kin Air bed, another type of specialized bed,
has a mattress of air-inflated pillows divided in sections Surgical
for the head, back, seat, legs, and feet. The pressure can Occasionally, surgical debridement may be necessary.

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538 UNIT 6 Nursing Care of the Client: Body Defenses

Pharmacological

COURTESY OF DELMAR CENGAGE LEARNING

30°
Vitamin and mineral supplements may be ordered. Antibiotics
may also be ordered.

Diet
Figure 15-21 Avoiding Pressure Points with the 30-Degree Eating a well-balanced diet should be encouraged, including
Lateral Position 2 half-cup servings of orange juice or other juice high in
vitamin C and 6 ounces of a high-protein drink. Adequate
calories, protein, vitamins, and minerals, especially vitamin C
PROFESSIONALTIP and zinc, improve wound healing and prevents tissue break-
down. Offering small, frequent feedings enhances nutritional
Preventing Pressure Ulcers needs.
• Establish written repositioning/turning schedule
for clients, including those on pressure-reducing Activity
support surfaces. Active ROM exercises should be performed, if possible. If not,
• Use 30-degree position when side-lying position passive ROM exercises should be performed with the client
is used. several times a day.
• Prevent direct contact between bony
prominences by using pillows and foam wedges.
Nursing Management
• Use a lifting sheet.
Assess skin several times a day. Keep linens clean, dry,
• Encourage clients in wheelchairs to shift their and free from wrinkles. Provide daily bath and skin care
weight every 15 minutes. when the client is incontinent of bowel or bladder. Encour-
• Raise heels off the bed with pillow lengthwise age adequate fluid intake, a well-balanced diet, and active or
to support legs. passive ROM exercises. Turn client at least every 2 hours.
Use the 30-degree lateral position to avoid pressure on the
• Use knee gatch when head of bed is elevated.
sacrum and trochanters. Position client on unaffected areas
• Keep head of bed elevated to less than and protect skin as ordered. Monitor vital signs, especially
30 degrees except at mealtimes. temperature.
• Limit sitting time to 1 hour at a time whether in
bed, chair, or wheelchair.
• Use proper positioning, transferring, and
turning techniques.
NURSING PROCESS
• Inspect skin at least once a day. Assessment
• Use mild cleansing agent, but avoid hot water
for bathing.
Subjective Data
Statements such as, “I’m tired of lying on my side”; “I wish I
• Avoid massage over bony prominences. could move more”; or “my hips (back, heels, and so on) are
• Use moisturizer on skin. sore” may be expressed.
• Use protective barrier on skin if client is
incontinent. Objective Data
• Cleanse skin at time of soiling and at routine Symptoms may include any of the risk factors already mentioned;
intervals. shiny, erythematous area; small blisters or erosions or ulcerations.
Check for reddened areas and blanching of those areas.

Nursing diagnoses for a client at risk for pressure ulcers or who has a pressure
ulcer include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Impaired Skin The client will maintain skin Assess skin 3 times a day for pressure areas.
Integrity related to integrity. Provide daily bath and skin care as needed for incontinence
immobility of urine or stool. Use mild cleansing agents with warm water,
use moisturizing lotion, and minimize exposure to cold and low
humidity.
(Continues)

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 CHAPTER 15 Integumentary System 539

Nursing diagnoses for a client at risk for pressure ulcers or who has a pressure
ulcer include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Avoid massage over bony prominences.
Keep bed linen clean, dry, and free from wrinkles.
Encourage adequate fluid intake and a well-balanced diet,
including 2 half-cup servings of orange juice or other juice high
in vitamin C, and 6 ounces of a high-protein drink.
Encourage active ROM exercises or provide passive ROM
exercises.
Turn and reposition client at least every 2 hours. If reddened
area does not blanch when you press it, turn the client more
often.
Use the 30-degree lateral position to avoid pressure on the
sacrum and trochanters.
Use pressure-reducing surfaces. Do not use donut-shaped
cushions; they put pressure around the pressure ulcer.

Impaired Skin Integrity The client will show healing Assess skin daily, identifying the stage of pressure ulcer
related to pressure ulcer of pressure ulcer. development (size, color, odor, and exudate).
formation Continue all preventive nursing interventions.
Position client on unaffected areas. Protect skin surface and
affected area as per facility protocol or as ordered.
Monitor temperature. Administer antibiotics as ordered.

Disturbed Body Image The client will make a Encourage client to discuss meaning of pressure ulcer to the
related to trauma or positive statement about client.
injury (pressure ulcer) body image. Provide information as requested by client.

Anxiety related to threat The client will discuss Schedule time to be with client, other than care times.
to or change in health concerns about pressure Encourage client to discuss fears and concerns.
status (pressure ulcer) ulcer with caregivers.
Provide information as requested by client.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

There are many types of alopecia, ranging from head

ALOPECIA or beard hair loss to loss of all hair over the entire body.
Treatment depends on the cause. Hair transplants may be

A lopecia, which is partial or complete baldness or loss

of hair, can be caused by illness, malnutrition, effects of
certain drugs such as those used in cancer therapy, hormonal
performed on the head, but this is very expensive. In some
clients, minoxidil (Rogaine) can promote hair growth, but
hair growth stops when the drug is stopped. This is also very
imbalances, heredity, or diseases that affect the scalp. expensive.

CASE STUDY
M.M., age 68, noticed that the skin on the outside of her left lower leg just above the ankle was changing in
color and texture. The skin felt rigid and did not move as easily as skin on the upper part of her leg did. Itching
was becoming a problem. Inadvertently, she would scratch the area, sometimes causing small excoriations. One
day she bumped her leg against the rough edge of the outside steps as she was going into the house. The cut
was only an inch long and was not very deep. Over the next few weeks, she noticed that instead of healing, it
was getting bigger and was becoming quite painful. The skin around the wound was red and swollen. The yellow

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540 UNIT 6 Nursing Care of the Client: Body Defenses

drainage coming from the wound had a bad smell. She had never had this kind of problem before. She did have
varicose veins in that leg, and while she knew that she was uncomfortable if she was standing for long periods,
she did not think the problem was serious. When she went to the doctor, he diagnosed a venous stasis ulcer and
cultured the drainage. He ordered the following treatment:
1. Cefaclor (Ceclor) 500 mg p.o. every 8 hours for 2 weeks (culture of the wound identified Staphylococcus
aureus)
2. Wet-to-dry dressings with normal saline solution. Change every 8 hours.
3. Bed rest with left leg elevated. May have bathroom privileges and be up for meals.
The doctor explained that he would be ordering an Unna’s boot after the wound was debrided and the infection
controlled so that she could be ambulatory, but that even after the Unna’s boot was applied, he would want her
to have rest periods during the day with her leg elevated. M.M. thought she could learn to change the dressings,
but she expressed doubt that she could stay in bed most of the time. She was used to being up and active and
getting her work done each day.
The following questions will guide your development of a nursing care plan for the case study.
1. List the clinical manifestations of a venous stasis ulcer.
2. What is the usual medical treatment?
3. List the subjective and objective assessment data that the nurse should obtain from M.M.
4. Write two to four individualized nursing diagnoses to address these problems.
5. What will be the goals (expected outcomes) of nursing treatment?
6. List appropriate nursing actions for each diagnosis. Include basic nursing care measures. Be specific about
client education needs. Address nutrition and pharmacologic implications. Give a rationale for each action.
7. Describe how to evaluate goal achievement for M.M.

SUMMARY
• Maintaining intact skin and mucous membranes to protect • Skin infections caused by bacteria, viruses, fungi, or
internal body structures from harmful substances and from parasites are effectively treated with medications and
invasion by microorganisms is an important independent supportive nursing care.
nursing responsibility. • Dermatitis, an inflammation of the skin, can have many
• Burns are devastating, traumatic injuries that can often be causes.
prevented. • Eczema is a term that is often used for chronic forms of
• In general, skin cancers can be prevented by avoiding dermatitis.
excessive sun exposure. • Venous ulcers are more common in older persons, heal
• Treatment of benign skin tumors such as nevi, lipomas, slowly, and often recur following a slight injury.
keloids, sebaceous cysts, and angiomas depends on the • Alopecia, or baldness, can be caused by illness, drugs,
kind of tumor and its location. hormonal imbalances, or heredity.
• Psoriasis is a chronic skin condition that can be treated but
not cured.

REVIEW QUESTIONS
1. A client is brought into the emergency room with 3. turgor and mobility.
facial burns, singed nasal hairs, and change in voice. 4. vascularity.
The client states he is having pain of a 7 on a 0–10 3. An effective nursing intervention related to the care
pain scale in the facial area and he appears anxious. of open burn wounds that require daily dressing
Based on these clinical findings, what is the most changes would be:
important initial nursing intervention? 1. keep the head of the bed elevated 30 degrees with
1. Attempt to calm client. all four side rails up.
2. Maintain an adequate level of oxygenation. 2. set a fluid intake goal of 2,500 mL/24 hours
3. Protect burns with a sterile dressing. (1,200 mL during the day; 950 mL during the
4. Administer pain medication. evening; 350 mL during the night).
2. The nurse charted that the client’s skin was loose, 3. wear a cap, gown, mask, and sterile gloves when
wrinkled, and thin with mild scaling. The nurse was providing wound care.
describing: 4. weigh daily, preferably before breakfast, and in
1. integrity. the same type of clothing each day.
2. texture.
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 CHAPTER 15 Integumentary System 541

4. The client has lesions on his scalp and on his arms 8. When admitting a new client, the nurse performs a
near his elbows. The lesions appear as red patches physical assessment of the client’s skin. What param-
covered with thick silvery scales. The most likely eters will the nurse assess? (Select all that apply.)
cause of these lesions is: 1. Integrity and color.
1. herpes zoster (shingles). 2. Temperature and moisture.
2. pemphigus vulgaris. 3. Texture and vascularity.
3. psoriasis. 4. Culture and sensitivity.
4. tinea (ringworm). 5. Turgor and mobility.
5. A nursing care plan for a client with an infectious 6. Sensation.
disorder of the skin would include interventions to 9. A 75-year-old man comes to the outpatient clinic.
teach the client: He has long-standing severe chronic obstructive
1. how to avoid spreading the infection to pulmonary disease. He is short of breath at rest
others. with oxygen at 3 yes L per minute via nasal cannula.
2. how to do range-of-motion exercises to maintain When inspecting his nail beds, you would expect his
joint flexibility. nail angle to be:
3. ways to conserve energy. 1. greater than 160 degrees.
4. which foods are most likely to cause allergic 2. less than 140 degrees.
reactions. 3. less than 90 degrees.
6. The nursing care plan of a client at risk for impaired 4. greater than 90 degrees.
skin integrity is likely to include: 10. The nurse is teaching a client’s wife about preventing
1. turning and repositioning client every 4 hours. pressure ulcers. Which statement best demonstrates
2. massaging bony prominences. that the wife correctly understands the risk factors
3. using a donut shaped cushion around the for pressure ulcers?
pressure ulcer. 1. “I need to assess the skin once a week for redness
4. using the 30-degree lateral positioning when or open areas.”
turning client. 2. “If my husband is wearing Depends®, they will
7. The nurse is assessing a client’s dressing after an absorb his urine incontinence, so I will need to
abdominal surgery. The nurse notices clear with change his Depends only when saturated.”
some blood-tinged drainage on the dressing. The 3. “He has his favorite foods, so as long as he is
nurse would document the drainage to be: eating, I will not need to worry.”
1. purulent exudates. 4. “I will try to encourage him to change positions
2. serosanguineous exudates. frequently during the day.”
3. serous exudates.
4. sanguineous exudates.

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.html American Cancer Society (ACS). (2009a). How is melanoma skin
American Cancer Society (ACS). (2008a). What are the key statistics cancer treated? Retrieved May 25, 2009 from www.cancer.org/
about squamous and basal cell skin cancer? Retrieved May 22, docroot/CRI/content/CRI_2_2_4X_How_Is_Melanoma_Skin_
2009 from www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ Cancer_Treated_50.asp?rnav=cri
What_are_the_key_statistics_for_skin_cancer_51 American Cancer Society (ACS). (2009b). The ABCD rule for early
.asp?sitearea=cri detection of melanoma. Retrieved May 25, 2009 from www.cancer
American Cancer Society (ACS). (2008b). What are the risk factors of .org/docroot/SPC/content/SPC_1_ABCD_Mole_Check_Tips.asp
melanoma? Retrieved May 22, 2009 from www.cancer.org/docroot/ Bolton, L. (2008). Compression in venous ulcer management. Journal
CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_ of Wound, Ostomy & Continence Nursing, 35(1), 40−49.
melanoma_50.asp?rnav=cri Brunicardi, F., Anderson, D., Billiar, T., & Dunn, D. (2005). Schwartz’s
American Cancer Society (ACS). (2008c). What are the key statistics principles of surgery (8th ed.). New York: McGraw-Hill.
about melanomas? Retrieved May 20, 2009 from www.cancer Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds.
.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_ (2008). Nursing Interventions Classification (NIC) (5th ed.).
statistics_for_melanoma_50.asp?sitearea= St. Louis, MO: Mosby/Elsevier.
American Cancer Society (ACS). (2008d). Treating squamous cell Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic tests (2nd
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Drisdelle, R. (2003). Maggot debridement therapy: A living cure. Milner, S., Mottar, R., & Smith, C. (2001). The burn wheel. AJN,
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Goldsmith, J. (2003). Nit-Picking. AJN, 103(9), 22–23. Moses, M. (2003). A simple matter of grooming. AJN, 103(9), 11.
Grunwald, T., & Garner, W. (2008). Acute burns. Plastic and National Institutes of Health (NIH). (2008). Burns. Retrieved May
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RESOURCES
American Burn Association, National Psoriasis Foundation,
http://www.ameriburn.org http://www.psoriasis.org
American Hair Loss Council, http://www.ahlc.org Skin Cancer Foundation, http://www.skincancer.org
Dermatology Foundation, http://www.dermfnd.org Wound Healing Society,
National Burn Victim Foundation, http://www.nbvf.org http://www.woundheal.org
National Decubitus Foundation, Wound, Ostomy and Continence Nurses Society,
http://www.decubitus.org http://www.wocn.org
National Pressure Ulcer Advisory Panel (NPUAP),
http://www.npuap.org

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 16
Immune System

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of immune system disorders:
Adult Health Nursing
• Oncology • Musculoskeletal System
• Respiratory System • Neurologic System
• Cardiovascular System • Sexually Transmitted Infections
• Hematologic and Lymphatic Systems • Integumentary System
• Gastrointestinal System • Substance Abuse

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Identify three allergic reactions with a systemic response.
• Describe symptoms of anaphylaxis and appropriate first aid.
• Recall common diagnostic tests used to evaluate immunological functioning.
• Discuss the medical–surgical management of clients with immunological
disorders.
• Relate signs and symptoms of complications clients with immunological
disorders could experience.
• Explain the modes of transmission of HIV.
• Identify methods of risk reduction of HIV for health care workers.
• Use the nursing process to plan the care of clients with immune system
disorders.

KEY TERMS
acquired immunodeficiency antigen exacerbation
syndrome (AIDS) autoimmune disorder histamine
allergen autologous human immunodeficiency
allogeneic cellular immunity virus (HIV)
anaphylaxis diplopia human leukocyte
angioedema enzyme-linked antigen
antibody immunosorbent assay (ELISA) humoral immunity

543

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544 UNIT 6 Nursing Care of the Client: Body Defenses

hypersensitivity opportunistic infection urticaria

immune response ptosis viral load test
immunity remission Western blot test
immunotherapy seroconversion

INTRODUCTION Cells of the Immune System

Leukocytes, white blood cells (WBCs), are vital components
Immunity is the body’s ability to protect itself from foreign of the immune system. They are formed mostly in the bone
agents or organisms. This occurs through the complex inter- marrow and partially in the lymph tissue. After formation,
action of the tissues within the immune system. Constant they are transported to different parts of the body, where
surveillance of cells within the body occurs to differentiate they fight infectious organisms. There are five types of
self from nonself. Those identified as nonself are then neutral- WBCs normally found in the blood: neutrophils, eosino-
ized or destroyed. Dead or damaged cells are eliminated and phils, basophils, monocytes, and lymphocytes. Adults
homeostasis is maintained. When alterations in the system have between 4,000 and 11,000 WBCs/mm3 of blood.
develop, immunological conditions develop. They may be Each type is a percentage of the total number of WBCs
hypersensitivity responses, such as allergies; immunologi- (Table 16-1).
cal deficiencies, such as those associated with corticosteroid Those cells with granules in the cytoplasm are called
medications; or autoimmune disorders, where the body granulocytes, while those lacking them are called agranulocytes
identifies its own cells as foreign and activates mechanisms to (Figure 16-1). Eosinophils, neutrophils, and basophils are
destroy them. Rheumatoid arthritis, systemic lupus erythe- granular leukocytes. Monocytes and lymphocytes are agranu-
matosus, and myasthenia gravis are examples of autoimmune lar leukocytes. Each has its own unique function. Eosinophils
disorders. Immunosuppressive disorders suppress the body’s come into play during allergic reactions or parasitic invasions.
natural immune response to an antigen. Kaposi’s sarcoma and Neutrophils are useful in ingesting bacteria (Figure 16-2).
non-Hodgkin’s lymphoma are examples of immunosuppres- Basophils secrete histamine, a substance released during
sive disorders. allergic reactions, and heparin. Monocytes travel to the sites of
invading organisms and transform into macrophages, capable
of ingesting large quantities of microorganisms and damaged
ANATOMY AND PHYSIOLOGY cells, a process known as phagocytosis. They also secrete Inter-
leuken-1, which stimulates the activation of specific lympho-
REVIEW cytes. Granulocytes, also called polymorphonuclear leukocytes,
The human body has a variety of natural physical and chem- make up the greatest number of WBCs.
ical mechanisms that enhance immunological functioning. B-lymphocytes (or B-cells) and T-lymphocytes (or
The skin, eyelashes, cilia in the nose and respiratory system, T-cells) play a vital role in the immune response. B-cells
gastric acidity, intestinal mucosa, and pH of vaginal mucosa are responsible for humoral immunity (antibody-
all act to protect against invading organisms. In addition, mediated defenses), or immunity dominated by antibodies
all body tissues are linked together via lymphatic ducts (Table 16-2). They stimulate plasma cells to secrete
and blood vessels to the organs and cells of the immune antibodies (proteins that react with antigens to neutralize
system. or destroy them) in response to antigens (any substance
identified by the body as nonself ). Antibodies are also
Organs of the Immune System
called immunoglobulins. IgA, IgD, IgE, IgG, and IgM are
common antibodies found in plasma. When an antibody-
The organs of the immune system are classified as primary antigen reaction occurs, the complement system, a com-
or peripheral lymphoid organs. Primary lymphoid organs are plex sequential immunological process, is activated. This
bone marrow and the thymus gland. Within bone marrow,
stem cells, the parent cells for all blood cells, are produced.
Peripheral lymphoid organs are lymph nodes, spleen, tonsils,
appendix, Peyer’s patches of the small intestines, and the liver. Table 16-1 Percentages of Different
Lymph nodes, located throughout the body, connected by WBC Types
an elaborate ductal system, filter lymphatic fluid, removing
COURTESY OF DELMAR CENGAGE LEARNING

Neutrophils 55%–70%
destroyed matter. Enlargement of lymphoid organs indicates
an infectious or malignant process is occurring. The spleen Eosinophils 1%–4%
serves as a reservoir for macrophages, lymphocytes, and Basophils 0%–2%
plasma cells. The tonsils, appendix, and Peyer’s patches also
contain plasma cells and lymphocytes. The Kupffer cells of Monocytes 2%–8%
the liver house monocytes that ingest and destroy foreign Lymphocytes 20%–40%
organisms in hepatic circulation.

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 CHAPTER 16 Immune System 545

Table 16-2 Humoral and Cellular

Responses
HUMORAL RESPONSE CELLULAR RESPONSE
Eosinophils Neutrophils Basophils (B-CELL RESPONSE) (T-CELL RESPONSE)
• B-lymphocytes • Plasma cells are
Granular leukocytes
stimulate plasma cells, transformed into special
which manufacture T-lymphocyte cells,
antibodies in response which detect, attack, and
to an antigen and destroy invading antigens.
release them into the • Predominant role in
bloodstream. response to:
Monocytes Small T Small B Plasma cell • Predominant role in Viral and some bacterial
response to: infections
Lymphocytes
Bacteria and some Delayed hypersensitivity
viral infections (TB testing)
Agranular leukocytes

COURTESY OF DELMAR CENGAGE LEARNING

Allergic reactions Transplant rejection
Autoimmune Graft-versus-host

COURTESY OF DELMAR CENGAGE LEARNING

diseases disease
Fungal and parasitic
infections
Wandering macrophage
Detection and destruc-
Figure 16-1 Cells of the Immune System tion of tumor cells

Afferent lymphatic vessel

antibody-antigen reaction site. When a B-cell identifies
Capsule
an antigen, it places the characteristics of that antigen in a
Cortex memory bank. B-cells also produce “memory cells” capable
of identifying the antigen, if and when it is introduced to
the body again.
Nodal vein T-cells are responsible for cellular immunity (cell-
Nodal artery mediated defenses), a type of acquired immunity involv-
Hilus ing T-cell lymphocytes (Table 16-2). With T-cell−mediated
Valve
Efferent lymphatic
immunity, large numbers of activated lymphocytes are formed
vessel specifically to destroy the foreign agent. T cells include helper
cells (CD4), suppressor cells (CD8), and killer (cytotoxic)
cells. CD4 and CD8 are molecules on the T-helper and
Bacteria T-suppressor cells and are important in understanding how
Cellular HIV attacks the immune system.
COURTESY OF DELMAR CENGAGE LEARNING

Lymphocytes components Human immunodeficiency virus (HIV) infection affects

of the Immune the immune system and the brain. In the immune system, the
system
main characteristic of HIV infection is progressive depletion
Neutrophil
of the CD4-T helper cells. The normal ratio of T-helper cells
Antibody molecule to T-suppressor cells (CD4:CD8 ratio) is 2:1. As immuno-
Plasma cell (enlarged)
Macrophage Antigen deficiency worsens, it is not uncommon for the CD4:CD8
(enlarged) ratio to fall to as low as 0:1. The altered T-helper cells cause
malfunction of the B-cells and macrophages, which leads to
Figure 16-2 Bacteria and Common Cellular Components collapse of the immune system. HIV also affects the CD4 mol-
of the Immune System ecule present on microglial cells in the brain, causing memory
loss and other brain dysfunctions.
HIV is a retrovirus. Retroviruses use RNA to make DNA
system is composed of plasma proteins made in the liver. copies that then become part of the genetic material of the
They alter cell membranes in the antibody-antigen reac- human cell. These viruses are called retroviruses because this
tion, facilitating the cellular breakdown of the invading is a reversal of the usual DNA-to-RNA transcription of genetic
antigen, and attract macrophages and granulocytes to the information.

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546 UNIT 6 Nursing Care of the Client: Body Defenses

Table 16-3 Comparison of Natural and Acquired Immunity

ACQUIRED IMMUNITY
NATURAL IMMUNITY ACTIVE ACQUIRED IMMUNITY PASSIVE ACQUIRED IMMUNITY

COURTESY OF DELMAR CENGAGE LEARNING

• Innate immunity • Long-term immunity • Temporary immunity
• Present at birth • Antibodies develop as a result of • Antibodies obtained from an
• Includes physical and chemical exposure to a disease or vaccine animal or another human who
barriers to invading antigens • Antibodies neutralize future invasions has been exposed to an antigen
of the same antigen • Examples are gamma-globulin
or antiserum

Types of Immunity Elevated temperature may indicate infection. Joints must

be evaluated for possible tenderness, swelling, or limited
There are two types of immunity: natural (innate) and range of motion. Changes in the rate and rhythm of respira-
acquired (adaptive) (Table 16-3). One is born with natural tions, presence of a cough, or abnormal lung sounds may
immunity; it is species specific. For example, humans have an indicate immunological conditions. Cardiovascular status,
innate resistance to distemper, whereas dogs never develop including rate, rhythm, arrhythmias, and peripheral vascular
measles or syphilis. Acquired immunity develops after birth circulation, must be assessed. Enlarged liver or spleen and
and may be active or passive. Active acquired immunity is the gastrointestinal conditions, such as nausea, vomiting, or
result of exposure to the disease or its vaccine. As a result, the diarrhea, may have an immunological basis. Alterations in
body develops antibodies and memory cells for the causative vision, hearing, urinary habits, and neurological function
microorganism. A repeated exposure results in rapid activation may occur.
of these components of the immune system and annihilation
of the invading agent. Passive acquired immunity utilizes
antibodies produced by another human being or an animal. BOX 16-1: QUESTIONS TO ASK AND
Injection of these immunoglobulins temporarily prevents OBSERVATIONS TO MAKE WHEN
development of the disease after exposure. Transmission of COLLECTING DATA
antibodies through fetal circulation is an example of passive
acquired immunity. Subjective Data
Have you had a history of infections?
Factors Influencing Have you experienced a loss of appetite?

Immunity
How would you describe your diet?
Do you have food, seasonal, or medication
Although the exact physiological mechanisms involved are allergies?
unknown, it has been well documented that several fac- If so, how are they treated?
tors influence the immune response (body’s reaction Describe allergic reactions you have experienced?
to substances identified as nonself, neutralization of anti- Are your immunizations current?
gen). These include age, sex, nutritional status, stress, and When was the last time you were tested for
treatment modalities. As one ages, the immune system
tuberculosis?
becomes less effective. Sex hormones affect immunity;
estrogen enhances immunological functioning, while andro- Have you been tired more than usual?
gen suppresses it. Therefore, women are especially prone How would you describe the stress in your life?
to autoimmune diseases, whereas men are more prone to Are you currently taking immunosuppressive
immunosuppressive disorders. Poor nutritional status and medication?
emotional stress lead to increased susceptibility to infec-
Objective Data
tions. Radiation therapy and a variety of medications, such
as corticosteroids and chemotherapeutic agents, suppress Nasal stuffiness
the immune system. Sneezing
Watery discharge from the nose
Skin rash or hives

ASSESSMENT Puffy swollen eyelids

Difficulty breathing
Physical assessment of the immune system involves the Fever
entire body. The skin and mucous membranes are evaluated Increased pulse and respirations
for urticaria, inflammation, or bleeding. Superficial head, Enlargement and tenderness of lymph nodes
neck, supraclavicular, axilla, and inguinal lymph nodes are Weight loss
inspected and palpated for redness, tenderness, or swelling.

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 CHAPTER 16 Immune System 547

and activate the release of chemical mediators, such as his-

Table 16-4 Common Diagnostic Tests tamine, bradykinin, and serotonin. These chemicals cause
for Immune System Disorders vasodilation, enhanced capillary permeability, and bronchoc-
onstriction (Figure 16-3).
• Antinuclear antibodies (ANA) The most common Type I reactions include allergic
• Complement assay (Total complement, C3 and C4) rhinitis, urticaria, and angioedema. Anaphylaxis is the most
• C-reactive protein test (CRP)
severe and is covered separately.
Allergic rhinitis, also known as hay fever or pollinosis, is a
• CD4 T-cells common allergy in our society caused by airborne allergens
• Enzyme-linked immunosorbent assay (ELISA) such as pollen, mold, animal dander, dust, and ragweed.
Symptoms include nasal congestion; thin, clear, watery dis-
• Erythrocyte sedimentation rate (ESR or Sed Rate Test)
charge; sneezing; itching; swelling; and redness of the eyes.
• Human leukocyte antigen DW4 (HLA-DW4) Headaches and ear infections may also develop. Approxi-
• Lupus erythematosus test (LE Prep) mately 12.2 million office visits to health care providers each
year are for allergic rhinitis (Centers for Disease Control and
• Polymerase chain reaction (PCR) Prevention, 2008e).
• Red blood cell count (RBC count) Urticaria (hives) are raised pruritic, red, nontender
• Rheumatoid factor (RF) wheals on the skin. They are usually on the trunk and on the
areas of the extremities closest to the trunk.
• Total white blood cell count Angioedema, edema of subcutaneous layers and mucous
Differential count membranes, is painless and only slightly pruritic.
Neutrophils
Drug and food allergies are also Type I hypersensitiv-
ity. Any drug potentially may cause a drug reaction, but
—Segs (mature neutrophils) common ones include penicillin, cephalosporins, codeine,
—Bands (immature neutrophils) pain medications, vaccines, and local anesthetics. Reac-
COURTESY OF DELMAR CENGAGE LEARNING

tions vary from mild to severe. Usually, symptoms do not

Eosinophils
occur until the client has taken several doses of the medi-
Basophils cation, although they can occur at first exposure. The most
Lymphocytes common reaction is the sudden development of a bright
red, itchy rash, often appearing initially on the trunk or
Monocytes arms. Occasionally, a client may develop an anaphylactic
• Western blot reaction.
Although individuals may be allergic to any edible sub-
stance, certain foods, such as milk, shellfish, eggs, wheat, and
nuts, are common allergens. According to the CDC (2008a), 4
COMMON DIAGNOSTIC TESTS of every 100 children in the United States have a food allergy.
Diarrhea is a result of immunological reaction in the intestinal
Commonly used diagnostic tests for clients with symptoms of
immune system disorders are listed in Table 16-4.
Allergic response

First exposure
HYPERSENSITIVE IMMUNE
RESPONSE Allergen IgE
IgE

H ypersensitive immune responses include allergies, ana-

phylaxis, transfusion reactions, transplant rejection, and
latex allergy. IgE
Mast cell

B cell

■ ALLERGIES Second or subsequent exposure

A llergic disorders are the result of hypersensitivity

COURTESY OF DELMAR CENGAGE LEARNING

Allergen Allergen
(excessive reaction to a stimulus) of the immune system
IgE

to allergens (a type of antigen commonly found in the envi-

E

+
Ig

ronment). Allergens may be inhaled, injected, ingested, or IgE Bradykinin

IgE Mast cell Serotonin Symptoms:
contacted. There are four types of hypersensitivity reactions Histamine Vasodilation
based on how tissue is injured. Mast cell Increased
capillary
Type I reactions occur immediately upon exposure to permeability
a specific antigen. Upon first exposure to an allergen, IgE Bronchoconstriction
antibodies are produced. They adhere to mast cells. When a
subsequent exposure occurs, these cells attach to the antigen Figure 16-3 Allergic Response

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548 UNIT 6 Nursing Care of the Client: Body Defenses

mucosa. Headache, nausea, vomiting, rash, itching, and wheez-

ing may also develop. LIFE SPAN CONSIDERATIONS
Type II reactions are the destruction of cells or sub-
stances with antigens attached that either immunoglobulin G Allergy to Foods
(IgG) or immunoglobulin M (IgM) senses as being foreign.
Antibodies cause either lysis of the cells or accelerated phago- • Food allergies have increased among children in
cytosis. Hemolytic transfusion reactions are this type of reac- the United States during the past 10 years
tion. Transfusion reactions are discussed in detail later. by 18%.
Type III reaction involves IgG immune antigen- • Boys and girls have similar rates of food
antibody complexes. It is a local reaction evident after several allergies.
hours that may change from red skin to hemorrhage and
tissue necrosis. Occasionally, this is noted after penicillin or • Children younger than the age of 5 have
sulfonamide use. a greater rate of reported food allergies
Type IV is a delayed reaction involving sensitized T-lym- than children between the ages of 5 to 17
phocytes coming in contact with the allergen. Contact der- years.
matitis and transplant rejection are examples of this type of • Children with food allergies are two to four
reaction. Poison ivy and poison oak are the most common times more likely to have other related condi-
causes of contact dermatitis. Latex rubber is a more recently tions such as asthma, compares with children
discovered cause of contact dermatitis or occasionally a Type I without food allergies.
(anaphylactic) reaction. Transplant rejection and latex allergy
are covered separately. (CDC, 2008a)

Medical–Surgical Management
Medical
Medical management of clients experiencing an allergic For instance, individuals who are allergic to pollen may need
response (reaction to allergen) includes drug therapy to to stay in air-conditioned environments on those days when
treat symptoms and identification of precipitating agents. the pollen count is extremely high.
Allergen immunotherapy (treatment to suppress or
enhance immunological functioning) involves repeated
injections of the diluted allergen. Decreased levels of hista-
mine are released upon subsequent exposure to the allergen.
Nursing Management
Venom can be used to treat allergies to bees, wasps, yellow- Teach the client that with allergic rhinitis to stay indoors
jackets, and hornets. when airborne allergens are present in great numbers. Ask
about pets in the house. Encourage the client to read labels if
there are food allergies and to inform all health care person-
Pharmacological nel if there are drug allergies. Assist the client to plan life-
Several medications are employed to treat the symptoms of style changes to avoid exposure to allergens. Emphasize the
an allergic response. Antihistamines counteract the effects importance of following the medication regimen prescribed.
of histamine. They may be taken orally, topically, or intra- Figure 16-4 outlines the differences between a cold and an
venously, depending on the type of allergic response and airborne allergy.
urgency for treatment. Nasal decongestants help relieve respi-
ratory symptoms. Topical corticosteroids effectively relieve
inflammation associated with contact dermatitis and dermati-
tis medicamentosa. Oral or injectable forms of corticosteroids NURSING PROCESS
may be used either alone or in combination with antihista-
mines and nasal decongestants. Assessment
Skin testing by a physician can determine the specific
causative allergen. Subjective Data
Take detailed, comprehensive client history, including
information about previous allergic reactions, foods eaten
Diet or medications taken recently, and contact with environ-
Individuals who are allergic to certain foods should be taught mental pollutants or anything not normally encountered.
to check food labels carefully, be aware of how food is The client may describe having nausea, pruritus, and being
prepared, and not eat any product that could lead to a reaction. uneasy.
This includes restaurant foods and foods prepared in another
person’s home.
Objective Data
Assess gastrointestinal and respiratory functioning, cardiovas-
Activity cular and neurological status, and the presence of urticaria,
Avoidance of the causative allergen prevents allergic reactions. angioedema, sneezing, excessive nasal secretions, diarrhea,
Activities should be centered around this, if at all possible. wheezes, cough, or hypotension.

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 CHAPTER 16 Immune System 549

Is It a Cold or an Allergy?
Symptoms Cold Airborne Allergy
Cough Common Sometimes
General Aches, Pains Slight Never
Fatique, Weakness Sometimes Sometimes
Itchy Eyes Rare or Never Common
Sneezing Usual Usual
Sore Throat Common Sometimes
Runny Nose Common Common
Stuffy Nose Common Common
Fever Rare Never
Duration 3 to 14 days Weeks (for example, 6 weeks for
ragweed or grass pollen seasons)

Treatment Antihistamines Antihistamines

Decongestants Nasal steroids
Nonsteroidal anti- Decongestants
inflammatory medicines

Prevention Wash your hands often Avoid those things that

with soap and water you are allergic to such
Avoid close contact as pollen, house dust
with anyone with a cold mites, mold, pet dander,
cockroaches

Complications Sinus infection Sinus infection

Middle ear infection Asthma
Asthma

Figure 16-4 Differences Between a Cold and an Airborne Allergy (National Institute of Allergy and Infectious Diseases. (2008).
http://www3.naid.nih.gov/topics/allergicDiseases/PDF/ColdAllergy.pdf.)

Nursing diagnoses for clients with allergies include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury, related to The client will identify factors Assist client in identifying those factors that increase
an allergic reaction that increase the potential of the potential for a reaction.
a reaction.
Health-Seeking Behaviors The client will relate methods Assist client in planning lifestyle changes that will help
related to causative to avoid exposure to in avoiding exposure to allergens.
allergen, therapeutic allergens.
modalities, and/or
preventive measures

(Continues)

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550 UNIT 6 Nursing Care of the Client: Body Defenses

Nursing diagnoses for clients with allergies include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The client will demonstrate Teach client about allergy treatments and what to do
related to lack of an understanding of and if a reaction occurs.
information about compliance with therapeutic
allergens, treatment, or modalities if a reaction
preventive measures occurs.
The client will demonstrate
an understanding of and
compliance with preventive
measures to avoid subsequent
allergic reactions.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ ANAPHYLACTIC REACTION CASE STUDY

A naphylaxis is a type I systemic reaction to allergens and

is the most serious type of allergic reaction. It occurs
in individuals who are extremely sensitive to an allergen.
Allergic Reaction
A client is stung by a bee and experiences an
allergic reaction with severe shortness of breath.
Symptoms develop suddenly and can progress to severe levels The client is transported to the local emergency
within minutes. Usually, the faster the reaction, the worse it is.
department.
Foods, drugs, hormones, insect bites, blood, and vaccines all
are associated with anaphylactic reactions. Shellfish, eggs, nuts, Answer the following questions and state the
berries, and chocolates are the most common foods involved. rationale for your answer.
According to the National Institute of Allergy and Infectious 1. Briefly describe the role of B-cells and T-helper
Diseases (2008a), peanut and tree nut allergies are the leading lymphocytes in immune physiology.
causes of anaphylaxis in the United States. Any medication has
the potential of causing a reaction, but antibiotics (especially 2. What role does the antigen play in an immune
penicillin), insulin, muscle relaxants, and x-ray dyes are the response?
most frequent precipitating agents. Bee, wasp, hornet, and 3. What is the difference between an “allergen”
snake bites may also cause anaphylactic reactions. According and an “antigen”?
to Golden (2007), anaphylaxis to insect bites occurs in 3% of
adults and can be fatal on the first reaction.
Anaphylactic reactions may be life-threatening. Symp-
toms involve the skin, GI tract, and cardiovascular and respira-
tory systems. Clients experience peripheral tingling, flushing, Medical–Surgical
Management
fullness in the mouth, throat/nasal congestion, tearing and
swelling around the eyes, itching, cough, laryngeal edema,
bronchospasms, severe dyspnea, vasodilation, and cyanosis. If Medical
untreated, these catastrophic effects lead to respiratory failure,
severe hypotension, anaphylactic shock, and death. Therefore, Medical management centers around establishing an intra-
it is crucial that symptoms be identified early and treatment venous line, administering fluids and emergency drugs, and
initiated immediately because death can occur in minutes. maintaining an airway. Provide oxygen via a nonrebreather
oxygen mask. In severe cases, endotracheal intubation or a
tracheotomy may be required.

CLIENTTEACHING Pharmacological
Severe Allergies Epinephrine is administered subcutaneously as soon as symp-
toms develop to dilate bronchioles, increase heart contrac-
• Advise clients with severe allergies to wear a tions, and constrict blood vessels. Antihistamines, such as
Medic Alert tag. diphenhydramine hydrochloride (Benadryl), block the effects
• Encourage clients who are allergic to insect of histamine in bronchioles, blood vessels, and the GI tract.
stings to carry an emergency anaphylactic kit
Corticosteroids are given for their anti-inflammatory effect.
Vasopressors, such as norepinephrine bitartrate (Levophed) or
containing epinephrine at all times.
dopamine hydrochloride (Intropin), may be needed to increase
blood pressure. If bronchoconstriction and spasms are severe,

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 CHAPTER 16 Immune System 551

albuterol (Proventil), metaproterenol sulfate (Alupent), and/

or aminophylline (Aminophyllin) may be administered. NURSING PROCESS
Diet Assessment
Clients will be NPO until normal respiratory and circulatory Subjective Data
function have been restored. Client history may reveal a previous anaphylaxis reaction. The
client may describe feelings of uneasiness, anxiety, weakness,
Activity itching, dizziness, nausea, peripheral tingling, and a general-
Clients will remain on bed rest until vital signs are stable ized warm sensation throughout the body.
and normal breathing patterns have been restored. Those
experiencing severe anaphylactic responses are generally Objective Data
transferred to intensive care units for continued treatment Because anaphylaxis is a sudden, unexpected event, be aware
and observation. that variations in a client’s cardiovascular and respiratory status
may be signs of an impending anaphylactic reaction. The first
Nursing Management symptoms are sweating, sneezing, tachycardia, hypotension,
dysrhythmias, cyanosis, edema of tongue and larynx, wheezing,
Monitor vital signs frequently as well as I&O. Administer IV bronchospasms, vascular collapse, and cardiac arrest. Regularly
fluids and medications as ordered. Teach client and family the assessing client’s vital signs and cardiovascular, respiratory, and
importance of providing the name of the causative agent and a neurological status will detect changes before the severe signs
description of the reaction when asked about allergies. of respiratory distress and impending shock develop.

Nursing diagnoses for clients with anaphylaxis include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Tissue Perfusion, The client will have adequate Monitor vital signs frequently. Place client in
related to increased capillary tissue perfusion. Trendelenburg position for hypotension.
permeability and vasodilation Monitor I&O. Administer IV fluids and medications
as ordered.
Ineffective Breathing The client will have effective Monitor vital signs.
Pattern related to breathing patterns. Maintain patent airway. Suction secretions as
bronchoconstriction, needed. Administer oxygen and medications as
laryngeal edema, and ordered.
increased secretions
Deficient Knowledge related The client will relate causative Teach client and family importance of avoiding
to causative allergen, allergen, therapeutic allergen and symptoms of anaphylactic reactions.
therapeutic modalities, and/ modalities, and preventive Teach client to provide the name of the causative
or preventive measures measures. agent and a description of reaction experienced
when asked about allergies.
Document allergy on all medical records.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ TRANSFUSION REACTIONS There are five types of transfusion reactions: febrile

B
nonhemolytic, allergic urticarial, delayed hemolytic, acute
lood components, such as whole blood, packed or frozen hemolytic, and anaphylactic. Febrile nonhemolytic reactions
red blood cells (RBCs), leukocytes, platelets, and plasma, are the most common and occur in clients who have had previ-
may be administered to clients when their own bodies are ous blood transfusions as a result of an antibody-antigen reac-
incapable of manufacturing them at a rate required to maintain tion to WBCs. Symptoms may develop soon after the infusion
vascular homeostasis. Any client receiving blood products has started or up to 5 to 6 hours after completion. Fever is the
that are allogeneic, or from a donor of the same species, may classic symptom and may be accompanied by chills, nausea,
develop a transfusion reaction. For this reason, some clients headache, hypotension, and respiratory problems. Clients who
are arranging to have their own blood collected, saved, and have allergic urticarial reactions develop a skin rash during or
available for infusion, if needed, during or following elective within 1 hour following the transfusion. A delayed hemolytic
surgeries. This is known as an autologous blood transfusion. reaction may occur days to weeks following the transfusion.
Immunological reactions do not develop with this type of The client’s hemoglobin level falls because of incompatibility
blood transfusion. of RBC antigens. This type of reaction is often misdiagnosed

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552 UNIT 6 Nursing Care of the Client: Body Defenses

CRITICAL THINKING
Pharmacological
If a febrile nonhemolytic or allergic urticarial reaction occurs,
Donor Blood Transfusion
diphenhydramine hydrochloride (Benadryl) and a corticosteroid
(hydrocortisone or prednisone) are administered to counteract
What are the pros and cons of receiving a blood the immunological response. Antipyretics are ordered to
transfusion from a donor? control fever. For life-threatening conditions, emergency medi-
cations are employed. (Refer back to Anaphylactic Reaction.)

Diet
and thought to be related to the condition that created the Clients should not be fed if a reaction is occurring, especially
need for blood replacement rather than a transfusion reaction. if respiratory symptoms have developed, because aspiration
An acute hemolytic reaction is potentially a life-threatening could occur.
situation. Symptoms, resulting from the incompatibility of
ABO groups, usually occur during the first 15 minutes of Activity
administration, but can develop anytime during the transfu-
sion. Clients complain of chills, nausea, and back pain. Fever, Clients should remain in bed until symptoms of the reaction
drop in blood pressure (hypotension), vomiting, hematuria, have subsided.
or oliguria may be observed. As the condition progresses,
chest pain, dyspnea, anuria, and shock develop. Anaphylactic Nursing Management
reactions, although rare, are also life-threatening. Symptoms of Follow agency protocol for use and administration of blood
acute gastrointestinal malfunctioning and cardiovascular and products. Assess vital signs before administration of blood
respiratory collapse develop moments after the transfusion products and at 15-minute intervals four times. Stay with the
has started. client for at least the first 15 minutes of administration. When
reaction occurs, stop transfusion, but keep saline going for IV
Medical–Surgical access if needed. Notify physician immediately.

Management NURSING PROCESS

Medical
Medical management of clients experiencing a blood trans- Assessment
fusion reaction depends on the type of reaction. Treatment
of a febrile nonhemolytic reaction includes stopping the
Subjective Data
blood, infusing normal saline, and treating the symptoms. Occasionally, clients verbalize the feeling of something “not
For clients experiencing an allergic urticarial reaction, the being right” or “something strange is going on in my body”
transfusion should be slowed and an antihistamine adminis- before actual symptoms become apparent. They may have
tered. Delayed hemolytic reactions often go undetected and itching, headache, or low-back pain.
untreated. Both acute hemolytic reactions and anaphylactic
reactions are medical emergencies. The transfusion must be Objective Data
stopped immediately. Normal saline and emergency drugs are Assess for any signs of a transfusion reaction, such as fever,
given intravenously. chills, or respiratory problems.

A nursing diagnosis for clients with transfusion reactions is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related to The client will not have injury Follow protocol for blood products and
infusion of allogeneic blood from infusion of allogeneic administration.
components blood products. Check client’s identification and blood product
with another nurse.
If a reaction occurs, stop transfusion immediately,
then call the physician.
Administer medications as ordered.
Send blood tubing and a urine specimen to the lab
for analysis.
Monitor and document client’s condition.
Teach client who has a blood transfusion reaction
to inform health care providers whenever
questioned about allergies.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 16 Immune System 553

elevated glucose level, impaired wound healing, mood swings,

■ TRANSPLANT REJECTION and masculinization in women. Cyclosporine may be toxic to

I
the kidneys and liver. Imuran may cause hair loss and lower
n 2005, more than 163,000 organ transplants were per- platelet level. OKT 3 also causes fluid retention.
formed in the United States (Department of Health and
Human Services, 2007). The success of these procedures is
directly related to matching antibodies and antigens of the Activity
donor and recipient and to the effectiveness of immunosup- Activity depends on the type of transplant. Clients who
pressive medications in preventing rejection. Immunosuppres- receive a major organ, such as a heart, lung, pancreas, or liver,
sive medications make the client prone to the development of are placed in reverse isolation in the hospital setting for at least
infections and cancers. Clients must have a regular medical 2 weeks. They are carefully observed for signs of rejection.
checkup, including cancer screening tests. Exposure to others is limited. Before discharge, they are taught
to avoid contact with anyone who may have an infection and
Medical–Surgical to wear a mask whenever out in public.
Management
Medical Nursing Management
Although blood components are the most common type Monitor vital signs, fluid balance, nutritional status, mental
of tissue transplants, today it is possible to transplant bone status, and cardiovascular and respiratory functioning. Prevent
marrow, corneal tissue, skin, kidneys, pancreas, hearts, livers, and contact with anyone who may have an infection. Teach client
lungs. Bone marrow and blood components often employ autolo- and family proper hand hygiene. Emphasize the importance of
gous donations. Allogeneic donations may be from living related taking all medications as prescribed.
donors or living nonrelated donors. Cadaveric donations are
harvested from individuals after they are pronounced clinically
dead. It is important to match ABO blood groups and human
leukocyte antigen (antigens present in human blood) to pre-
vent rejection when allogeneic and cadaveric donors are used.
NURSING PROCESS
Pharmacological
Assessment
A combination of immunosuppressive medications is used to Subjective Data
hinder rejection. Steroids such as prednisone (Deltasone) and Client history may reveal fear of possible transplant rejec-
methylprednisolone sodium succinate (Solu-Medrol) decrease tion. The client generally describes tenderness at the trans-
the inflammatory response. Cyclosporine (Sandimmune), anti- plant site.
thymocyte globulin (equine), ATG (Atgam), and tacrolimus
(Prograf) inhibit T-cells. Azathioprine (Imuran) inhibits purine
synthesis. Muromonab-CD3 (Orthoclone, OKT 3) prevents Objective Data
acute rejection in kidney transplant clients. Clients taking immu- After transplantation, carefully monitor clients’ vital signs, nutri-
nosuppressive medications are especially prone to developing tional status, fluid balance, urinary output, mental status, and
infections. Antibiotics may be prescribed prophylactically. respiratory and cardiovascular functioning. Weigh client daily.
Steroids cause fluid and sodium retention, low potassium Check wound sites frequently. Signs of rejection include fever,
level, elevated blood pressure, moon face, muscle wasting, weight gain, and swelling or tenderness at the transplant site.

Nursing diagnoses for clients with organ transplants include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Fear related to possible The client will relate less Allow client to verbalize concerns and develop
transplant rejection. fear regarding rejection. realistic expectations. Set aside time to sit down
and talk to client.
Deficient Knowledge The client will discuss signs Teach client and family about signs of rejection
related to home care and symptoms of rejection. and infection.
following transplantation The client will demonstrate Teach client and family ramifications of taking
an understanding of immunosuppressive medications. Teach client
the side effects of to watch for side effects and report them to
immunosuppressive drugs physician.
and lifestyle changes to
adapt to their effects.
(Continues)

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
554 UNIT 6 Nursing Care of the Client: Body Defenses

Nursing diagnoses for clients with organ transplants include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Infection related The client will demonstrate Teach client and family appropriate wound care
to immunosuppressive appropriate wound care. and proper hand hygiene.
medications The client will be free of Teach client importance of taking antibiotics
infection. as ordered, wearing a mask whenever out in
public, and regular checkups, including cancer
screening tests.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ LATEX ALLERGY SAFETY

S ince 1987, when universal precautions (now called Stan-
dard Precautions) were mandated, exposure to latex
by health care workers has dramatically increased. Today,
Latex Allergy

A Medic Alert tag stating “latex allergy” should be

between 8% and 17% of health care workers and less than 1% worn by any individual with a latex allergy.
of the general population are sensitized to natural rubber latex
(American Latex Allergy Association, 2009).
The latex proteins can enter the body through the skin and
mucous membranes, intravascularly, and by inhalation. The corn- of products are often available. An individual product may
starch powder on gloves absorbs the latex proteins and becomes be “latex free,” but an environment is “latex safe” only when
airborne when the gloves are put on or taken off. From the air, the all items of latex that might come in contact with the allergic
latex proteins may be inhaled or may be in contact with the skin individual are removed.
and mucous membranes. Anyone, client or health care worker,
who after exposure to latex develops red, watery, itchy eyes; sinus
or nasal irritation; hives; shortness of breath; dry cough; wheez-
ing; chest tightness; or flushing, tachycardia, and hypotension AUTOIMMUNE DISEASES

D
should be suspected of latex allergy.
Latex allergy has the potential to induce a life-threatening isorders in this category include rheumatoid arthri-
anaphylactic reaction with repeated exposure; avoidance of tis, systemic lupus erythematosus, and myasthenia
latex products is of utmost importance. Synthetic versions gravis.

CLIENTTEACHING
■ RHEUMATOID ARTHRITIS
Latex Safety
• Clients with latex allergy are at risk for cross-
reactivity to banana, avocado, chestnuts, kiwi,
R heumatoid arthritis (RA) is a chronic, systemic autoim-
mune disease characterized by joint stiffness. It affects
1.3 million people in the United States, and occurs in women
and passion fruit (NIAID, 2003). two to three times more often than men (Arthritis Founda-
• Clients with spina bifida, or who need tion, 2009e). Rheumatoid arthritis can affect anyone, including
multiple surgeries, have a risk of nearly 50% children, and onset usually occurs between 30 to 50 years of
of developing allergies to latex (American age. Clients with the genetic marker HLA-DR4 may have an
Academy of Allergy Asthma & Immunology, increased risk of developing rheumatoid arthritis (Arthritis
2007). These clients need to avoid exposure Foundation, 2009f).
to latex products such as gloves, band-aids,
The cause of RA is unknown, but there seems to be a
genetic predisposition (susceptibility) in many, but not all,
rubber bands, condoms, and latex birthday
persons affected. It is believed that something must trigger
balloons. the disease process such as a virus, bacterium, hormonal fac-
• Health care workers and others whose job tors, or stress. The person’s immune system attacks the cells
requires wearing latex gloves have nearly a 10% inside the joint(s), producing substances that act as antigens.
risk of developing a latex allergy (American Immune complexes are formed within the joint, causing
Academy of Allergy Asthma & Immunology, inflammation, swelling, and increased synovial fluid. As this
2007). chronic, systemic condition progresses, surrounding cartilage,
tendons, and ligaments become involved. Thickening of syn-
• Clients with latex allergy are instructed to avoid
ovial tissue eventually leads to calcification of the joint, joint
all latex products, including the powder/dust pain, limited mobility, and deformity.
from inside latex gloves. It is believed that the damage to the bones begins within
the first two years of the onset of RA. Early diagnosis and
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 16 Immune System 555

aggressive treatment are important to control the disease. promoting general health. Therapeutic regimen includes med-
Usually, the joints of the hand and wrist are affected initially. ications, exercise, rest, hot and cold applications, and stress
As the disease progresses, shoulder, elbow, hip, knee, ankle, management. Currently researchers are working on develop-
and cervical spine joints become affected. The pattern of joint ing and testing a vaccine for the prevention of rheumatoid
involvement is symmetrical (i.e., if a joint is affected on the arthritis (Arthritis Foundation, 2009a).
right side of the body, the same joint will also be affected on
the left side) (Arthritis Foundation, 2009). Other areas of the Surgical
body where connective tissue is present may also be involved, Hip, knee, and finger joints may be surgically replaced. Refer
such as blood vessels, lining of the lungs, and pericordial sac. to the Musculoskeletal System chapter for a discussion of joint
Clients experience periods of remission, a decrease or replacement.
absence of symptoms, and exacerbations, an increase in symp-
toms. Both physical and emotional stressors lead to increased Pharmacological
symptomatology. This means that simple tasks such as answering Nonsteroidal anti-inflammatory drugs (NSAIDs) and salicylates
the telephone or buttoning clothes may become very challenging. have the potential to relieve symptoms such as joint pain, stiffness,
and swelling but do not control the disease. Disease-modifying
Medical–Surgical Management antirheumatic drugs (DMARDs) have the potential to modify
the disease and should be given early in the disease to control
Medical progression. The commonly used DMARDs include prednisone
Medical management centers around reducing inflammation, (Deltasone), gold salts, and sulfasalazine (Azulfidine EN-Tabs)
relieving pain, slowing down or a stopping joint damage, and (Table 16-5). Aggressive treatment includes disease-modifying

Table 16-5 Medications Used to Treat Rheumatoid Arthritis

DRUG USE/ACTIONS SIDE EFFECTS NURSING CONSIDERATIONS
Salicylates
• aspirin Inhibit prostaglandin GI upset, tinnitus, easy Instruct client to take with food
synthesis resulting bruising, nausea, prolonged or take enteric coated aspirin
in decreased pain. bleeding time. and to report ringing in ears.
(Analgesia) antipyretic Do not give to clients on oral
and anti-inflammatory anticoagulants. Assess for
effects. bleeding/bruising.

Nonsteroidal Anti-
inflammatory Drugs
(NSAIDs)
• ibuprofen (Motrin, Inhibit prostaglandin GI irritation, nausea, Administer with food. May
Rufen) synthesis. Reduce vomiting, heartburn. GI prolong bleeding time, may
• naproxen (Naprosyn) joint swelling stiffness. bleeding and ulceration, require frequent blood count.
• phenylbutazone Analgesic and antipyretic dizziness, headache, liver
(Butazolidin) properties. toxicity.
• nabumetone (Relafen)

Indole Analogues
• indomethacin (Indocin) Analgesic anti- Gastric bleeding, Administer with food. Instruct
• sulindac (Clinoril) inflammatory effect. headaches, dizziness, client to report any bleeding
psychiatric disturbances. (tarry stools, hematemesis).
Avoid giving aspirin.

Corticosteroids
• prednisone (Deltasone) Decreases inflammation. GI irritation, muscle Administer with food. Weigh
weakness, fluid retention, daily. Monitor BP, sleep pattern,
moon face, muscle wasting, and serum potassium.
impaired wound healing.

Antimalarials
• hydroxychloroquine Not a drug of choice. Visual disturbances, Monitor CBC and liver function
sulfate (Plaquenil Sulfate) nightmares, skin lesions, tests. Discontinue after 6 months
nausea, diarrhea, low blood if no beneficial effects noted.
count.

(Continues)

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556 UNIT 6 Nursing Care of the Client: Body Defenses

Table 16-5 Medications Used to Treat Rheumatoid Arthritis (Continued)

DRUG USE/ACTIONS SIDE EFFECTS NURSING CONSIDERATIONS
Gold Salts Remind client to keep all
• auranofin (Ridaura) Anti-inflammatory effect. Diarrhea, nausea, vomiting, physician appointments.
jaundice. Beneficial effects may take
3 months to appear.

Chelating Agent
• penicillamine (Depen) Palliative when other Bone marrow depression, Give on empty stomach.
medications have failed. fever, rashes, blood Have epinephrine 1;1,000
dyscrasias, liver toxicity. handy for anaphylaxis.
Fluids to 3,000 mL/day to
prevent renal failure.

Sulfonamide
• sulfasalazine (Azulfidine For clients who do not Anorexia, headache, Give with food. May discolor
EN-TABS) respond well to NSAIDs. nausea, vomiting, gastric urine or skin yellow-orange.
distress, reversible Take at least 2–3 L/day of
oligospermia. water. May increase sensitivity
to sun.

Immunomodulator
• adalimumab (Humira) Decreases inflammation Increased risk for infections, Drug must be refrigerated but
and inhibits progression redness and pain, itching, not frozen. Comes in pre-filled
of structural damage. swelling and/or bruising at syringes and is injected into the
the injection site. abdomen, upper arm, or thigh.

• etanercept (Enbrel) Delays structural Redness and pain, itching, Comes in pre-filled syringe or
damage and improves swelling and/or bruising at pen device. The needle cover
physical function. the injection site. contains latex; do not handle if
sensitive to latex. Drug must be
refrigerated and allowed to come
to room temperature before
administration.

Immunosuppressant
• azathioprine (Imuran ) For clients that are Bone marrow depression, Take with food. Improvement
nonresponsive to loss of appetite, liver may take 6 to 12 weeks.
conventional therapy. problems, low blood
counts, unusual tiredness
or weakness.

Antibiotic
• minocycline (Minocin) Increasingly being used Cramps or burning of Take on an empty stomach.
for clients that do not the stomach, diarrhea,
respond to conventional darkening of the skin,
therapy. dizziness, light-headed
or unsteadiness, liver
problems, and sun
sensitivity.
COURTESY OF DELMAR CENGAGE LEARNING

Antimetabolite
• methotrexate For clients that do not Bone marrow depression, Take tablets at bedtime with an
(Rheumatrex, Trexall) respond well to NSAIDS. increased sun sensitivity, antacid to minimize GI upset.
hair loss, liver problems, Monitor CBC and liver function
low blood counts, mouth tests.
sores, yeast infections.

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 CHAPTER 16 Immune System 557

antirheumatic drugs such as methotrexate, hydroxychloroquine anemia develop, along with malaise, loss of appetite, fatigue,
(Plaquenil), sulfasalazine (Azulfidine), a biologic agent such as and muscle weakness. Obtain information about periods of
etanercept (Enbrel), or adalimumab (Humira), or a combination remissions and exacerbations as well as the client’s under-
of both a biologic and a DMARD (Arthritis Foundation, 2009b). standing of and compliance with the treatment regimen.
Because of the large doses required to control inflammation and
the long-term use because of the chronicity of this condition, Objective Data
side effects often develop. In severe cases, azathioprine (Imuran),
hydroxychloroquine sulfate (Plaquenil Sulfate), D-penicillamine Assessment of the hands may reveal the classic deformities
(Depen), or methotrexate sodium (Rheumatrex) may be used. associated with RA: boutonniere deformity (fixed flexion
These medications also have serious side effects. Minocycline, an of the proximal interphalangeal joint and hyperextension of
antibiotic, is increasingly being used to treat rheumatoid arthritis. the distal interphalangeal joint), ulnar drift (deviation of the
Researchers have been investigating the use of the antimalarial fingers to the ulnar side of the hand), and swan-neck defor-
drug, hydrochloroquine in protecting clients with RA from devel- mity (fixed flexion of the distal interphalangeal joint and
oping diabetes (Arthritis Foundation, 2009b). hyperextension of the proximal interphalangeal joint). Figure
16-5 illustrates these changes in the hands.
Skin may show the presence of ulcers, caused by vasculi-
Diet tis, and moveable, subcutaneous skin nodes, known as rheu-
Clients should eat a nutritious, well-balanced diet. Poorly matoid nodules. Eye tissue may be inflamed. Reduction in tear
nourished individuals are prone to infections. For clients with and saliva production can occur, causing dryness of the eyes,
RA, an infection results in exacerbation of symptoms. Foods mouth, and mucous membranes. This is known as Sjögren’s
high in iron are encouraged when RBCs are low. syndrome. The client may have weight loss and an elevated
temperature.
Activity X-rays demonstrate the amount and degree of defor-
Because joint mobility is a major problem, occupational and mity. No specific laboratory test confirms a diagnosis of
physical therapists are part of the therapeutic team. Range- RA, although alterations in the following may occur: RBCs
of-motion exercises, resting splints, and assistive devices such as decrease (anemia) as the disease progresses, elevation of
canes and hand rails are often employed to promote mobility. WBCs, erythrocyte sedimentation rate (ESR), antinuclear
antibodies (ANAs), C-reactive proteins, and platelet count.
Nursing Management
The rheumatoid factor (RF) is present in about 75% of adult
clients with RA (Daniels, 2010).
Encourage the client to practice relaxation techniques and
take a warm shower to relieve joint stiffness and pain. Empha-
size the importance of doing ROM exercises several times a
day and to have planned rest periods. Teach the client to use
assistive devices such as handrails, tools to pick up objects,
raised toilet seat, walker, or cane.

NURSING PROCESS
Assessment
Subjective Data
Client history frequently reveals a gradual development of
symptoms, beginning initially with early-morning stiffness
and pain in finger joints. Eventually, other joints become Figure 16-5 Arthritic Hands (Courtesy of the Arthritis
involved. Fatigue, weight loss, temperature elevation, and Foundation.)

Nursing diagnoses for clients with rheumatoid arthritis include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Chronic Pain related to The client will relate Teach client about prescribed analgesics and anti-
swollen, inflamed joints appropriate use of anti- inflammatory medications.
inflammatory medications. Encourage client to practice relaxation techniques and take
The client will relate methods warm shower to relieve early morning joint stiffness and
to decrease pain. pain. Use hot and cold packs to decrease muscle spasms.
Teach client proper body alignment and to avoid
using pillows under the knees, which leads to
pooling of blood in the feet.

(Continues)

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 Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.

558 UNIT 6 Nursing Care of the Client: Body Defenses

Nursing diagnoses for clients with rheumatoid arthritis include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Physical Mobility The client will demonstrate Teach hospitalized clients to use the overhead
related to edema, and joint measures to maintain joint trapeze when moving in bed and to change
immobility mobility. position frequently.
The client will demonstrate use Assist with ROM exercises and maintain planned
of adaptive devices. rest periods.
Teach client use of assistive devices, such as
handrests, tools to pick up objects, or three-legged
canes, as needed.
Check with occupational and physical therapists for
available equipment. Assist client to use handrails
in tub, shower, and toilet; raised toilet seat; and
rubber-tipped walker or cane.
Bathing/Dressing/Grooming The client will bathe, dress, Encourage client to stop and rest when tired.
Self-care Deficit related and groom to abilities. Teach self-care using assistive devices, as required.
to joint inflammation or Recommend shoes with Velcro® closures.
deformity
Assist with routine plan for ADLs.
Fatigue related to chronic The client will state less Explain that fatigue is a common symptom of
inflammatory process fatigue. autoimmune disorders. Plan rest periods between
activities.
The client will establish Allow the client to express feelings about altered
priorities for daily activities. lifestyle.
Inform client of community services such as Meals
on Wheels.
The client will balance daily Help identify activities client should perform
activities with periods of rest. and what can be delegated. Instruct client to
record level of fatigue and activities performed
on an hourly basis for 24 hours. One method uses
0 to 10 scale (0 = not tired, peppy; 10 = totally
exhausted).
Help plan important tasks during high-energy
periods and distribute difficult ones throughout
the week.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

criteria include a malar rash (over cheeks); discoid rash; photo-

■ SYSTEMIC LUPUS sensitivity; oral ulcers; arthritis; serositis (pleuritis or pericarditis);
ERYTHEMATOSUS excessive protein or cellular casts in the urine; seizures or psycho-

S
sis; hemolytic anemia, or leukopenia, or lymphopenia, or throm-
ystemic lupus erythematosus (SLE) is a chronic, progressive, bocytopenia; and positive for LE cells, or anti-DNA antibody, or
incurable autoimmune disease affecting multiple body organs. anti-Sm, or a false-positive syphilis test. If four or more of these
It is characterized by periods of exacerbation (flares) and remission. criteria are present, a client is diagnosed with SLE.
SLE occurs most commonly in women during their childbearing
years and is 2 to 3 times more common in African-American
women (Lupus Foundation of America, 2009). In clients with Medical–Surgical Management
SLE, abnormal B-lymphocyte cells produce autoantibodies that
destroy body cells. Immune complexes are formed and circulate in Medical
serum, causing inflammation and tissue damage in the skin, brain, Medical treatment is aimed at decreasing tissue inflammation and
kidney, lung, heart, or joints. Production of these autoantibodies destruction. A knowledgeable client can assist in controlling the
is influenced by genetic predisposition, medications, infections, disease process through stress management, rest, exercise, taking
stress, and sunlight (ultraviolet light rays). medications as prescribed, and immediately reporting symptoms
No single test is conclusive for a diagnosis. The American to the health care provider. During acute exacerbations, plasma-
College of Rheumatology has established criteria for SLE. These pheresis may be used. This treatment modality involves removal
 CHAPTER 16 Immune System 559

CRITICAL THINKING
CLIENTTEACHING
Lifestyle Implications
Systemic Lupus Erythematosus
• Get adequate rest. What are the lifestyle implications of being diag-
• Use stress-reduction techniques such as nosed with a chronic disease such as rheumatoid
visualization, guided imagery, meditation, or arthritis or systemic lupus erythematosus?
yoga.
• Avoid exposure to sunlight; use sunscreen.
• Involve family and friends in care.
Nursing Management
• Report fever, chills, anorexia, or symptom
Teach the client the importance of avoiding direct sunlight and
the use of protective clothing and sunscreen (SPF 15 or higher).
worsening to health care provider immediately.
Encourage the client to balance rest and activity and to eat a
• Never just stop taking medications. balanced diet with reduced sodium. Emphasize the signs of exac-
• Contact the Lupus Foundation of America, Inc., erbation (rash, fever, cough, or increased joint and muscle pain)
for information and support (see Resources at and early signs of infection. Provide emotional, psychosocial, and
the end of chapter). spiritual support.

NURSING PROCESS
Assessment
of the client’s plasma, processing it through a special machine to
eliminate various cellular elements, and reinfusing the cleansed
plasma. In SLE, autoantibodies are removed.
Because clients with SLE are prone to a variety of com-
Subjective Data
plications, they are carefully monitored for renal, cardiac, Ask when the disease began, what symptoms have developed, and
pulmonary, hematological, and neurological damage. A large how they have been treated. Note information about medications
percentage of SLE clients eventually develop renal failure, the client is taking and side effects, activity level, and degree of
requiring dialysis to maintain life. fatigue. Determine client’s understanding of the disease process,
how lifestyle has changed, and how effectively client is coping.
The client may describe having malaise, photosensitivity, pain in
Pharmacological joints, irregular menses, irritability, confusion, or hallucinations.
NSAIDs are used for muscle and joint pain. The lowest possible
dose of corticosteroid is used to suppress immune system activity. Objective Data
During periods of exacerbations, higher doses may be required. Most common findings include joint swelling and pain,
Prolonged use of these medications leads to multiple side effects. fever, swollen glands, nausea, vomiting, anorexia, hyperten-
Hydroxychloroquine sulfate (Plaquenil sulfate), an antimalarial sion, respiratory and cardiac infections, renal involvement,
agent, is used. Although the exact mechanism involved is unknown, enlarged liver and spleen, and skin lesions, especially the
it does work effectively in decreasing joint and skin problems. It classic “ butterfly” rash. Figure 16-6 shows an individual with
can lead to the development of retinal toxicity; therefore, clients a “butterfly” rash. If exposed to the cold, Raynaud’s phenom-
should have yearly eye exams. Cyclophosphamide (Cytoxan) or enon (intermittent attacks of diminished blood supply to
azathioprine (Imuran) may be used for severe SLE. fingers, toes, ears, and nose) may develop.
Laboratory tests frequently reveal serum antinuclear anti-
Diet bodies (ANA) and anti-DNA antibodies. Lupus erythematosus
Clients on corticosteroids are prone to developing hyperna- cells (LE cells) are present in most clients. Anemia, leukope-
tremia, hyperglycemia, hypokalemia, and fluid retention. Diet nia, and thrombocytopenia are evident.
should be low in sodium and glucose and high in potassium.
Excessive fluid intake should be discouraged.
Activity
Clients should be encouraged to sleep at least 8 hours a night
and rest periodically during the day. Regular exercise helps
prevent muscle weakness and fatigue.

PROFESSIONALTIP

RA and SLE
Clients with RA and SLE have common nursing
diagnoses of fatigue and impaired mobility. Clients
with SLE have an additional risk for infection if
WBC count is low. Figure 16-6 Butterfly Rash (Courtesy of the American
Academy of Dermatology.)
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560 UNIT 6 Nursing Care of the Client: Body Defenses

Nursing diagnoses for a client with SLE include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Skin Integrity The client will participate in Teach client to clean and dry area prior to
related to presence of a plan to promote wound application of topical corticosteroids.
butterfly rash, skin lesions, healing. Warn client that sunlight and ultraviolet rays
Raynaud’s phenomenon, increase symptoms and tanning sessions are
and/or oral ulcers contraindicated.
Encourage client to wear protective clothing,
sunscreen of at least SPF 15, and sunglasses.
In cold weather, client should wear a hat and
gloves.
Encourage client in regular oral care to promote
healing of mouth sores.
Deficient Knowledge related The client will describe disease Teach client effects of disease and methods to
to adapting lifestyle with process, factors contributing control complications.
treatment and prevention of to symptoms, and regimen for Teach stress management techniques. Allow client
complications control. to vent feelings.
Help client plan methods to adapt lifestyle.
Encourage client to visit the physician on a regular
basis to monitor for early symptoms of major organ
involvement.
Advise client to have regular eye exam if taking
Plaquenil Sulfate.
Inform client of community support groups
available through the Lupus Foundation of
America, Inc. (see Resources).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

There are three possible complications: respiratory

■ MYASTHENIA GRAVIS distress, myasthenic crisis, and cholinergic crisis. Clients

M
need to be carefully monitored for early signs of respiratory
yasthenia gravis (MG) is an autoimmune disease distress, such as dyspnea, tachypnea, tachycardia, and
characterized by extreme muscle weakness and fatigue diaphoresis.
caused by the body’s inability to transmit nerve impulses to Myasthenia crisis is an acute emergency characterized by
voluntary muscles. It is thought that clients with MG develop increased muscle weakness; difficulty swallowing, chewing, or
antibodies that act to decrease the number and effectiveness talking; and respiratory distress. It occurs in newly diagnosed
of acetylcholine receptor sites at neuromuscular junctions. clients who are not responding to anticholinesterase medica-
Voluntary muscles are most commonly involved, especially tions following infections, surgery, or delivery of a child.
those innervated by cranial nerves. Muscle weakness increases Cholinergic crisis is the result of an overdose of anticho-
during periods of activity and improves after a period of rest. linesterase medications. Physical symptoms of both myasthe-
Severity of symptoms varies. In mild conditions known as nia crisis and cholinergic crisis are the same. An edrophonium
Group I ocular myasthenia, only the eye muscles are involved. chloride (Tensilon) test is used to differentiate between the
As severity increases, symptoms of Group II generalized myas- two. Tensilon is administered intravenously; symptoms of
thenia develop: Facial, neck, skeletal, and respiratory muscles clients experiencing a myasthenia crisis will be relieved within
become affected. The thymus gland is enlarged in most cli- seconds, whereas clients in cholinergic crisis will show no
ents. Anti-ACh receptor antibodies are produced in this organ. response. Atropine is administered to counteract the effects of
MG affects men more frequently than women, with the onset excessive amounts of anticholinesterase drugs. The treatment
of symptoms after age 50. Periods of remission and exacerba- goal for both is restoration of normal respiratory functioning
tion occur, usually during the first few years. and alleviation of symptoms.

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 CHAPTER 16 Immune System 561

Medical–Surgical PROFESSIONALTIP
Management
Medical Myasthenia Gravis
Medical management involves the use of anticholinesterase
medications and plasmapheresis, which removes anti-ACh Clients with myasthenia gravis experience
receptor antibodies. Because it affords only temporary relief problems similar to those with RA and SLE (e.g.,
of symptoms, it is used primarily for clients in acute crisis who fatigue and impaired physical mobility). Although
are not responding to drug therapy or before a thymectomy. A the cause, in this case, is weakness of voluntary
client’s relief of symptoms is a good indicator of how successful muscles, client goals and nursing interventions are
surgery might be. the same.

Surgical
Surgical removal of the thymus gland has shown the best
results in young people early in the course of the disease. In
some people, the weakness may completely disappear, but it Nursing Management
varies with each client. Teach the client airway protective techniques (e.g., double swal-
lowing, chin tuck). Encourage the client to change daily activ-
Pharmacological ity pattern for minimal energy expenditure, and to do ROM
exercises to help maintain muscle function. Emphasize the need
Anticholinesterase medications, such as pyridostigmine bro- to see the physician at the first sign of an upper respiratory infec-
mide (Mestinon), neostigmine bromide (Prostigmin), and tion. Advise client to avoid crowds during cold and flu season
ambenonium chloride (Mytelase), are prescribed early in and anyone known to have either.
the course of the disease and act to increase acetylcholine at
the neuromuscular junction. Dosages need to be individually
determined. Early side effects of overdosage include nausea,
abdominal cramping, vomiting, diarrhea, increased saliva, NURSING PROCESS
diaphoresis, and low pulse rate. Variation may occur in mus-
cle group responses for the same client. Steroids may slow
down the immunological response.
Assessment
Subjective Data
Diet Client describes muscle weakness, fatigue, and possibly dif-
Clients need to be encouraged to eat a snack before taking ficulty chewing or swallowing.
anticholinesterase medications to avoid GI irritation. If the
client’s ability to chew and swallow is affected, food should be Objective Data
chopped, mashed, or pureed. A commercial thickener can be
added to liquids to reduce the risk of aspiration. Sit upright Assess muscle groups affecting the eyes, face, neck, and chest,
when eating and do not talk. looking for diplopia (double vision), ptosis (drooping upper
eyelids), and facial symmetry. Note chewing or swallowing prob-
lems and weakness in arm and legs muscles as well as muscles
Activity used for breathing. Assess vocal tones and breath sounds.
Symptoms of MG increase with exercise. Clients should ACh receptor antibody and LE cell tests are often posi-
avoid excessive muscular activity and should rest periodically tive. X-rays and CT scans of the thymus gland are used to
throughout the day. ROM exercises, braces, splints, and walk- detect enlargement. Electromyogram (EMG) determines the
ers assist in keeping the client independent. extent of muscle damage.

Nursing diagnoses for a client with MG include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Breathing Pattern The client will have normal Monitor client’s respiratory rate and rhythm and
related to muscle weakness respiratory rate and rhythm breath sounds frequently.
and normal breath sounds
Administer oxygen as ordered. Notify physician
bilaterally.
immediately if respiratory problem develops.
Elevate head of client’s bed.

(Continues)

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562 UNIT 6 Nursing Care of the Client: Body Defenses

Nursing diagnoses for a client with MG include the following: (Continued)

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Aspiration related to The client will not experience Have client eat in a sitting position or with
impaired swallowing aspiration. head of the bed elevated. Teach client to
chew food well and swallow only small
bites. Request a special diet of thickened,
soft foods.
Suction oral secretions as required. Teach client to
suction secretions as needed.

Deficient Knowledge related The client will describe disease Teach client stress management techniques and
to disease process and process, factors contributing to methods to avoid infections.
understanding of methods symptoms, and regimen for
Teach clients to take medications at regularly
to control disease and control.
scheduled times to maintain appropriate level.
prevent complications
The client will practice health
Encourage client to wear a Medic Alert bracelet
behaviors needed to manage
indicating the name and dosage of medications being
the effects of MG and methods
taken. Refer to the Myasthenia Gravis Foundation for
to prevent complications.
information and support groups (see Resources).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with Myasthenia Gravis
M.H., a 29-year-old mother of two preschool children, was diagnosed with myasthenia gravis 2 years
ago. Initially, she had double vision and drooping eyelids, but after beginning a course of pyridostigmine
bromide (Mestinon), she went into remission. Recently, she has been experiencing facial, neck, and chest
muscle weakness and is now admitted to the hospital for evaluation. Occasionally, she has difficulty swal-
lowing and breathing. Her thymus gland is enlarged. She has asked the nurse to teach her some strate-
gies for managing this chronic illness.
NURSING DIAGNOSIS 1 Ineffective Breathing Pattern related to respiratory muscle fatigue as evi-
denced by facial, neck, and chest weakness
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Respiratory Status: Ventilation Airway Management
Energy Management
Neurologic Monitoring

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

M.H.’s respiratory rate and Assess M.H.’s breathing patterns Detects early signs of respiratory
rhythm and breath sounds will q2h. distress.
remain within normal limits.
Ask M.H. to notify the nurse May be reluctant to call the nurse
immediately if she has any and needs to be encouraged to
breathing difficulties. do so.
Notify physician immediately if Physician must determine the cause
respiratory problems develop. and if a tracheostomy is needed.

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 CHAPTER 16 Immune System 563

SAMPLE NURSING CARE PLAN (Continued)

EVALUATION
M.H.’s respiratory rate and rhythm have remained within normal limits.

NURSING DIAGNOSIS 2 Risk for Aspiration related to impaired swallowing as evidenced by diffi-
culty swallowing
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Neurological Status Aspiration Precautions
Respiratory Status: Ventilation Neurologic Monitoring

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

M.H. will not experience Position M.H. to eat in a sitting Promotes passage of food into
aspiration. position. the stomach.
Teach M.H. the importance of Can cause aspiration.
thoroughly chewing food, and
swallowing only small bites.
Have oral suctioning equipment Readily available if required.
at the bedside.

EVALUATION
M.H. has not aspirated. She makes a point of always sitting up when eating.

NURSING DIAGNOSIS 3 Deficient Knowledge, related to disease process and understanding of

methods to control effects of myasthenia gravis and prevent complications as evidenced by verbalization
of need for future teaching

Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)

Knowledge: Disease Process Teaching: Disease Process
Knowledge: Energy Conservation Teaching: Individual

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

M.H. will practice health behav- Assess M.H.’s prior knowledge of Provides a basis for planning
iors needed to manage the ef- MG and methods of controlling teaching.
fects of MG and prevent compli- the effects of prescribed
cations. medications and preventing
complications.
Include M.H.’s family members in Fosters implementation of
teaching sessions. regimen at home.
Teach M.H. and family members Information about one’s disease,
basic information about MG, medications, and when to
the actions of anticholinesterase notify the physician is essential
medication, the need to take it knowledge the client and family
on a regular basis with a snack, members need to effectively
side effects of overdose, and manage this chronic illness.
the importance of notifying
the physician of any signs of
respiratory problems or infection.
(Continues)

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564 UNIT 6 Nursing Care of the Client: Body Defenses

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Encourage M.H. to wear a Medic Provides accurate information to
Alert bracelet, which lists here medical personnel in case of an
name, diagnoses, and dosage of emergency.
prescribed medications.
Provide M.H. with the address Facilitates future attainment
and telephone number of the of knowledge and possible
Myasthenia Gravis Foundation involvement with a support
and encourage her to contact group.
them for additional information
and support.

EVALUATION
M.H. and her husband related information about MG, action and side effects of Mestinon, signs and
symptoms to watch for, and when to notify the physician. She has obtained a Medic Alert bracelet and
has contacted the MG Foundation. She plans to attend the next local chapter meeting.

are very infectious during this period, with large quantities of

INADEQUATE HIV present in genital secretions.
IMMUNOLOGICAL RESPONSE Most individuals will remain symptom free for years
(10 or more), but some may begin to have symptoms in a few

T his category includes HIV/AIDS; pulmonary, gastro-

intestinal, oral, gynecological, and central nervous
system opportunistic infections; and opportunistic malig-
months. During this “asymptomatic” period, HIV is multi-
plying, infecting, and killing the CD4 T-cells of the immune
system.
nancies. A variety of symptoms become evident as the CD4
T-cells disappear. Lymph nodes enlarged for more than
3 months are one of the first symptoms. Others may include
weight loss, lack of energy, fevers and sweats, persistent skin
■ HIV/AIDS

A lthough allergies are hypersensitive immune responses,

and autoimmune diseases literally have the body attack-
ing itself, acquired immunodeficiency syndrome (AIDS) is a Initial
exposure
disease that causes an inadequate immunological response by
the body. The human immunodeficiency virus (HIV) may be
acquired anytime after conception. Primary HIV infection (Acute Infection)
Flu-like symptoms; develop antibodies
The human immunodeficiency virus (HIV), a retro- to HIV in 1 to 6 months
virus that causes acquired immunodeficiency syndrome
(AIDS), was first reported in the United States in 1981. Asymptomatic HIV infection (HIV Seropositivity)
AIDS is a progressively fatal disease that destroys the immune Infectious but no evidence of illness except
positive HIV antibody test
system and the body’s ability to fight infection. By the end of
2007, it was estimated that 33 million people in the world were
living with HIV/AIDS (World Health Organization [WHO], Early HIV disease (Symptomatic Infection)
Persistent, unexplained fever, night sweats,
COURTESY OF DELMAR CENGAGE LEARNING

2008a). In the United States, 1,051,875 cases of AIDS had diarrhea, weight loss, fatigue, and lymphaden-
been reported by the end of 2007, and as many as 1,106,400 opathy; signs and symptoms may not occur
until 10 or more years after initial exposure.
may be infected with HIV (CDC, 2008d).
Following exposure to HIV and an incubation period of
Advanced HIV disease (AIDS)
2 to 4 weeks, some individuals, but not all, will experience CD4 T-cell count<
flulike symptoms such as fever, sweats, headache, myalgia, 200 cells/mm3
Have AIDS-defining disease
neuralgia, sore throat, GI distress, and photophobia (Figure
16-7). Many persons, if tested at this time, will test negative
because antibodies may not yet be present in the blood. In 2
or 3 weeks, these symptoms disappear. Infected individuals Figure 16-7 Continuum of HIV Disease

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 CHAPTER 16 Immune System 565

Gender
PROFESSIONALTIP Trends in HIV-related mortality reflect changes in the demo-
graphic patterns of the HIV epidemic. Although more men
Prevention for Health Care Workers than women are infected with HIV, the number of AIDS
cases in women in the United States has increased from 7% in
Health care workers are at risk for contracting HIV 1985 to 25% in 2001. By the end of 2005, the proportion had
because of being near blood, semen, vaginal fluids, decreased to 23% (CDC, 2008c).
and placentas. The health care worker needs to
follow standard precautions and wear gloves at all
Race Of the new AIDS cases reported in the United States in
2005:
times when in contact with these fluids. The health
care worker should wear goggles and a gown • African Americans accounted for 71.3/100,000
if there is potential of HIV contaminated fluids
population.
spraying or splashing into their eyes or on their • Hispanic Americans accounted for 27.8/100,000
clothes.
population.
• Caucasians accounted for 8.8/100,000 population.
• American Indian/Alaska Natives accounted for
rashes or flaky skin, persistent or frequent oral or vaginal yeast 10.4/100,000 population.
infections, PID that does not respond to treatment, and short- • Asian American/Pacific Islanders accounted for
term memory loss. Oral, genital, or anal herpes infection or 7.4/100,000 population (CDC, 2008)
shingles may also develop. The HIV/AIDS epidemic is growing most rapidly among
When the CD4 T-cell count is less than 200 cells/mm3 some minority populations (see Figure 16-8) and is a leading
(healthy persons have 1,000 or more CD4 cells/mm3) and cause of death of African-American men ages 25 to 44 (CDC,
the individual has 1 or more of the 26 clinical conditions that 2009b).
affect persons with advanced HIV disease, the individual is
considered to have AIDS. Most of the AIDS-defining condi-
tions are opportunistic infections (infections in persons
Modes of Transmission
with a defective immune system that rarely cause harm in There are many way to become infected with HIV. The
healthy individuals). Tuberculosis is the most common life- virus may be found in blood, semen, vaginal secretions,
threatening opportunistic infection affecting people living and breast milk of infected individuals. There is no evi-
with HIV/AIDS (WHO, 2008b). It kills nearly 250,000 peo- dence that HIV is spread through sweat, tears, urine, or
ple living with HIV each year, and is the leading cause of death feces. The saliva of infected individuals has the virus, but
among HIV-infected people living in Africa (WHO, 2008b). there is no evidence that it is spread to others through
The enzyme-linked immunosorbent assay (ELISA) kissing. The risk of infection from “deep kissing” and oral
is the basic screening test to detect antibodies to HIV. A sex is unknown. Tissue transplantation (including arti-
positive test result is always retested to rule out false-positive ficial insemination), blood transfusion, and needlesticks
results and/or technician error. A confirmatory test, the are high-risk situations but are relatively rare methods of
Western blot test, is always employed when the ELISA test transmission in the United States today. Having another
is positive. Results of both the ELISA and Western blot taken sexually transmitted infection such as chlamydia, genital
together have an extremely high accuracy rate. herpes, syphilis, or gonorrhea seems to make an individual
Obtaining a signed informed consent for testing is often more susceptible to becoming infected with HIV during
a nursing responsibility. Most states mandate a consent form sexual intercourse with an infected partner. Theoretically,
solely for HIV testing. Some states allow verbal consent and HIV is present in sufficient quantities in amniotic fluid,
a statement of the client’s consent signed by the health care
provider.
The FDA has approved the OraQuick Rapid HIV-1 Anti-
body Test, which provides results with over 99.3% accuracy in LIFE SPAN CONSIDERATIONS
20 minutes (FDA, 2004).
Life Span Considerations
Demographics of AIDS in Mark Cichocki (2007) wrote in an article for
the United States amazon.com titled HIV and the Older Adult—A
Growing Population, that there is a myth regarding
Demographics are viewed in terms of clients’ age, gender, and the population aged 50 years and older not having
race.
sex. This age group is sexually active, contracting
HIV, and needs to be assessed closely and asked
Age the same questions as the other population age
AIDS mainly affects people during the most productive years of groups as to their sexual behaviors. The 50 years of
their life. As of 2007, the age group with the highest number of age and older population also need to be educated
new HIV diagnoses (219, 601 cases) was persons between the about HIV, and how it is contracted to help reduce
ages of 35-39 (CDC, 2009).The estimated number of new cases the risk of transmission.
of AIDS among individuals younger than 13 in the United States
fell from 954 in 1992 to 28 in 2007 (CDC, 2009).

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566 UNIT 6 Nursing Care of the Client: Body Defenses

Percentages of AIDS Cases by Race/Ethnicity, Medical–Surgical

Reported in 2007—50 States and DC
Management
AIDS cases Medical
N = 37,281*
The goal of care is to keep the disease from progressing for
1% <1% as long as possible. The client’s chance of disease progression
can now be monitored by a viral load test that measures copies
of HIV RNA. The approved viral load test is the Amplicor
HIV-1 Monitor test, better known as the polymerase chain
reaction (PCR) test. It can be used to see if individuals with
HIV are at risk for getting sick, for checking the effects of
19% drugs taken by individuals with HIV to see if they are working
against the virus, and to distinguish the difference between
actual HIV infection in a newborn and maternally acquired
antibodies. The “ultra-sensitive” PCR test can measure as few
48% as 50 copies/mL of HIV RNA. There is no “safe” level of viral
load. The risk is less, but HIV can be passed to another person
if the viral load is undetectable.
31%
Pharmacological
The goal of anti-HIV treatment is to keep the viral load
as low as possible for as long as possible, ideally below
what the viral load test can detect. Currently available
antiretroviral drugs do not cure HIV/AIDS. Treatment is
American Indian/ usually begun at the time of seroconversion (evidence
Alaska Native Hispanic/Latino† of antibody formation in response to disease or vaccine).
Native Hawaiian/ In high-risk occupational exposures, treatment may be
Asian‡ Other Pacific Islander started immediately.
Black/African One group of drugs, called nucleoside analog reverse
White
American transcriptase inhibitors (NRTIs), interrupt HIV’s life cycle
*Includes 411 persons of unknown race or multiple races.
at an early stage. The spread of HIV in the body may be
†Hispanics/Latinos can be of any race. slowed and the onset of opportunistic infections may be
‡Includes Asian and Pacific Islander legacy cases. delayed by NRTIs, but these drugs do not prevent HIV
transmission to other individuals. This group includes
Taken from: HIV/AIDS surveillance by race/ethnicity (through 2007). zidovudine (Retrovir), formerly known as AZT, zalcit-
Retrieved 4-27-09 from www.cdc.gov/hiv/topics/surveillance/resources/
slides/race-ethnicity/index.htm abine (Hivid), didanosine (Videx), stavudine (Zerit),
lamivudine (Epivir), and abacavir (Ziagen). A combina-
Figure 16-8 Percentages of AIDS Cases by Race/Ethnicity tion of zidovudine and lamivudine (Combivir) is avail-
in 2007 (Centers for Dieseas Control and Prevention, 2009b, able. Zidovudine (Retrovir) may cause depletion of red or
Atlanta, GA.) white blood cells. If this depletion is severe, the drug must
be discontinued. Painful nerve damage and pancreatitis
may be caused by didanosine (Videx).
cerebrospinal fluid, pleural fluid, peritoneal fluid, and peri- Non-nucleoside reverse transcriptase inhibitors
cardial fluid whereby infection could occur with exchange (NNRTIs) are available to be used only in combination with
of these body fluids, particularly in health care settings
where contact with these fluids may occur. Behaviors asso-
ciated with increased risk of sexual transmission of HIV by
infected persons include unprotected sexual intercourse, MEMORYTRICK
multiple sex partners, failure to disclose HIV status, and
trading sex for money or drugs. Transmission of HIV can ABCs of HIV/AIDS Prevention
also take place by having contact with infected blood or
To protect oneself from acquiring HIV/AIDS,
sharing needles or syringes; it may also transmit from
mother to fetus during pregnancy or birth. remember these ABCs:
Sexual intercourse (anal, oral, vaginal) without using A = Abstinence
a condom is the most frequently reported risk behavior for
infection with HIV. Injection-drug use is the second most fre- B = Be Faithful
quently reported risk behavior for infection with HIV. When C = Condoms
HIV seropositive women take zidovudine (AZT) during
(CDC, 2008)
pregnancy and labor and zidovudine is given to the newborn,
perinatal transmission is significantly reduced.

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 CHAPTER 16 Immune System 567

CRITICAL THINKING
PROFESSIONALTIP
HIV and Lifestyle
HIV Testing
How might a person’s lifestyle change after receiv-
Although physicians are responsible for client ing a diagnosis of being HIV positive?
counseling, the nurse must know the information
to be able to answer questions and clarify the
client’s knowledge. Pretest counseling should
include the following:
• Ask why the client believes the test should be
done.
is referred to as highly active antiretroviral therapy or HAART.
• Explain the meaning of a positive or negative Researchers credit HAART with significantly reducing the
test result and the possibility of a false-negative number of AIDS deaths in the United States. Current guide-
result. lines recommend drug therapy for any client with symptom-
• Discuss risk reduction and ways to modify atic HIV disease (evidence of opportunistic infections or
behavior. tumors). For asymptomatic HIV-positive clients, drug therapy
is recommended if:
• Share state reporting requirements.
• Viral load test results are greater than 500 copies/mL,
• Ensure confidentiality of test results.
or
• Explain that there is often stress related to test
• The client’s CD4 T-cell count is under 500 cells/mm3.
results and possible reactions to learning the
results, such as depression or anxiety.
Health Promotion
• Discuss the potential negative social consequences
The CDC and the Occupational Safety and Health Admin-
of positive results.
istration (OSHA) have developed Standard Precautions to
• Assist the client in making a decision about testing. reduce the risk of health care personnel exposure to blood and
• Arrange a return appointment for the client to body fluids. Personal protective equipment should be worn
receive test results. while caring for all clients when there is a reasonable likeli-
hood of contact with any blood or body fluids.
Post-test counseling should include the following:
• Review the test results with the client.
• Assess the client’s understanding of the test ■ PULMONARY OPPORTUNISTIC
results.
INFECTIONS

C
• Allow the client to express feelings about the
test results. onditions discussed following include pneumocystis
• Review routes of HIV transmission. carinii pneumonia, histoplasmosis, and tuberculosis.
• Assess the client’s psychological condition
including the risk for suicide.
• Assess the client’s risk behavior and strategies PNEUMOCYSTIS CARINII
for reducing risk. PNEUMONIA
• Provide information about support groups and
Pneumocystis carinii pneumonia (PCP) is the most common
national/ local resources.
serious infection among HIV-infected individuals. PCP can
be prevented and treated, yet it also can be fatal. A marked
decrease in the number of AIDS clients diagnosed with PCP is
a result of initiation of prophylactic treatment when the CD4
T-cell count is 200 or less/mm3. Although Pneumocystis carinii
is found primarily in the lungs, it has also been reported in
other antiretroviral drugs. These include delavirdine (Rescrip- the adrenal glands, bone marrow, skin, thyroid, kidneys, and
tor), nevirapine (Viramune), and efavirenz (Sustiva). spleen of persons with AIDS.
The protease inhibitors interrupt HIV’s life cycle at a later Clinical signs and symptoms include fever, dyspnea,
step. These include ritonavir (Norvir), saquinavir mesylate nonproductive cough, and crackles. Initial diagnosis is made
(Fortovase, Invirase), indinavir sulfate (Crixivan), and nelfinavir by chest x-ray, which shows diffuse infiltrates. Fiber-optic
mesylate (Viracept). Nausea, diarrhea, and other GI symptoms bronchoscopy is the procedure of choice to obtain a definitive
are common side effects of protease inhibitors. diagnosis. During the bronchoscopy, sputum is obtained to
HIV can become resistant to any of three drugs, so com- demonstrate the presence of the organism.
bination treatments are necessary to effectively suppress the Current standard treatment for PCP includes either
virus. When NRTIs and protease inhibitors are combined, it intravenous pentamidine isethionate (Pneumopent,

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568 UNIT 6 Nursing Care of the Client: Body Defenses

Pentam 300) or sulfamethoxazole-trimethoprim (Bactrim,

Septra), given orally or intravenously. Oral sulfamethox-
azole-trimethoprim is the treatment of choice; however,
approximately one-third of people with AIDS eventually
INFECTION CONTROL
develop hypersensitivity reactions and must switch to
pentamidine for primary therapy. Prophylaxis against PCP TB
is a therapeutic necessity for all persons infected with A densely woven, snug-fitting mask (N95 partic-
HIV when the CD4 T-cell count is 200 or less. Primary ulate respirator) should be worn by all persons
prophylaxis refers to therapy for those considered at risk in contact with the person who has TB until the
for PCP based on the CD4 count to prevent infection with
person has received treatment for 2 to 3 weeks.
PCP. Secondary prophylaxis refers to therapy to prevent
recurrences in clients who have already had PCP. Cur- Persons with TB should also be taught to cover
rent guidelines recommend either oral sulfamethoxazole- their mouths while coughing and should wear
trimethoprim or aerosolized pentamidine for prophylaxis. a particulate respirator when they are out of
For those allergic to sulfamethoxazole-trimethoprim, pen- their room for tests.
tamidine diluted in sterile water administered by a Respi-
gard II nebulizer can be used.

HISTOPLASMOSIS The risk of transmission of TB to health care workers

Histoplasmosis is an infection caused by the fungus His- is highest during and immediately after procedures that
toplasma capsulatum. The fungus has been isolated in bird induce coughing. In the home and health care setting, cough-
droppings, dirt from chicken coops, and caves. The spores inducing procedures should be performed only in well-
from the fungus are introduced into the body by inhalation. ventilated areas.
Histoplasmosis is not specific to the lung. In most clients with Because of the upsurge of multidrug-resistant TB
HIV disease, histoplasmosis is disseminated (spread out). (MDR-TB), the CDC recommends treating with multiple
Histoplasmosis should be suspected if the person presents medications. Treatment is provided in two phases. In the
with fever of uncertain origin, cough, and malaise. initial treatment phase, the client receives isoniazid (Lani-
The diagnosis is confirmed by culture or biopsy of the azid), rifampin (Rifadin), pyrazinamide, and ethambutol Hcl
bone marrow, blood, lymph nodes, lungs, or skin. Initial treat- (Myambutol) or streptomycin sulfate for 2 to 6 months,
ment of histoplasmosis is usually IV amphotericin B. Oral depending on whether Mycobacterium tuberculosis is identified
ketoconazole (Nizoral) can be used for maintenance therapy. outside the lungs. In the continuation phase, treatment with
Prophylaxis against recurrence of histoplasmosis is provided two to four of the medications used in the initial phase is indi-
by itraconazole (Sporanox). cated for 4 to 6 months longer.

TUBERCULOSIS Nursing Management

Monitor vital signs and laboratory test results. Encourage
Mycobacterium tuberculosis, an acid-fast aerobic bacterium, is fluid intake of 2.5 to 3 L per day. Administer oxygen and
the cause of tuberculosis (TB). It is spread through airborne medications as ordered. Encourage the use of an incentive
particles and enters the body by inhalation. The particles spirometer, unless contraindicated. Reposition client at
usually lodge in the apex of the lungs; however, one-half to least every 2 hours. Plan for client rest periods during the
two-thirds of cases of HIV-associated or AIDS-associated TB day.
involve organs outside the lungs as well.
Clinical manifestations include fever, night sweats,
cough, and weight loss. People with AIDS will commonly
present with a productive cough and pleuritic pain. Diag- NURSING PROCESS
nosis is made by a combination of tests: skin testing with
purified protein derivative (PPD); examination and cul- Assessment
ture of sputum, urine, and other fluids; x-rays; and other
tests such as IVP. Subjective Data
The most common test for exposure to TB is the Assess the client’s ability to dress, bathe, ambulate, and so on.
Mantoux skin test, which consists of injecting 0.1 mL of Note the client’s perception of breathlessness.
(PPD) intradermally. A negative reaction does not rule
out infection. HIV-positive clients with a CD4 count lower
than 200/mm3 may no longer have an immune response to Objective Data
the PPD. The chest x-ray may reveal middle and lower lobe Assess the client’s respiratory rate, depth, and breath sounds.
infiltrates. A sputum specimen is smeared and stained with Note cough (productive or nonproductive), cyanosis, dys-
an acid-fast stain, then examined under the microscope for pnea, use of accessory muscles, and fever. Monitor arte-
acid-fast bacillus (AFB). Other body fluids such as urine, rial blood gas (ABG) results for decreased PaO2, increased
blood, and stool may also be tested for AFB. PaCO2, and decreased pH.

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 CHAPTER 16 Immune System 569

Nursing diagnoses for the HIV-positive client with pulmonary disorders

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Airway The client will mobilize Administer 2.5–3 L of fluid per day (oral or IV) to decrease
Clearance related to secretions effectively. thick secretions and medications as ordered to suppress
chronic, unrelieved cough, cough and decrease pain.
pain, or viscous secretions Reposition client every 2 hours and PRN.

Impaired Gas Exchange The client will maintain an Administer oxygen as ordered. Encourage use of incentive
related to inadequate SaO2 > 90%. spirometer, if not contraindicated.
ventilation/oxygenation

Ineffective Breathing The client will pace activities Plan care to allow rest periods.
Pattern related to fatigue to minimize fatigue.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

The virus lies dormant in tissues waiting to be reactivated in

■ GASTROINTESTINAL the immunocompromised client. The potential for infection
OPPORTUNISTIC INFECTIONS with CMV is increased during two periods: the perinatal period

D
through the preschool years, and later during the sexually active
isorders discussed following include Mycobacterium years.
avium complex, cytomegalovirus, cryptosporidiosis, CMV causes disease by destroying the brain, lung, retina, and
hepatitis, and HIV-wasting syndrome. liver, CMV infection has been identified in all parts of the gastro-
intestinal tract from the oral cavity to the perianal area. CMV can
be life-threatening for persons with suppressed immune systems.
MYCOBACTERIUM AVIUM Persons with HIV infection or AIDS may develop severe infec-
COMPLEX tions, including CMV retinitis that can lead to blindness.
Signs and symptoms of CMV include weight loss, fever,
Mycobacterium avium and Mycobacterium intracellulare are two diarrhea, and malaise. The diagnosis of CMV is based on
closely related mycobacteria that are grouped together and called microscopic identification of CMV from specific organs such
Mycobacterium avium complex (MAC). The source of exposure as the brain, lung, liver, or adrenal gland. Ganciclovir sodium
to MAC for humans is contaminated water, although it has been (Cytovene) is the drug of choice for treating individuals
isolated from soil, dust, sediments, and aerosols. In persons with infected with CMV. Maintenance therapy is required to pre-
AIDS, MAC involvement of the bowel is usually extensive, sug- vent relapse. Intravenous foscarnet sodium (Foscavir) has
gesting that the gastrointestinal tract may be the site of initial infec- been approved as an alternative therapy.
tion, with spread to other organs after that. The microorganism
can fill the bone marrow and lymph nodes.
The most common symptoms of MAC include chronic
fever, malaise, anemia, weight loss, diarrhea, and abdominal CRYPTOSPORIDIOSIS
pain. Often the client will appear cachectic because of mal- Cryptosporidium, a protozoan causing cryptosporidiosis, usu-
absorption. Because the symptoms are nonspecific, MAC is ally infects the epithelial cells that line the digestive tract. Trans-
often difficult to distinguish from other AIDS-related infec- mission is often by the fecal-oral route, but can be spread from
tions. MAC is usually disseminated at the time of diagnosis. animal to person as well as person to person. Cryptosporidium
Diagnosis is made by tissue biopsy and cultures of the lung, can also be spread by ingesting contaminated food and water.
bone marrow, lymph nodes, liver, or blood. Clinical signs and symptoms include profuse watery
Treatment for MAC infection may include one or more diarrhea. Abdominal pain, serious weight loss, abdominal
of the following medications: clarithromycin (Biaxin cramping, anorexia, low-grade fever, dehydration, electrolyte
Filmtabs) to treat disseminated MAC; and a combination of imbalance, and malaise may also be present. Diagnosis is made
amikacin sulfate (Amikin), azithromycin (Zithromax), cipro- by identifying the organism in fresh stool specimens.
floxacin hydrochloride (Cipro), cycloserine (Seromycin), and There is no effective treatment for cryptosporidiosis.
ethionamide (Trecator-SC). For persons with AIDS who have Antidiarrheals such as diphenoxylate hydrochloride with atro-
a CD4 count of less than 75/mm3, rifabutin (Mycobutin) is pine sulfate (Lomotil), loperamide hydrochloride (Imodium),
recommended for prevention of disseminated MAC. and opium tincture (Paregoric) should be given on a pro-
grammed schedule rather than PRN. Treatment is palliative
CYTOMEGALOVIRUS and focused toward the symptoms. This includes fluid and
electrolyte replacement (orally if possible), analgesics, and
Cytomegalovirus (CMV) belongs to the herpes virus group. occasionally the use of total parenteral nutrition (TPN).
Thus it shares the same phenomena of latency and reactivation. Anticryptosporidial agents are under investigation. Protecting

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570 UNIT 6 Nursing Care of the Client: Body Defenses

the integrity of the client’s perianal skin is extremely impor- be given routinely, not PRN. Treatment of anorexia includes
tant. A low-residue, high-protein, high-calorie diet helps main- megestrol acetate (Megace) or dronabinol (Marinol). Antim-
tain nutritional status. otility drugs such as loperamide hydrochloride (Imodium),
luminal acting agents such as kaolin and pectin mixture
(Kaopectate) and hormonal agents such as octreotide acetate
HEPATITIS (Sandostatin) are used to treat diarrhea. This makes eating
much easier. Oral nutritional supplements are most frequently
Only hepatitis B virus (HBV), hepatitis C virus (HCV), used for weight loss. TPN is usually considered a final option
and hepatitis D virus (HDV) are commonly seen with HIV except in cases of severe malnutrition, because of the risk and
infection. All three viruses have been associated with chronic expense involved.
infection and have similar transmission and risk factors. Risk
factors include exposure to blood or blood products, exposure
to contaminated needles and syringes, and multiple sexual
Nursing Management
contacts. Monitor stools for blood, fat, and undigested food. Keep peri-
Signs and symptoms include malaise, weakness, anorexia, rectal area clean and protect with ointment as ordered. Have a
nausea, vomiting, and right upper quadrant pain. Abnormalities schedule for turning the client. Encourage the client to drink
in bilirubin and hepatic enzymes may also occur. Diagnosis is fluids between meals and to use hard candy or chewing gum
made by serologic assays identifying antigens and antibodies. to stimulate saliva production. Monitor laboratory test results.
Interferon has been approved for treatment of chronic HBV Provide a prescribed diet in small frequent meals at room
and HCV and is being investigated for the treatment of HDV. temperature. Assist with oral hygiene before and after meals.
Response to therapy varies but is decreased with HIV infection. Weigh client daily. Administer antiemetics and antidiarrheals
as ordered.

HIV-WASTING SYNDROME
HIV-wasting syndrome is defined as unexplained weight loss
NURSING PROCESS
of more than 10% of body weight accompanied by weakness,
chronic diarrhea, and fever in those infected with HIV. Weight
Assessment
loss and malnutrition are related to reduced food intake, mal- Subjective Data
absorption of nutrients, and altered metabolism of nutrients. Ask the client about bowel habits and what causes and relieves
Some of the factors related to reduced intake include anorexia, diarrhea. Inquire about alcohol consumption because excessive
oral or esophageal lesions, nausea, neurologic or psychiatric alcohol intake depletes B vitamins and provides no nutrition.
conditions, fatigue, inadequate finances, and side effects of Note activities that cause fatigue. Discuss food likes/dislikes,
medications. Nutritional malabsorption is related to injury of food intolerances, and food intake for the previous 3 days.
the small intestine caused by opportunistic infections or by
HIV infection of the cells in the gastrointestinal tract. Oppor-
tunistic infections produce fever that depletes the body’s Objective Data
energy stores and causes weight loss. Assess the client’s skin integrity, including temperature, mois-
Signs and symptoms of HIV-wasting syndrome are anorexia, ture, color, vascularity, texture, lesions, areas of excoriation,
diarrhea, nausea, vomiting, changes in taste and smell, aphthous and wound healing. Note fever, weight, and daily nutritional
ulcers of mouth and esophagus, and abdominal pain. intake. Monitor laboratory values of nutritional status, includ-
Symptom control is the major focus for HIV-wasting syn- ing serum albumin, total protein, hemoglobin, and hematocrit,
drome. Medications to control nausea and vomiting should as well as stool specimens for ova and parasites.

Nursing diagnoses for the HIV-positive client with gastrointestinal disorders

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Fluid Volume The client will have Suggest client use hard candy or chewing gum to
related to nausea, normal skin turgor and stimulate saliva production if mouth is dry. Encourage
vomiting, diarrhea, or decreased frequency and client to drink liquids between (not with) meals.
inadequate oral intake amount of stools. Monitor and record intake and output. Monitor client
for evidence of electrolyte imbalance (hypokalemia,
hypochloremia, confusion, muscle weakness).

Imbalanced Nutrition: The client will eat 75% Provide the prescribed diet (usually low-residue, high-
Less than Body of prescribed diet and calorie, high-protein) in small frequent meals at room
Requirements maintain current weight. temperature. Provide oral hygiene before and after
related to anorexia, meals to enhance taste sensation.
dysphagia,
malabsorption, or side
effects of medications

(Continues)
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 CHAPTER 16 Immune System 571

Nursing diagnoses for the HIV-positive client with gastrointestinal disorders

include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Offer commercially prepared nutritional supplements
between meals. Weigh client daily.
Administer supplemental vitamins and minerals as
prescribed.
Administer antiemetics and antidiarrheals as ordered.
Teach client to keep a food diary and a
log of exacerbation and remission of signs and
symptoms.

Risk for Impaired Skin The client will maintain Monitor stool for presence of blood, fat, undigested
Integrity related to skin integrity. food and stool cultures for evidence of new infections.
diarrhea, malnutrition, Protect the perirectal area by keeping it clean and
decreased mobility using compounds such as Aloe Vesta cream.
Avoid prolonged pressure on bony prominences by
a scheduled turning plan. If nonambulatory, provide
client with a pressure relief mattress. Use soft sheets
on the bed and avoid wrinkles.
Teach client to use nondrying soaps and to pat skin dry.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ ORAL OPPORTUNISTIC ORAL HAIRY LEUKOPLAKIA

INFECTIONS Oral hairy leukoplakia (OHL) usually appears as a white patch

C
on the lateral borders of the tongue as shown in Figure 16-10.
andidiasis and leukoplakia are discussed following. It is caused by the Epstein-Barr virus. The lesions are rarely
in other areas of the mouth and are different in appearance
from candidiasis. The irregular surface of the lesion appears
as projections that resemble hairs and cannot be scraped off.
ORAL AND ESOPHAGEAL Diagnosis is made by visual inspection of the lesion. OHL is
CANDIDIASIS
Oral candidiasis (thrush) is a fungal infection caused by
Candida albicans (Figure 16-9), and usually only appears
if CD4 levels fall below 300 (Mayo Clinic, 2007). Many
clients complain of an unpleasant taste or mouth dryness.
Other clinical signs and symptoms include creamy, white oral
plaques and mucosal tenderness. When the white oral plaques
are wiped off, they leave an erythematous or even bleeding
mucosal lesions. Esophageal candidiasis, an AIDS-defining
disease, causes dysphagia and painful swallowing.
These symptoms may interfere with the client’s eating,
nutrition, and weight. Diagnosis is established by the presence
of the characteristic lesions in the oral cavity. Microscopic
examination of oral or esophageal lesions reveals budding
COURTESY OF DELMAR CENGAGE LEARNING

yeast cells.
Treatment for esophageal candidiasis is oral fluconazole
(Diflucan). Oral candidiasis is treated with nystatin sus-
pension (Mycostatin) and clotrimazole (Mycelex Troches).
Another medication used to treat candidiasis is ketoconazole
(Nizoral). Amphotericin B (Amphotericin B) is used to treat
disseminated candida infection. The antiulcer drug sucralfate
(Carafate) may be used as a slurry to relieve mouth pain
before eating. Figure 16-9 Oral Candidiasis (Thrush)

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572 UNIT 6 Nursing Care of the Client: Body Defenses

Nursing Management
Assess oral cavity frequently. Assist with oral hygiene before
and after meals. Administer prescribed medications. Teach
client to avoid mouthwashes containing alcohol or glycerine
because they are very drying.

NURSING PROCESS
Assessment
Subjective Data
Assess the client’s symptoms and oral hygiene habits. Ask
Figure 16-10 Oral Hairy Leukoplakia (Courtesy of about recent nutritional intake, use of alcohol and tobacco,
Dr. Joseph Konzelman, School of Dentistry, Medical College of and current medications.
Georgia.)

not usually bothersome to the client and may regress sponta- Objective Data
neously. No treatment is necessary for most cases of OHL; Assess the client’s lips, tongue, and buccal mucosal surfaces
however, oral acyclovir (Zovirax) may be given to selected for lesions, white cheesy patches, and bleeding. Note any dif-
clients. ficulty swallowing.

A nursing diagnosis for an HIV-positive client with oral manifestations is:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Oral Mucous The client will be free Administer prescribed medications.
Membrane related to from oral lesions. Frequently assess the oral cavity. Provide oral hygiene
oral lesions with a small soft toothbrush before and after meals.
Instruct client to avoid commercial mouthwashes
containing alcohol or glycerine.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

■ GYNECOLOGICAL CERVICAL INTRAEPITHELIAL

OPPORTUNISTIC INFECTIONS NEOPLASIA
G ynecological infections discussed include vaginal can-
didiasis and cervical intraepithelial neoplasia.
Women infected with HIV have a much higher incidence of
cervical intraepithelial neoplasia (CIN) than women who are
not infected. CIN and cancer of the cervix are considered to be
on a continuum of abnormal cervical cells, ranging from mild
abnormality (Grade I) to severe abnormality and cancer Grade
VAGINAL CANDIDIASIS III). CIN in HIV-infected women progresses more rapidly and
is less responsive to standard treatments than in noninfected
Vaginal candidiasis is a fungal infection caused by Candida women. Factors related to increased risk of CIN in HIV-
albicans. It is the most common initial infection occurring in positive women include a decreased number of CD4 T-cells
HIV-infected women. Clinical manifestations include a white, and infection with human papilloma virus (HPV). It is thought
clumped-appearing vaginal discharge, vaginal wall inflamma- that HIV activates HPV, causing cellular abnormalities.
tion, and vaginal itching. Diagnosis is made by microscopic The early stages of CIN have no symptoms. Clinical
identification of yeast. manifestations of cervical cancer include painless postcoital
Most cases of vaginal candidiasis are treated with topi- bleeding and blood-tinged vaginal discharge. As CIN pro-
cal antifungal agents such as clotrimazole (Gyne-Lotrimin). gresses, back pain, abdominal or pelvic pain, weight loss,
For clients who do not respond to treatment with clotri- anorexia, and leg edema caused by obstruction of lymph
mazole, ketoconazole (Nizoral) or fluconazole (Diflucan) is nodes may occur. Initial diagnosis is made by Pap smear
recommended. to determine the presence of abnormal cells. Clients with

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 CHAPTER 16 Immune System 573

abnormal Pap smears are referred for cervical biopsy and

colposcopy. NURSING PROCESS
Treatment for CIN includes laser therapy, conization, and
hysterectomy. Treatment for invasive cervical cancer depends Assessment
on the stage of the disease and may include chemotherapy, Subjective Data
surgery, and radiation.
Assess the client’s history of symptoms, and ask the client
Nursing Management about bleeding after intercourse, abdominal and pelvic pain,
and vaginal itching or discharge.
Encourage the client to have a Pap test every 6 months, to
keep vaginal area clean and dry, and to wear loose-fitting
cotton underwear. Inquire about bleeding following sexual Objective Data
intercourse, pelvic and abdominal pain, and vaginal itching or Assess vaginal discharge for white or blood-tinged secretions.
discharge. Note weight loss and edema.

Nursing diagnoses for a female HIV-positive client with gynecological

manifestations include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Tissue The client will be free of Teach the client to have Pap smears every 6 months.
Integrity related vaginal infections. Assess the frequency and consistency of vaginal
to vaginal mucosal discharge.
lesions
Teach client to keep the vaginal area clean and dry and to
wear loose-fitting cotton underwear to prevent irritation.

Disturbed Body Image The client will verbalize Encourage client to verbalize feelings and concerns
related to chronic feelings and concerns about body image.
vaginal infections or about body image. Refer client to a support group for women with HIV.
surgery, radiation, or
removal of cervix

Evaluation: Evaluate each outcome to determine how it has been met by the client.

other pathogens. Clients treated with zidovudine (Retrovir)

■ CENTRAL NERVOUS SYSTEM have shown a delay in disease progression in asymptomatic
OPPORTUNISTIC INFECTIONS HIV-infected clients (FDA, 2003).

D isorders covered include AIDS dementia complex, toxo-

plasmosis, and cryptococcosis. TOXOPLASMOSIS
Toxoplasmosis is caused by the protozoan Toxoplasma
AIDS DEMENTIA COMPLEX gondii. Cats and other animals serve as a reservoir for this
organism. It is spread to humans by ingestion of oocytes
The most common central nervous system complication in found in contaminated water, soil, or food, especially raw
persons with AIDS is AIDS dementia complex (ADC). This or undercooked meat. After entering the body, Toxoplasma
disorder is chronic and progressive, with cognitive, motor, gondii reproduces and spreads via the blood or lymph sys-
and behavioral dysfunction. ADC is caused by infection of tem. A person with an intact immune system may have no
glial cells in the brain with HIV. Signs and symptoms are symptoms or mild symptoms, and the organism may remain
sometimes vague during the initial stages of ADC. Early signs dormant for years. In the immunocompromised person,
include poor concentration, forgetfulness, loss of balance, the infection may be reactivated (secondary) or occur with
leg weakness, apathy, and social withdrawal. Clients with the ingestion of oocytes from contaminated sources. Clini-
advanced ADC may exhibit psychotic behaviors and delirium cal signs and symptoms may be vague and nonspecific, or
and progress to a catatonic-like state with minimal responsive- range from a mild headache, fever, and lethargy to poor
ness to the environment. coordination, seizures, and coma. Diagnosis is made by
Diagnosis is made by neurological testing of cognitive, identification of a lesion through brain imaging (computer-
motor, and behavioral functioning. Other diagnostic tests ized tomography or magnetic resonance imaging), presence
include brain imaging to look for cerebral atrophy. Cerebrospi- of serum antibodies to Toxoplasma gondii, and recent onset
nal fluid analysis can show elevated proteins and will exclude of a neurologic abnormality.

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574 UNIT 6 Nursing Care of the Client: Body Defenses

The treatment of choice is oral pyrimethamine (Dara-

prim) and sulfadiazine (Microsulfon). Lifelong suppressive
Nursing Management
therapy of pyrimethamine plus sulfadiazine and leukovorin Monitor client for forgetfulness, poor concentration,
calcium (Wellcovorin) is needed. loss of balance, leg weakness, social withdrawal, apa-
thy, stiff neck, seizures, nausea, and headache. Assess vital
signs. Provide cues for orientation (e.g., calendar, clock)
and a structured environment and activities for social
CRYPTOCOCCOSIS interaction.
Cryptococcosis is a fungal infection caused by Cryptococcus
neoformans. Cryptococcosis is one of the most life-threatening
fungal infections in clients with AIDS (National Institutes NURSING PROCESS
of Health, 2008). The organism is acquired in the environ-
ment, usually from bird droppings. In the noncompromised Assessment
host, the fungus is inhaled and contained in the lungs. In the
immunocompromised host with AIDS, Cryptococcus neofor- Subjective Data
mans can be disseminated, remain in the lungs, or infect the Ask the client about forgetfulness, missing appointments, abil-
brain and meninges. Clinical manifestations include fever, ity to complete activities of daily living, and if there have been
headache, nausea and vomiting, dizziness, photophobia, any recent falls or accidents. Ask the client’s family and signifi-
mental status changes, seizures, and a stiff neck. Detection cant others about behavior changes such as social withdrawal
of cryptococcal antigen in cerebrospinal fluid, urine, or or unusual behavior.
blood can be used for diagnosis. If untreated, this condition
is fatal. Objective Data
Treatment for acute cryptococcal infections includes Assess the client for subtle mental status changes such as
intravenous amphotericin B (Fungizone Intravenous) to be poor concentration and inability to remember instruc-
given for at least 2 weeks, followed by fluconazole (Diflucan) tions or previous conversations. Assess the client for motor
for 10 to 12 weeks. Once treatment for acute infection is com- impairment such as dropping things, poor coordination, or
plete, lifelong suppressive therapy with oral fluconazole daily changes in writing ability. Assess the client’s ability to remember
is recommended. usual medication schedule. Observe the environment for safety.

Nursing diagnoses for an HIV-positive client with central nervous system

manifestations include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Thought The client will maintain Assess client’s mental and neurologic status and
Processes related to cognitive functioning. emotional, cognitive, and motor skills.
mental status changes Provide cues for orientation (clock, calendar).
Monitor client for adherence to medical regimen.

Social Isolation related The client will have Encourage family and significant others to visit client.
to alteration in mental contact and interact Provide structured activities and environment for
status with significant others. social interaction.
Encourage client to verbalize feelings and concerns.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

more immunosuppressed the person is, the more aggressive the

■ OPPORTUNISTIC spread of KS. Clinical manifestations of KS are red to purple
MALIGNANCIES lesions, which are painless, nonblanching, and palpable (Fig-

K
ure 16-11). These lesions are sometimes mistaken for bruises.
aposi’s sarcoma and non-Hodgkin’s lymphoma are dis- Edema in the face, penis, scrotum, and legs can occur as a result
cussed. of blockages in the lymphatic system. KS can also be found in
the GI tract and lungs. Diagnosis is made by tissue biopsy.
KAPOSI’S SARCOMA Treatment involves a variety of options depending
on whether the lesions are local or systemic. Radiation
Kaposi’s sarcoma (KS) is a vascular malignancy that can occur therapy, intralesional therapy with interferon alpha 2a or
any place in the body, including internal organs. The first 2b (Roferon A, Intron A) or vinblastine sulfate (Velban),
lesions often appear subtly on the face or in the oral cavity. The laser therapy, and cryotherapy are used on single or isolated

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 CHAPTER 16 Immune System 575

Diagnosis of NHL is complicated because of the nonspe-

cific symptoms. Examination of tissue is the recommended
diagnostic procedure. There is no standard treatment of
NHL. Individualized treatment may include a combination
of chemotherapy, antiretroviral agents, prophylaxis against
opportunistic infections, and colony-stimulating factors to
enhance bone marrow production of blood cells; however, in
many clients with advanced HIV disease, treatment of NHL is
withheld because it is not tolerated well and may even lead to
earlier death.

Nursing Management
Assess client for fever, night sweats, weight loss, confusion,
lethargy, memory loss, and ability to perform ADLs. Empha-
size no scratching of skin lesions, not using drying soaps,
and making sure clothing and linens are thoroughly rinsed of
detergent. Encourage significant others to participate in the
Figure 16-11 Kaposi’s Sarcoma (Courtesy of Daniel J. client’s care. Provide access to clergy, social worker, or HIV
Barbaro, MD, Fort Worth, TX.)
counselor.

KS lesions. For clients with advanced widespread symp-

tomatic disease, single or combination chemotherapeutic
regimens include vinblastine sulfate (Velban), vincristine
NURSING PROCESS
sulfate (Oncovin), etoposide (VePesid), bleomycin sulfate
(Blenoxane), doxorubicin Hcl (Rubex), and mitoxantrone
Assessment
Hcl (Novantrone). Subjective Data
Ask the client about frequency, onset, and persistence of
current symptoms. Note the effect of current symptoms on
NON-HODGKIN’S LYMPHOMA ability to perform activities of daily living and relationships
with others, as well as the effect of treatment plan on quality
Lymphomas are malignant tumors of the immune sys- of life.
tem. B-cells are the origin of malignancy for most cli-
ents with AIDS-related non-Hodgkin’s lymphoma (NHL).
Clinical manifestations are nonspecific and may include Objective Data
fever, night sweats, and weight loss. Confusion, lethargy, Assess skin lesions. Document increased frequency, intensity,
and memory loss may be present in persons with CNS or recurrence of nonspecific symptoms, including fever, night
involvement. sweats, and weight loss.

Nursing diagnoses for an HIV-positive client with a malignancy include

the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Impaired Skin The client will maintain skin Teach client to avoid scratching skin lesions, to avoid
Integrity related to integrity. drying soaps, and to make sure clothing and linen have
lesions or treatment been thoroughly rinsed of detergent.

Social Isolation related to The client will maintain Facilitate the client’s interaction with others.
change in appearance usual social interactions Keep client and significant others aware of treatment
and identify factors that plan. Encourage significant others to participate in the
enhance quality of life. care of the client.
Encourage physical closeness between the client and
significant others.
Provide client with access to clergy, social worker, or HIV
counselor. Encourage the client to join a support group or
obtain peer support.
Assist client in identifying positive coping strategies.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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576 UNIT 6 Nursing Care of the Client: Body Defenses

CASE STUDY
J.H., a 37-year-old man, suspects that he is HIV positive. He enters the medical unit with chronic symptoms such as fever,
night sweats, diarrhea, weight loss, shortness of breath, and a nonproductive cough. On the initial assessment, he is alert
and oriented, color is pale, temperature 100.6°F, pulse 92, respirations 36, and blood pressure 140/70. He has generalized
lymphadenopathy. His height is 5’11”, and his weight is 125 pounds. J.H. states that he is not currently taking any medica-
tions, although he is “familiar” with the drug zidovudine (Retrovir).
The following questions will guide your development of a nursing care plan for the case study.
1. List symptoms/clinical manifestations, other than J.H., that a client may experience when HIV-positive.
2. List two reasons zidovudine (Retrovir) may be initiated for J.H.
3. List two diagnostic tests that will confirm the diagnosis of HIV.
4. List subjective and objective data the nurse would want to obtain about J.H.
5. Write three individual nursing diagnoses and goals for J.H.
6. List pertinent nursing actions the nurse would perform in caring for J.H. related to:
hydration
fatigue
nutrition
oxygenation
medications
7. List resources that could assist J.H. with his diagnosis.
8. List teaching J.H. will need before leaving the medical unit.

SUMMARY
• The immune system identifies substances as self or nonself • Systemic lupus erythematosus affects multiple body
and protects the body by neutralizing or destroying foreign systems.
organisms. • Clients with myasthenia gravis experience extreme muscle
• Immunity to a disease is either natural or acquired. weakness and fatigue and must be carefully monitored for
• Age, sex, nutritional status, medications, and stress signs of respiratory distress, and myasthenic or cholinergic
influence the immune response. crisis.
• Clients receiving blood transfusions must be carefully • Diagnosis of HIV/AIDS is made by the ELISA and
monitored, especially during the first half-hour, for signs of Western blot test. These tests determine the presence of
a reaction. antibodies to HIV, not the virus itself.
• Anaphylactic reactions, which may occur as a result of • Pneumocystis carinii pneumonia is the most common
exposure to foods, medications, blood, or insect bites, can opportunistic infection associated with HIV.
potentially be life-threatening. • Oral candidiasis can be painful and interfere with the
• Organ transplant clients must understand the implications client’s nutritional status.
of taking immunosuppressive medications. • AIDS dementia complex is a progressive disorder with
• Clients with rheumatoid arthritis must be taught methods cognitive, motor, and behavioral dysfunction.
of adapting to the effects of synovial joint inflammation,
immobility, and deformity.

REVIEW QUESTIONS
1. A client has just been diagnosed with syphilis and anxious and weak. You note she is diaphoretic,
has an order for 1,000,000 units of penicillin IM. scratching her forearm, and is breathing faster than
She has no history of allergies to medications. normal. Based upon this assessment data, you
She has never had penicillin. When giving her would conclude:
the injection in the right upper outer quadrant of 1. she is embarrassed because you saw her tattoo.
her buttocks, you note a tattoo. Several minutes 2. she is probably anxious since you know she has a
after receiving the injection, she tells you she feels sexually transmitted disease.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 16 Immune System 577

3. her syphilis is getting worse. 7. The client tells the nurse, “I am going to quit taking
4. these are early signs of an anaphylactic reaction. my HIV medication because I have no symptoms
2. Which of the following statements shows that the and the medication makes me very nauseated”
client understands a diagnosis of HIV positive? What would be the best response from the nurse?
1. “Being HIV positive means that I have AIDs.” 1. “I agree with you and I will not give you your
2. “Since I am only HIV positive, I cannot infect medication.”
others.” 2. “Let me ask the physician first to see what he
3. “Because I am HIV positive, I have the virus that thinks.”
causes AIDS.” 3. “Taking the medication with food will help with
4. “I became infected by donating blood.” the nausea.”
3. The nurse is caring for a client who is experiencing 4. “I am going to continue to give you your
diarrhea and weight loss. Which of the following medications, it is up to you if you decide to take
nursing interventions is appropriate for him? the medications or not.”
1. Encourage fluids with meals. 8. A client diagnosed with AIDS spends most of his
2. Substitute a milk shake for lunch. day sitting at a window. The nurse wants the client
3. Offer small, frequent meals. to implement a physical activity plan. The nurse
4. Suggest he eat more sweets. knows that the purpose of this plan is to:
4. The nurse is caring for a client who asks when zido- 1. Help the client discuss the problems creating his
vudine (Retrovir) is normally started. Which of the depression.
following would be the nurse’s correct response? 2. Help reduce the client’s risk for obesity.
1. When the client becomes symptomatic. 3. Encourage socialization.
2. When CD4 level reaches 500/mm3. 4. Increase the client’s appetite.
3. After the client’s first opportunistic infection. 9. A client is admitted to the hospital with a diagnosis
4. As soon as the client is diagnosed as HIV positive. of AIDS and is being treated for Kaposi’s sarcoma.
5. The nurse is discussing transmission of HIV with a Which client would be an appropriate roommate for
client. Which of the following statements indicates this client?
that the client needs more education? 1. A client who just had abdominal surgery.
1. “I should not share needles with anyone.” 2. A client that has pneumonia.
2. “I can spread the virus through sexual contact.” 3. A client that has lymphoma.
3. “I can no longer donate blood.” 4. A client that has Kaposi’s sarcoma.
4. “I should not hug or kiss anyone.” 10. Which client is at highest risk for developing an
6. The nurse enters the room of an HIV client who infection?
cannot remember where he is. What is the first 1. A 16-year-old student who plays football on the
priority for the nurse to implement? high school team.
1. Call the physician. 2. A 34-year-old pregnant school teacher.
2. Perform a neurological assessment on the client. 3. A 45-year-old homemaker who smokes two
3. Tell the client where he is. packages of cigarettes daily.
4. Give the client his medication that is due at this 4. A 73-year-old retired banker who lives in an
time. assisted living facility.

REFERENCES/SUGGESTED READINGS

American Academy of Allergy Asthma & Immunology (AAAAI). Arthritis Foundation. (2009c). Arthritis today: how rheumatoid
(2007). Tips to remember: latex allergy. [Online] Retrieved arthritis is diagnosed. [Online] Retrieved April 26, 2009, from
April 26, 2009, from www.aaaai.org/patients/publicedmat/tips/ www.arthritistoday.org/conditions/rheumatoid-arthritis/
latexallergy.stm all-about-ra/diagnosing-ra.php
American Latex Allergy Association. (2009). Latex allergy statistics. Arthritis Foundation. (2009d). Arthritis today: how to treat
[Online] Retrieved April 26, 2009, from www.latexallergyresources rheumatoid arthritis. [Online] Retrieved April 26, 2009, from www
.org/topics/LatexAllergyStatistics.cfm .arthritistoday.org/conditions/rheumatoid-arthritis/ra-treatment/
Arthritis Foundation. (2009a). Arthritis today: a vaccine for how-to-treat-ra.php
rheumatoid arthritis. [Online] Retrieved April 26, 2009, from Arthritis Foundation. (2009e). Rheumatoid arthritis what is it? [Online]
www.arthritistoday.org/conditions/rheumatoid-arthritis/ Retrieved April 27, 2009, from www.arthritis.org/disease-center
news-and-research/rheumatoid-arthritis-vaccine.php .php?disease_id=31
Arthritis Foundation. (2009b). Arthritis today: antimalarial drug may Arthritis Foundation. (2009f). Rheumatoid arthritis: who is at risk?
help rheumatoid arthritis and diabetes. [Online] Retrieved April 26, [Online] Retrieved April 27, 2009, from www.arthritis.org/
2009, from www.arthritistoday.org/conditions/rheumatoid-arthritis/ disease-center.php?disease_id=31&df=whos_at_risk
news-and-research/antimalarial-drug.php Arnold, L. (2001). Living with AIDS. Nursing2001, 31(10), 53.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
578 UNIT 6 Nursing Care of the Client: Body Defenses

Barroso, J. (2002). HIV-related fatigue. AJN, 102(5), 83–86. Food and Drug Administration (FDA). (2003). Retrovir. [Online]
Bradley-Springer, L. (2001). HIV prevention: what works? AJN, Retrieved May 3, 2009, from www.fda.gov/medwatch/
101(6), 45–50. SAFETY/2003/03Oct_PI/Retrovir_PI.pdf
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. Food and Drug Administration (FDA). (2004). OraQuick ADVANCE
(2008). Nursing Interventions Classification (NIC) (5th ed.). Rapid HIV-1/2 antibody test. [Online] Retrieved May 3, 2009,
St. Louis, MO: Mosby/Elsevier. from www.fda.gov/cber/pma/p01004716.htm
Bursaw, M., Keenan, K., & Ehrhart, M. (2001). HIV update. Golden, D. (2007). Insect sting anaphylaxis. [Online] Retrieved
Nursing2001, 31(2), 62–63. April 26, 2009, from www.pubmedcentral.nih.gov/articlerender
Carroll, P. (2001). Anaphylaxis. RN, 64(12), 45–49. .fcgi?artid=1961691.
Centers for Disease Control and Prevention. (2006). Revised Goldrick, B. (2005). Emerging infections: infection in the older adult.
recommendations for HIV testing of adults, adolescents, and American Journal of Nursing, 105(6), 31−34.
pregnant women in health-care settings. Morbidity and Mortality Halzemer, W. (2002). HIV and AIDS: the symptom experience. AJN,
Weekly Report, 55(RR14), 1–17. 102(4), 48–52.
Centers for Disease Control and Prevention. (2008). Basic information. Jones, S. (2001). Taking HAART: How to support patients with HIV/
[Online] Retrieved May 3, 2009, from www.cdc.gov/hiv/topics/ AIDS. Nursing2001, 31(2), 36–41.
basic/index.htm Jurewicz, M. (2000). Anaphylaxis: When the body overreacts.
Centers for Disease Control and Prevention. (2008a). Food allergy Nursing2000, 30(7), 58.
among U.S. children: trends in prevalence and hospitalizations. Lenehan, G. (2002). Latex allergy: Separating fact from fiction.
[Online] Retrieved April 26, 2009, from www.cdc.gov/nchs/data/ Nursing2002, 32(3), 58–63.
databriefs/db10.htm Lenehan, G. (2003). Latex allergy. Nursing2003, 33(6), 54–55.
Centers for Disease Control and Prevention. (2008b). HIV/AIDS Litton, K. (2003). Defenses gone awry: lupus. RN, 66(3),
among American Indians and Alaska Natives. [Online] Retrieved 53–59.
April 29, 2009, from www.cdc.gov/hiv/resources/factsheets/aian.htm Lupus Foundation of America (LFA). (2009a). How lupus affects
Centers for Disease Control and Prevention. (2008c). HIV/AIDS the body. [Online] Retrieved April 27, 2009, from www.lupus
among women. [Online] Retrieved April 29, 2009, from www.cdc .org/webmodules/webarticlesnet/templates/new_learnaffects
.gov/hiv/topics/women/resources/factsheets/women.htm .aspx?articleid=2268&zoneid=526
Centers for Disease Control and Prevention. (2008d). HIV prevalence Lupus Foundation of America (LFA). (2009b). Living with lupus.
estimates-United States, 2006. Morbidity and Mortality Weekly [Online] Retrieved April 27, 2009, from www.lupus.org/
Report, 57(39), 1073−1076. webmodules/webarticlesnet/templates/new_learnliving
Centers for Disease Control and Prevention. (2008e). National .aspx?articleid=2252&zoneid=527
ambulatory medical care survey: 2006 summary. [Online] Retrieved Lupus Foundation of America (LFA). (2009c). Medications to
April 26, 2009, from www.cdc.gov/nchs/data/nhsr/nhsr003.pdf treat lupus symptoms. [Online] Retrieved April 27, 2009, from
Centers for Disease Control and Prevention. (2009). Basic statistics. www.lupus.org/webmodules/webarticlesnet/templates/new_
[Online] Retrieved May 3, 2009, from www.cdc.gov/hiv/topics/ learntreating.aspx?articleid=2246&zoneid=525
surveillance/basic.htm#aidsage Lupus Foundation of America (LFA). (2009d). What is lupus.
Centers for Disease Control and Prevention. (2009a). Guidelines [Online] Retrieved April 27, 2009, from www.lupus.org/
for prevention and treatment of opportunistic infections in HIV- webmodules/webarticlesnet/templates/new_learnunderstanding
infected adults and adolescents. Morbidity and Mortality Weekly .aspx?articleid=2232&zoneid=523
Report, 58(RR-4), 1−207. Mayo Clinic. (2007). Oral thrush. [Online] Retrieved May 3, 2009,
Centers for Disease Control and Prevention. (2009b). HIV/AIDS from www.mayoclinic.com/print/oral-thrush/DS00408/
surveillance by race/ethnicity (through 2007). [Online] Retrieved DSECTION=all&METHOD=print
April 27, 2009, from www.cdc.gov/hiv/topics/surveillance/ Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing
resources/slides/race-ethnicity/index.htm Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby.
Cichocki, M. (2007). HIV and the older adult—a growing population. National Institute for Occupational Safety and Health (2009). Latex
[Online] Retrieved May 17, 2008 from http://aids.about.com/cs/ allergy a prevention guide. [Online] Retrieved April 26, 2009, from
aidsfactsheets/a/seniors.htm www.cdc.gov/niosh/98-113.html
Cohen, S. (2001). Myths & facts…about latex allergy. Nursing2001, National Institute of Allergy and Infectious Diseases (NIAID).
31(2), 76. (2003). Current trends in allergic reactions: a multidisciplinary
Coyne, P., Lyne, M., & Watson, A. (2002). Symptom management in approach to patient management. [Online] Retrieved April 26,
people with AIDS. AJN, 102(9), 48–55. 2009, from www3.niaid.nih.gov/about/organization/dait/PDF/
Daniels, R., Nosek, L., & Nicoll, L. (2007). Contemporary medical- Allergic_Reactions.pdf
surgical nursing. Clifton Park, NY: Delmar Cengage Learning. National Institute of Allergy and Infectious Diseases (NIAID).
Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic tests (2008a). Food allergy: living with food allergies. [Online] Retrieved
(2nd ed.). Clifton Park, NY: Delmar Cengage Learning. April 26, 2009, from www3.niaid.nih.gov/topics/foodAllergy/
D’Arcy, Y. (2002). How to treat arthritis pain. Nursing 2002, 32(7), 30–31. living.htm
Daughtry, L., Bankston, J., & Deshotels, J. (2002). HIV meds: keeping National Institute of Allergy and Infectious Diseases (NIAID).
trouble at bay. RN, 65(2), 31–35. (2008b). Is it a cold or an allergy? [Online] Retrieved April 26,
Department of Health and Human Services. (2007). OPTN/SRTR 2009, from www3.niaid.nih.gov/topics/allergicDiseases/PDF/
annual report: transplant data 1997-2006, chapter 1, trends in organ ColdAllergy.pdf
donation and transplantation in the United States, 1997-2006. National Institutes of Health. (2008). Cryptococcosis. [Online]
[Online] Retrieved April 26, 2009, from www.ustransplant.org/ Retrieved May 3, 2009, from www.nlm.nih.gov/medlineplus/ency/
annual_reports/current/chapter_i_AR_cd.htm?cp=2 article/001328.htm
Estes, M. (2010). Health assessment & physical examination Putnam, J., & May, K. (2001). Relief for patients with severe allergies.
(4nd ed.). Clifton Park, NY: Delmar Cengage Learning. RN, 64(6), 26–30.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 16 Immune System 579

Spratto, G., & Woods, A. (2009). 2009 PDR nurses’ drug handbook. World Health Organization (2008b). HIV/AIDS. [Online] Retrieved
Clifton Park, NY: Delmar Cengage Learning. April 27, 2009, from www.who.int/features/qa/71/en/index.html
Trzcianowska, H., & Mortensen, E. (2001). HIV and AIDS: Separating World Health Organization (2009). TB/HIV facts 2009. [Online]
fact from fiction. AJN, 101(6), 53–59. Retrieved April 27, 2009, from www.who.int/tb/challenges/hiv/
Veronesi, J. (2003). Rheumatoid arthritis. RN, 66(8), 46–52. factsheet_hivtb_2009.pdf
World Health Organization (2008a). Global summary of the AIDS Yee, C. (2002). Getting a grip on myasthenia gravis. Nursing2002,
epidemic, December 2007. [Online] Retrieved April 27, 2009, from 32(1), 32hn1–32hn4.
www.who.int/hiv/data/2008_global_summary_AIDS_ep.png

RESOURCES
The American Academy of Allergy, Asthma, and Asthma and Allergy Foundation of America,
Immunology, http:// www.aaaai.org http:// www.aafa.org
American Association of Blood Banks, CDC National STD & AIDS Hotlines, 800-232-4636
http:// www.aabb.org Lupus Foundation of America, Inc., http:// www.lupus.org
American College of Rheumatology, Myasthenia Gravis Foundation of America,
http:// www.rheumatology.org http:// www.myasthenia.org
American Latex Allergy Association, National Institute of Arthritis and Musculoskeletal and
http:// www.latexallergyresources.org Skin Diseases (NIAMS), http:// www.niams.nih.gov
Arthritis Foundation, http:// www.arthritis.org United Network for Organ Sharing,
Association of Nurses in AIDS Care, http:// www.unos.org
http:// www.anacnet.org

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 7
Physical and Mental Integrity
Chapter 17 Mental Illness / 582

Chapter 18 Substance Abuse / 617

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 17
Mental Illness

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of mental illness:
Adult Health Nursing
• Immune System • The Older Adult
• Substance Abuse

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Identify and describe the components of a therapeutic nurse–client relationship.
• Cite nursing interventions for working with clients who are angry,
aggressive, homicidal, and/or suicidal.
• Detail nursing interventions for working with clients who are experiencing
anxiety.
• Identify and explain the potential side effects associated with antianxiety
medications.
• Recount nursing interventions for working with clients who are depressed.
• Identify and explain the potential side effects associated with
antidepressant medications.
• Detail nursing interventions for working with clients who have schizophrenia.
• Identify and explain the potential side effects associated with antipsychotic
medications.
• Detail nursing interventions for working with clients who have bipolar disorder.
• Identify and explain the potential side effects associated with mood stabilizers.
• Cite nursing interventions for working with clients who have attention-deficit/
hyperactivity disorder.
• Recount nursing interventions for working with clients who have been
neglected or abused or who have been exposed to domestic violence.
• Discuss nursing interventions for working with clients who have an eating
disorder.

582

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 CHAPTER 17 Mental Illness 583

KEY TERMS
abuse electroconvulsive pressured speech
actively suicidal therapy (ECT) psychoanalysis
affect empathy psychosis
anger-control assistance euphoric psychotherapy
anxiety flashback rapport
anxiolytic genuineness respect
auditory hallucination hallucination seclusion
brief dynamic therapy hypervigilant serum lithium level
cognitive-behavior hypomania startle response
therapy mania suicidal ideation
command hallucination mental disorder tolerance
crisis mental illness trust
cycling mood verbally aggressive
delusion neglect visual hallucination
depression paradoxical reaction word salad
domestic violence physically aggressive

(i.e., negative response to stimuli that are perceived as threat-

INTRODUCTION ening) or disability (i.e., impairment in one or more impor-
Because they will encounter clients who are emotionally tant areas of functioning) or with a significantly increased
disturbed and/or mentally ill, it is imperative that nurses risk of suffering, death, pain, disability, or an important loss
understand and feel comfortable working with such individ- of freedom.”
uals—not just on psychiatric units, but in all types of circum- One of the ways to conceptualize psychiatric disorders is
stances and settings. This chapter is designed to give LP/ to think of a continuum, with mental health being situated at
VNs a beginning knowledge base regarding mental health and one end and mental illness at the other (Figure 17-1). Between
illness and to better prepare them for working with individuals these two extremes lie a variety of psychiatric disorders rang-
who are in a state of crisis or who have emotional needs and/ ing in nature from mild to severe. The fourth edition of the
or psychiatric problems. Diagnostic and Statistical Manual of Mental Disorders (better
As the nurse becomes more knowledgeable about mental known as the DSM-IV) (American Psychiatric Association
illness, opportunities arise to increase self-awareness and to [APA], 2000) is the reference tool used to identify and estab-
examine any personal experiences, preconceived ideas, or lish psychiatric diagnoses. The psychiatrist is the individual
prejudices that might negatively affect the nurse’s ability to most often involved in this process, although other mental
work effectively with clients. For example, the nurse who has health care practitioners may give input and make recommen-
unresolved issues regarding sexuality or becomes embarrassed dations for diagnoses.
when discussing sexuality will probably be uncomfortable One of the primary roles of the nurse in working with
talking about the potential problems in sexual functioning clients who have mental illness is that of teaching. The nurse is
secondary to antidepressant therapy. Examining personal responsible not only for teaching clients about their illnesses,
ideas and prejudices before working with clients will facilitate including the probable courses of their given disorders, but
a positive nurse–client relationship. also for adequately preparing and educating the client’s fam-
ily. The nurse is usually the first individual to have contact
with the family and is most often the one with whom family
MENTAL HEALTH AND ILLNESS members maintain consistent contact. Because of the highly
personal and sensitive nature of mental disorders, the concept
In general, people are considered mentally healthy when they of confidentiality, the nondisclosure of the identity of or per-
possess knowledge of themselves; meet their basic needs; sonal information about an individual, is vitally important in
assume responsibility for their behavior; have learned to inte- psychiatric nursing.
grate thoughts, feelings, and actions; can successfully resolve
COURTESY OF DELMAR CENGAGE LEARNING

conflicts; maintain relationships; communicate directly with n

others; respect others; and adapt to change. Mental illness ty sio os
is
ie res h
occurs when an individual is not able to view self clearly or nx ep yc
A D Ps
has a distorted view of self; is unable to maintain satisfying Mental Mental
personal relationships; and is unable to adapt to the environ- health illness
ment (Frisch & Frisch, 2010). The American Psychiatric
Association defines mental disorder as “clinically signifi-
cant behavior or psychological syndrome or pattern that
occurs in an individual and is associated with present distress Figure 17-1 Mental Health Continuum

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
584 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

feels free to express feelings. When seeking to develop trust, the

RELATIONSHIP DEVELOPMENT nurse acts in a manner that indicates recognition of the client
Psychiatric nursing differs from some of the other fields of as a unique individual and reinforces that individuality. Such
nursing in that the primary skill the nurse employs is what is actions, which serve to humanize the client, are therapeutic. To
referred to as “the therapeutic use of self.” Many theorists such establish rapport, the nurse must show that the client is impor-
as Rogers and Peplau have been instrumental in identifying and tant. Actions are implemented to boost the level of the client’s
exploring the factors that significantly influence the develop- self-esteem. Nonverbal interventions are of utmost importance
ment of therapeutic relationships. Townsend (2008) identifies in helping establish rapport. Interacting with family and signifi-
five components necessary to the development of a therapeutic cant others is also helpful in establishing rapport with the cli-
working relationship and of particular importance in the thera- ent. Recognizing the importance of the family and its influence
peutic nurse–client relationship. These five components are on the healing process allows the nurse to bond with those who
trust, rapport, respect, genuineness, and empathy. will encourage and support the client during recovery.

Trust Respect
Trust is the ability to rely on an individual’s character and abil- Respect is the acceptance of an individual as is, in a nonjudg-
ity. Trust must be present for help to be given and received. A mental manner. The concept of respect is an integral compo-
therapeutic relationship is firmly rooted in trust. Three major nent of the nurse–client relationship. Respect means caring for
activities facilitate the development of trust: consistency, respect, clients whose vvalue system may differ greatly from that of the
and honesty. Consistency includes following through on plans, nurse. To show respect, the nurse must not react with shock,
adhering to the schedule, being straightforward with no hidden surprise, or disapproval toward a client’s lifestyle, dress, or
motives, and seeking extra time for client interaction. Respect behaviors. The nurse respects the client’s choices and actions
includes addressing clients the way they wish to be addressed yet sets limits on unhealthy or undesirable behavior.
(e.g., Mr., Mrs., Ms., first name), listening to the clients, and pro-
viding clear explanations. Honesty includes keeping promises
and maintaining confidentiality. Being consistently trustworthy
Genuineness
Genuineness (sincerity) is an attribute easily perceived by
is an expression of the nurse’s personal integrity and builds the the client and can be the most significant aspect of the nurse–
foundation for nursing effectiveness (Figure 17-2). client relationship. Nurses are often concerned about whether
Many clients with emotional and/or psychiatric prob- they will say the right thing to a client; though saying the right
lems have great difficulty trusting and having confidence that thing is important, more important is that the nurse be honest
others will be good to their word. They may have been lied to and genuine in communications with the client.
or hurt in the past, and this makes it difficult for them to trust
again, even with health care professionals who are trying to
help them. It is very important, therefore, that the nurse fulfill Empathy
any promise made to the client. Empathy (the ability to perceive and relate to another’s per-
sonal experience) is an important quality necessary to success-
Rapport ful nurse–client interactions. The empathic nurse understands
that the client’s perception of the situation is real to him. By
Rapport is a bond or connection between two people that is perceiving the client’s understanding of her own needs, the
based on mutual trust. Such a bond does not just happen spon- nurse is better able to assist the client in determining what will
taneously; it is planned by the nurse, who purposefully imple- work best. Empathy enables the nurse to assist the client to
ments behaviors that promote trust. The nurse sets the tone of become a fully participating partner in treatment, rather than a
the relationship by creating an atmosphere wherein the client passive recipient of care. Through empathy, the nurse validates
the experiences of the client (Figure 17-3).

THE CLIENT EXPERIENCING

A CRISIS

I n psychological terms, a crisis is a stressor that forces an

individual to respond and/or adapt in some way. Emotions
may intensify during a crisis situation or serious illness, and any
situation or illness can potentially become a crisis if the stressors
COURTESY OF DELMAR CENGAGE LEARNING

are severe enough. The understanding of crisis is particularly

important in psychiatric and mental health nursing. A crisis taxes
the individual’s coping resources, and each person responds dif-
ferently to seemingly identical situations. Crisis requires that
an individual call on all of her personal skills as well as on the
outside social and familial supports that she has built through
her life (Frisch & Frisch, 2010). Each individual has personality
strengths, interpersonal networks, and socioeconomic resources
Figure 17-2 Spending time with the client one-to-one that offer some protection against the threat of crisis. When
helps promote a trusting relationship. any (or all) of these protections are weak, however, a person’s

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 17 Mental Illness 585

and respirations increase, and the client becomes diaphoretic.

The moderately anxious individual begins to have difficulty
concentrating or learning new material. This is important to
recognize before teaching a client about a medication or test,
or performing a procedure. Before teaching can be effective,
the client must be assisted in lowering the level of anxiety
(Townsend, 2008).

SEVERE ANXIETY

COURTESY OF DELMAR CENGAGE LEARNING

Severely anxious clients are significantly impaired in sev-
eral areas. Their ability to cognitively process material may
drastically diminish, they may experience tunnel vision,
their focus may become very limited, and the physiologic
symptoms of anxiety become much more pronounced.
Clients at this high level of anxiety are often very fear-
ful and may be irrational in their thought processes
(Townsend, 2008).
Figure 17-3 Through empathic listening, the nurse can
reach an understanding of the client’s experience and help the
client see the positive aspects of the experience. PANIC
The individual experiencing panic may begin to manifest
response to crisis may be dysfunctional, and the result may be symptoms of psychosis (losing touch with reality), such as
one or more symptoms of mental illness. Although theories dif- delusions (false beliefs that misrepresent reality) and/or
fer in their definitions of crisis and stress, it is generally accepted hallucinations (perceptions that something is present when
that most psychiatric problems result from or are strongly it is not, e.g., hearing voices that are not really there). The indi-
influenced by the interaction of stress and overwhelmed coping vidual with this level of anxiety requires constant reassurance
mechanisms (Frisch & Frisch, 2010). The client experiencing and continuous assessment for suicide risk and maladaptive
crisis may be anxious, angry, aggressive, homicidal, suicidal, coping behaviors (Antai-Otong, 2008).
psychotic, or any combination of these.

ANXIETY DISORDERS
■ ANXIETY

A nxiety is a state wherein a person feels a strong sense of

dread frequently accompanied by physical symptoms
S ome of the most common psychiatric diagnoses related to
anxiety are Generalized Anxiety Disorder, Panic Disorder,
Obsessive-Compulsive Disorder, and Post-Traumatic Stress
of increased heart and respiratory rates and elevated blood Disorder. It is estimated that 40 million adult Americans
pressure in the absence of a specific source or reason for these have an anxiety disorder (Anxiety Disorders Association of
emotions or responses. Nurses frequently encounter clients America [ADAA], 2009a).
and family members who are anxious because of alterations
in or threats to health and physical well-being. Peplau (1963)
identifies four escalating stages of anxiety beginning with
mild anxiety, moving to moderate anxiety, followed by severe
■ GENERALIZED ANXIETY
anxiety, and, finally, to the stage of panic, if not effectively DISORDER

T
treated. Intervention can occur at any point along the con-
tinuum, preferably before the stages of severe anxiety or panic he client with Generalized Anxiety Disorder (GAD)
are reached. exhibits symptoms of excessive anxiety, chronic worry,
or dread. Clients usually realize that their symptoms are out
of proportion to any real threat. The symptoms include three
or more of the following: restlessness, easy fatigue, difficulty
MILD ANXIETY concentrating, irritability, trembling, muscle tension, abdom-
The mildly anxious client is beginning to experience some inal upsets, and sleep disturbance. For anxiety to be termed
of the signs and symptoms of anxiety, such as irritability and excessive, clients must experience symptoms frequently over
restlessness; however, the person is still able to concentrate a period of 6 months or more (ADAA, 2009b).
and focus on the task at hand. In fact, mild anxiety can actually
benefit an individual as far as enhancing performance ability
(Townsend, 2008). ■ PANIC DISORDER

MODERATE ANXIETY P anic Disorder is diagnosed when the client experiences

at least two panic attacks followed by at least 1 month’s
concern about having another panic attack (ADAA, 2009d).
The individual with moderate anxiety experiences additional These attacks begin abruptly and peak within 10 minutes
physiologic and cognitive symptoms. Blood pressure, pulse, and are characterized by a set of any four of the following

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586 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

symptoms: palpitations or rapid heart rate, sweating, trem- In contrast, there is strong empirical evidence that
bling, shortness of breath, sensation of choking, chest pain, behaviorally based treatments are effective in treating at
nausea, dizziness, fear of losing control, fear of dying, numb- least some anxiety disorders. Cognitive-behavior therapy
ness or tingling, chills or hot flushes, and some sense of often results in significant benefit for persons experienc-
altered reality. The client has a strong desire to run away or ing panic attacks. Cognitive-behavior therapy assumes
escape from the situation that triggered the attack. In some that clients can learn to identify the common stimuli that
individuals, the attack is brought about by specific stimuli or create their anxiety, develop plans to respond to those
a particular setting, for example the dentist’s office. In others, stimuli with nonanxious responses, and problem solve
the attacks come on “out of the blue.” when unanticipated anxiety-provoking situations arise.
Although insight is very much involved in this process,
it is not insight into deep psychological causes, as in psy-
■ OBSESSIVE-COMPULSIVE choanalysis, but rather, practical, commonsense problem
DISORDER solving. Treatment appears both to be effective during the

I
relatively brief course of therapy and to remain effective
n Obsessive-Compulsive Disorder (OCD), the individual for some months after therapy finishes. Sometimes medi-
has persistent, recurring thoughts or impulses (obses- cal and psychological follow-up are important to ensure
sions) that are intrusive or inappropriate, causing anxiety or satisfactory improvement.
fears leading the individual to perform repetitive behaviors or A new treatment method for PTSD is eye-movement
rituals (compulsions) to neutralize the anxiety caused by the desensitization and reprocessing (EMDR). This method
obsession. The obsessions and/or compulsions may take up involves asking a client to imagine a traumatic event or anxiety
at least several hours a day and interfere with the individual’s provoking occurrence and processing the traumatic event in a
normal routine, occupation, social activities, or relationships non-threatening manner. Special training is necessary to per-
(ADAA, 2009c). form EMDR (Antai-Otong, 2008).

■ POST-TRAUMATIC STRESS Pharmacological

The drugs of choice for treating clients with anxiety are usu-
DISORDER ally the anxiolytics or antianxiety agents (Table 17-1). Some

C lients suffering from Post-Traumatic Stress Disorder

(PTSD) have experienced a serious trauma. Being
severely beaten or emotionally, physically, or sexually abused
of the antianxiety medications such as alprazolam (Xanax)
and lorazepam (Ativan) may also be helpful in alleviating
the symptoms of anxiety, nervousness, and sleeplessness fre-
or living through or witnessing a catastrophic event or natural quently associated with panic disorder and PTSD.
disaster such as a flood, earthquake, hurricane, war, or plane Most of these medications can be used on either a rou-
crash might lead to PTSD. The response to the trauma must tine or as-needed (PRN) basis and belong to the family of
have been one of fear or helplessness, and the event is persis- benzodiazepines. Onset of action for the benzodiazepines
tently reexperienced through recurrent recollections, dreams, usually occurs within 30 minutes after oral administration,
or hallucinatory-like flashbacks. Individuals with this disorder and most individuals respond favorably to these medications;
have symptoms for more than 1 month and exhibit impair- that is, a reduction or cessation of the symptoms of anxiety is
ment of social functioning, anxiety symptoms, avoidance of experienced.
stimuli associated with the trauma, and a general numbness. Clients should be warned about the potential risk of
More than 7.7 million Americans are diagnosed with PTSD addiction associated with antianxiety medications. These
(ADAA, 2009e). particular medications should be used with extreme caution
because long-term use can lead to an increased tolerance,
acquired resistance to the effects of the drug. Tolerance
Medical–Surgical results in the need to increase the frequency and amount of
medication in order to achieve the same benefit. Over time,
Management this may cause a dependency on the medication, actually
creating another serious problem for the client. Therefore,
Medical the antianxiety agents are usually indicated for short-term
Psychotherapy (the treatment of mental and emotional management of anxiety rather than for long-term use. The
disorders through psychological rather than physical meth- benefits of a particular medication for the client must
ods) continues to be widely used in the treatment of anxi- always be weighed against the possible risk of addiction,
ety disorders. Psychotherapy can be viewed as falling into particularly if long-term use is or may be indicated. The one
two general categories: those therapies based on helping exception is buspirone hydrochloride (BuSpar), a nonben-
individuals achieve insight into why they feel anxiety and zodiazepine antianxiety medication, which does not appear
those that emphasize behavioral means of controlling the to have any addictive potential; however, the therapeutic
anxiety. effectiveness of BuSpar is not reached for approximately
Psychotherapy based on insight into symptoms 7 to 10 days; thus, although it can be given as a regularly
may sometimes be valuable, especially for highly moti- scheduled antianxiety agent, BuSpar has absolutely no value
vated individuals whose symptoms are not disabling. as a PRN medication. When initiating therapy with BuSpar,
Psychoanalysis (therapy focused on uncovering uncon- another antianxiety medication such as alprazolam (Xanax)
scious memories and processes) is among the best known or lorazepam (Ativan) may be given concurrently until the
of the insight therapies and has been widely employed to therapeutic level is reached; then the other medication can
assist persons with anxiety. be gradually decreased.

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 CHAPTER 17 Mental Illness 587

Table 17-1 Antianxiety Medications

GENERIC TRADE NAME TYPE POTENTIAL SIDE EFFECTS
NAME
aprazolam Xanax Benzodiazepine Dizziness, drowsiness, lethargy, physical and
psychological dependence, tolerance

buspirone BuSpar Nonbenzodiazepine Blurred vision, chest pain, clamminess, dizziness,

hydrochloride drowsiness, excitement, fatigue, headache, insomnia,
nasal congestion, numbness, myalgia, nausea, ner-
vousness, palpitations, paresthesia, skin rashes, sore
throat, syncope, tachycardia, tinnitus, incoordination,
weakness

clonazepam Klonopin Benzodiazepine Ataxia, behavioral changes, drowsiness, physical and

psychological dependence, tolerance

diazepam Valium Benzodiazepine Dizziness, drowsiness, fatigue, hypotension, hyper-

tension, CV collapse, dependence, tolerance

lorazepam Ativan Benzodiazepine Agranulocytosis, CV collapse, dizziness, drowsiness,

lethargy
Data from Delmar Nurses’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Activity NURSING PROCESS

The anxious client’s activity level may be negatively affected
by both the anxiety disorder and the side effects of the pre-
scribed medication. The side effects of sedation and drowsi-
Assessment
ness can pose safety hazards for certain activities and must be Subjective Data
emphasized to the client. Clients experiencing anxiety report problems concentrat-
ing, and fear that something dreadful is about to happen.
Nursing Management They may verbalize an overwhelming feeling of impending
doom. They may also report that the anxiety is very fright-
Remain with the client while fear level and/or anxiety level ening to them and that they are afraid of losing control.
is high and speak in a calm, soothing voice. Reassure the cli- Table 17-2 lists questions that may help in identifying a
ent that she is in a safe place. Explore with the client what client’s anxiety.
things are relaxing and calming. Teach the client relaxation Clients with PTSD may describe unwanted memories
exercises. Encourage participation in recreation or sports of an event, express suicidal ideation, or express fantasies of
activities. retaliation toward the identified source of trauma. The client
Do not touch the client with PTSD without permission. with PTSD may describe feeling extremely fearful and “on
If the client is confused or disoriented, orient the client to guard” at all times and may report having flashbacks (reliv-
reality. ing of the original trauma as if currently experiencing it) along
with recurrent dreams and/or nightmares.

MEMORYTRICK Objective Data

Changes in vital signs, such as an increase in blood pressure,
CALM pulse, and respirations, as well as restlessness, irritability, pac-
ing, and agitation may become more pronounced as anxiety
A memory trick to remember nursing management
level increases.
methods for anxiety is CALM: Clients with PTSD may exhibit an exaggerated startle
C = Cognitive-behavior therapy response (overreaction to minor sounds or noises), or they
may be hypervigilant (constantly scanning the environment
A = Anxiolytic medication management for potentially dangerous situations). Clients with PTSD may
L = Learn methods to reduce/control anxiety react with survival responses appropriate for the trauma they
survived. For example, abused children may seek to placate
M = Maintain a safe, calm environment
adults and female incest victims may become flirtatious or
seductive with men.

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588 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Table 17-2 Asking Clients about Symptoms of Anxiety Disorders

Following are questions that have proven useful in eliciting information from clients about symptoms of anxiety disorders.
You may find that you prefer to word these questions somewhat differently, but the important thing is to ask them. Many
clients experience anxiety symptoms for years before a doctor, nurse, or psychologist takes the time to ask about these
symptoms.

Generalized Anxiety Disorder Do you find yourself worrying frequently about a number of different things,
such as the way things are going for you at home, work, or school?
Do you find yourself feeling anxious or tense much of the time without any
obvious reason?

Panic Disorder Have you ever experienced sudden, intense fear for no reason?
Have you found yourself experiencing intense physical symptoms of chest
pain, shortness of breath, dizziness, or sweating, along with a sense that
something terrible or life threatening was happening to you?

Post-Traumatic Stress Disorder Have you ever had a particularly traumatic experience such as witnessing or
experiencing violence or a catastrophic event (such as a flood or fire)?
Have you ever found yourself reexperiencing a violent or catastrophic event
through dreams or waking “flashbacks”?

From Psychiatric Mental Health Nursing, by N. Frisch and L. Frisch (4th ed.). 2010, Clifton Park, NY: Delmar Cengage Learning.

Nursing diagnoses for the client with anxiety include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Anxiety related to a subjec- The client will learn how Teach the client relaxation exercises. Explore with the client
tive sense of uneasiness and to demonstrate and utilize those things that are calming and relaxing.
tension new and more effective Encourage physical movement or participation in some type
methods of managing of recreational or sporting activity to release excess energy.
anxiety.

Fear related to a specific The client will report feeling Remain with the client while level of fear is high. Talk to the
object (e.g., hospitals) less fearful. client in a calm, soothing voice. Reassure the client that he is
in a safe place.

Post-Trauma Syndrome re- The client will experience a Orient the client to reality, if the client is confused, disori-
lated to anxiety felt following decrease in frequency and ented, or experiencing flashbacks.
a significant life-threatening intensity of symptoms. Do not touch the client without permission.
event
Teach the client, family, and significant others about the symp-
toms of PTSD, including flashbacks, amnesia, memory loss,
and nightmares.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

event, hormonal changes, altered health habits, presence of

■ DEPRESSION another illness, or substance abuse can bring on depression
(Depression and Bipolar Support Alliance [DBSA], 2007).

D epression is the state wherein an individual experiences

feelings of extreme sadness, hopelessness, and helpless-
ness. Several symptoms may be seen with depression, which
Symptoms of depression include prolonged sadness;
significant changes in appetite and sleep patterns; irritabil-
ity, agitation, anxiety, worry; pessimism; loss of energy;
can range anywhere from mild to severe and be manifested in feelings of guilt, worthlessness; inability to concentrate;
many different ways. inability to take pleasure in former interests; unexplained
It involves an imbalance of neurotransmitters and is aches and pains; and recurring thoughts of death or suicide.
treatable. The direct cause of depression is unclear; however, Adult Americans of all ages, races, ethnic groups, and social
changes in body chemistry caused by experiencing a traumatic class experience depression every day. According to the

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 CHAPTER 17 Mental Illness 589

PROFESSIONALTIP PROFESSIONALTIP
Achieving a State of Relaxation Flashbacks
Clients who are anxious and feeling overwhelmed The client experiencing a flashback is usually not
will often require assistance in achieving a state of aware of current surroundings and often does not
relaxation. Help the client identify activities that recognize familiar individuals. For the duration of
are relaxing, such as listening to favorite music, the flashback, the client is actually reexperiencing
watching television, reading a book, playing a and reliving the original trauma once again. For
game, drawing a picture, working a puzzle, or this reason, it is extremely important to never
whatever is calming to the client. Teach the client touch a client during a flashback, as the client may
a variety of stress-management techniques such perceive you as dangerous and react to you as if
as deep-breathing exercises, progressive deep- you are trying to inflict harm. Talk to the client in a
muscle relaxation, and guided imagery. All of these soft, calm voice and gently let the client know who
can assist the client in reaching a greater state of you are, where the client is, and what is happening.
relaxation. Explore with the client the possibility
of enrolling in a course such as Tai Chi. In addition
to providing physical activity, it assists the client this stage are most effective in arresting the depression before
in achieving a state of balance and an increasing the individual’s mental health deteriorates any further.
ability to focus.

SEVERE DEPRESSION
CRITICAL THINKING When depression progresses to a severe state, the individ-
ual becomes seriously impaired. The individual with severe
Anxiety depression may experience psychosis, or a loss of contact
with reality, in addition to the symptoms of depression.
A client shares with you that she is feeling anxious
and cannot stop worrying about who will take care
of her cat, how she will afford her health care, and
she is anxiously waiting for her lab results. DEPRESSION DISORDERS

S
1. Which client concern do you think should be
addressed first?
ome of the psychiatric diagnoses associated with depres-
sion include Major Depressive Disorder and Dysthymic
2. How will you handle this situation?
Disorder.

Substance Abuse and Mental Health Services Administration ■ MAJOR DEPRESSIVE

(SAMHSA) (2008), 16.5 million adult Americans had at
least one major depressive episode (MDE) between the years
DISORDER
2006-2007. Clients can experience mild, moderate, or severe
depression with varying degrees of symptomatology. T o qualify for the diagnosis of Major Depressive Disor-
der, DSM-IV requires the presence of at least one major
depressive episode that (1) lasts at least 2 weeks, (2) represents
a change from previous functioning, and (3) causes some
MILD DEPRESSION impairment in a person’s social or occupational functioning.
Five or more symptoms of depression must also be present.
Individuals with mild depression may notice a difference in One of these symptoms must be either depressed mood or loss
the way they are feeling and their ability to function in certain of interest in previously enjoyable activities. The other four
situations, but they may not be able to identify the problem at symptoms may include changes in appetite or weight; sleep
this point in time. Although they are still able to function and disturbance (usually trouble staying asleep); fatigue or loss of
carry on their daily routines, doing so may put quite a strain on energy; feelings of worthlessness or guilt; difficulty concentrat-
them both physically and mentally. ing, thinking, or making decisions; or recurrent thoughts of
death or suicide.
MODERATE DEPRESSION Some individuals, particularly adolescents, exhibit irri-
tability or crankiness rather than sadness. Family members
Moderate depression interferes with the individual’s life in a or close friends will notice a change in the individual, most
variety of ways. A decrease in the ability to perform on the job commonly a social withdrawal and a neglect of activities that
may be noticed. Relationships are affected as the individual previously brought the person pleasure.
becomes increasingly withdrawn and isolated and disinter- Major depressive episodes frequently develop over a few
ested in things that previously were pleasurable, such as hob- days or weeks, and without treatment commonly last longer
bies and leisure-time activities. Interventions performed at than 6 months (Frisch & Frisch, 2010).

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590 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

■ DYSTHYMIC DISORDER PROFESSIONALTIP

W hereas the essence of Major Depressive Disorder is dis-
crete episodes of depression, persons with Dysthymic
Disorder feel depressed nearly all of the time. The DSM-IV
Journaling
criteria for Dysthymic Disorder include “depressed mood for Suggest to depressed clients that they keep
most of the day, for more days than not . . . for at least 2 years.” personal journals in which they write down their
A person with Dysthymic Disorder must also have at least thoughts and feelings. Putting thoughts and
two of the following symptoms: appetite disturbance, sleep emotions down on paper may help clarify issues
disturbance, fatigue, low self-esteem, poor concentration or relating to depression and is an excellent way of
difficulty making decisions, and feelings of hopelessness. As venting or releasing pent-up feelings.
with Major Depressive Disorder, the symptoms must cause
clinically significant distress or impairment in social or occu-
pational functioning. Dysthymic Disorder is somewhat rarer Electroconvulsive therapy (ECT) is used for clients
than Major Depressive Disorder, occurring during a lifetime in with severe depression who have not responded to medications.
approximately 6% of persons (Frisch & Frisch, 2010). The client under anesthesia is treated with pulses of electrical
energy sufficient to cause a brief convulsion or seizure. Muscle-
depolarizing agents are also given so that no actual convul-
Medical–Surgical Management sive movements occur; the primary effect of ECT is on the
brain. Studies show that clients do not find the actual ECT
Medical treatment frightening, painful, or unpleasant. Although deaths
Psychotherapy refers to any of more than 250 types of largely have occurred from ECT, particularly in elderly clients or those
verbal techniques designed to help individuals surmount with heart disease, the risk is quite low. Side effects depend on
psychological stresses including depression. Psychotherapy the specific technique used but are mostly limited to memory
based on psychoanalytic interventions emphasizes helping deficits (Frisch & Frisch, 2010).
clients gain insight into the causes of their depression. This
approach is long term and requires much motivation on the Pharmacological
part of the client to invest considerable time, effort, and
money (Frisch & Frisch, 2010). The main classification of medications usually prescribed
Brief dynamic therapy focuses on core conflicts from for treatment of depression is the antidepressants. Within
personality and living situations. The goal is to resolve depres- this classification are several groups, including the tetracyclic
sive symptoms by improving these conflicts and resolving and atypical antidepressants (Table 17-3), the selective sero-
stresses. The therapist in this approach takes an active role to tonin reuptake inhibitors (SSRIs) (Table 17-4), the tricyclic
direct sessions toward resolution of conflicts. Techniques of antidepressants (Table 17-5), and the monoamine oxidase
confrontation and interpretation of behaviors and events are inhibitors (MAOIs) (Table 17-6). These antidepressant
frequently used. Conflicts, their meanings, and individuals’ families have unique properties, as do the individual medica-
choices are emphasized. This type of therapy can be done tions within each. Many of these medications must be taken
either with individuals or in a group format. at bedtime. It is a nursing responsibility to adequately edu-
Cognitive therapy focuses on removing symptoms by cate the client and family about the prescribed medications.
identifying and correcting perceptual biases in clients’ think-
ing and correcting unrecognized assumptions. The therapy Diet
concentrates on changing negative thoughts and behaviors The client experiencing depression often has a disturbance in
into alternatives that do not sustain depression. eating patterns. Some individuals will not be hungry and will

Table 17-3 Tetracyclic and Atypical Antidepressants

GENERIC TRADE NAME TYPE POTENTIAL SIDE EFFECTS
NAME
mirtazapine Remeron Tetracyclic Agranulocytosis, drowsiness, dry mouth, nausea, suicidal
ideation

nefazodone Serzone Antidepressant Constipation, dizziness, dry mouth, insomnia, nausea,

hydrochloride weight loss

venlafaxine Effexor Antidepressant Abnormal dreams, altered taste, anorexia, constipation,

hydrochloride diarrhea, dizziness, dry mouth, dyspepsia, headache, nau-
sea, nervousness, paresthesia, rectal hemorrhage, rhinitis,
seizures, sexual dysfunction, visual disturbances, vaginal/
uterine hemorrhage, weakness, weight loss
Data from Delmar Nurses’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 17 Mental Illness 591

eat very little or sometimes not at all, whereas others will client receiving SSRI therapy may experience an initial loss of
overeat. A nutritional assessment should be done as part of the appetite during the first part of therapy, because of the gastroin-
health history obtained by the nurse, and if any significant prob- testinal (GI) side effects frequently associated with these medi-
lem areas are identified, a dietary consult may be indicated. cations (Table 17-4). Anorectic clients or those at risk for weight
When a client is started on antidepressant therapy, the cli- loss must be closely monitored. The client receiving MAOI
ent and family must be educated regarding any special dietary therapy must be especially alert to the dietary restrictions asso-
needs, depending on the type of medication prescribed. The ciated with this particular type of medication (Table 17-6).

Table 17-4 Selective Serotonin Reuptake Inhibitors (SSRIs)

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS
fluoxetine hydrochloride Prozac Headache, abnormal dreams, anxiety, diarrhea, drowsiness,
excessive sweating, insomnia, nervousness, palpitations, pruritus,
seizures, tremors, visual disturbances, weight loss

fluvoxamine maleate Luvox Constipation, convulsions, impotence, dry mouth, drowsiness,

dyspepsia, headache, heart failure, insomnia, MI, nausea, nervous-
ness, weakness

paroxetine hydrochloride Paxil Anxiety, constipation, diarrhea, dizziness, drowsiness, dry mouth,
ejaculatory disturbance, headache, insomnia, nausea, seizures,
sweating, weakness, tremors

sertraline hydrochloride Zoloft Diarrhea, dizziness, drowsiness, dry mouth, fatigue, headache,
increased sweating, insomnia, nausea, palpitations, sexual dys-
function, tremors, vomiting when given with pimozide (Orap) raises
pimozide concentration by about 40% (FDA, 2002)

Data from Delmar Nurses’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Table 17-5 Tricyclic Antidepressants

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS
amitriptyline Elavil Arrhythmia, blurred vision, constipation, dry eyes, dry mouth, heart
hydrochloride block, hypotension, lethargy, MI, sedation, stroke

imipramine hydrochloride Tofranil Arrhythmia, blurred vision, constipation, drowsiness, dry eyes, dry
mouth, fatigue, hypotension, seizures, urinary retention

Data from Delmar Nurses’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Table 17-6 Monoamine Oxidase Inhibitors (MAOIs)

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS
isocarboxazid Marplan Arrhythmia, blurred vision, diarrhea, dizziness, headache, ortho-
static hypotension, insomnia, restlessness, seizures, weakness;
phenelzine sulfate Nardil these medications usually have the side-effect of lowering blood
pressure. A potentially fatal hypertensive crisis can result when
tranylcypromine sulfate Parnate
MAOIs are taken in combination with certain foods and drugs
such as broad beans, certain cheeses (e.g., brie, cheddar), liver,
caffeine, figs, dry sausage (pepperoni), tea, yogurt, amphetamine,
cocaine, dopa, and many OTC cold products, hay fever medica-
tions, and nasal decongestants.

Data from Delmar Nurses’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
592 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

PROFESSIONALTIP CLIENTTEACHING
Tetracyclic and SSRI Antidepressants
Antidepressant Therapy
Be sure to instruct each client taking a tetracyclic,
Before initiating antidepressant therapy, a baseline atypical, or SSRI antidepressant medication in the
electrocardiogram (EKG) is needed to determine following:
whether any preexisting underlying cardiac • Take the medication only as directed by your
problems are present. If the client develops cardiac physician.
difficulties during antidepressant therapy, another
• Do not take the medication unless prescribed by
EKG is obtained and compared to the original to
your physician.
assist in ascertaining whether the antidepressant
exacerbated the cardiac condition. • Do not take fluoxetine (Prozac), paroxetine
(Paxil), or sertraline (Zoloft) on an empty
stomach.
• Mirtazapine (Remeron) does not need to be
taken with food.
CLIENTTEACHING • Ability to drive and/or operate heavy
machinery may be impaired while taking
Tricyclic Antidepressants the medication.
Be sure to instruct each client taking a tricyclic anti- • Do not drink alcohol while taking the medication.
depressant medication in the following: • If female, advise your physician if you are
• Do not drink alcohol while on the medication. breastfeeding, suspect you are pregnant, or
• Do not take any other medications unless pre- are planning a pregnancy while taking the
scribed by your physician. medication.
• Drowsiness and sedation may impair the ability • Wear sunscreen and protective clothing while
to drive and operate heavy machinery. outdoors, as fluoxetine (Prozac), paroxetine
• Some of the side effects may diminish in inten- (Paxil), and sertraline (Zoloft) increase suscepti-
sity once your body adjusts to the medication. bility to sunburn.
• Do not stop taking the medications without • The medications may cause drowsiness.
physician approval. • If taking fluoxetine (Prozac), mirtazapine
• Increase fluid intake to assist in combating dry (Remeron), or nefazodone (Serzone), rise slowly
mouth and constipation. from a lying position to prevent dizziness and a
sudden drop in blood pressure.
• Sugarless candy and gum can help decrease the
side effect of dry mouth. • Utilize good oral hygiene in conjunction with
sugarless candy or gum to minimize the discom-
• Increase dietary fiber to decrease the side effect
forting side effect of dry mouth associated with
of constipation.
fluoxetine (Prozac), mirtazapine (Remeron),
• Rise slowly from a lying position to prevent diz-
nefazodone (Serzone), paroxetine (Paxil), and
ziness and a sudden drop in blood pressure.
sertraline (Zoloft).
• Monitor weight, as mirtazapine (Remeron) may
cause an increase in appetite.
• Do not take any over-the-counter (OTC) cold
medications with mirtazapine (Remeron).
CLIENTTEACHING • If taking mirtazapine (Remeron), inform your
physician of the medication regimen prior to
Potential Adverse Drug–Drug surgery.
Reactions with MAOIs
• If taking venlafaxine (Effexor), fluvoxamine
A serious drug–drug reaction can occur when an (Luvox), or nefazodone (Serzone), inform your
MAOI is taken concurrently with certain other physician if signs of allergic reaction occur.
medications. The combination of an MAOI and
some common prescription or OTC medications can
result in a hypertensive crisis that is often fatal.
Some of the most dangerous reactive medications
include meperidine (Demerol), stimulants, decon-
gestants, and weight-reduction aids.

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 CHAPTER 17 Mental Illness 593

CRITICAL THINKING
CLIENTTEACHING Coworker Depression
MAOIs
What actions would you take if you felt a
Be sure to instruct each client taking an MAOI anti- coworker was suffering from depression?
depressant medication in the following:
• Do not take any other medications, including
OTC medications, unless prescribed by your phy-
sician. Activity
• Take the medication exactly as prescribed. Clients experiencing depression often experience a signifi-
• Do not drink alcohol while on the medication. cant decrease in level of activity and report feeling tired and
lethargic. Clients experiencing depression will often require
• Rise slowly from a lying position to prevent diz-
encouragement to engage in any type of physical activity.
ziness and a sudden drop in blood pressure.
• Avoid all foods containing tyramine, including
alcoholic beverages, especially beer and wine;
Nursing Management
aged cheeses; avocados; bananas; caffeine; Spend time with the client one-on-one to build rapport and
chocolate; and smoked or pickled meats (such develop a therapeutic relationship. Encourage the client to ini-
as salami, pepperoni, smoked fish, and summer
tiate conversation and interact with others. Guide the client to
bathe, groom, and wear clean clothes. Praise the client verbally
sausage).
for conversing and interacting with others and for taking care
of hygiene and grooming.

NURSING DIAGNOSIS

Social Isolation related to inadequate resources, impaired or inadequate personal relationships

CLIENT GOAL
The client will increase social interactions

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Encourage client to join local organizations 1. Client can control the amount of social
or volunteer. interactions with others, and it encourages
social relationships.

2. Encourage client to surround themselves 2. This provides support and positive

with people with the same interests and reinforcement.
goals.

3. Encourage client to avoid negative relations. 3. Negative situations may lead to social
withdrawal.

EVALUATION
The client has joined the local ladies axillary that
volunteers services at the community hospital
once a week.

Concept Care Map 17-1

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594 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

reported. The depressed client who has become increasingly

NURSING PROCESS withdrawn and socially isolated may experience problems in
Assessment intimate, personal, and social relationships.

Subjective Data
The client may verbalize overwhelming feelings of sadness, Objective Data
thoughts of suicide, a loss of interest and pleasure in activities The client may manifest a noticeable decline in personal
that were previously enjoyable, and problems with memory, hygiene and grooming, possibly because of a lack of energy
recall, and concentration. In addition, a decreased libido, and an inability to perform even the simplest of tasks. Weight
extreme lethargy, and having insufficient energy to complete loss resulting from the client’s failure to eat may also be
activities of daily living (ADLs) and needed tasks may be noted.

Nursing diagnoses for the client with depression include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Social Isolation related The client will increase the Build rapport and develop therapeutic relationship with client.
to inability to engage number of interactions with Spend time with client individually.
in satisfying personal other individuals. Encourage client to initiate conversation and interact with oth-
relationships ers.
Verbally praise client for increasing interactions and initiating
conversation.

Bathing/Dressing and The client will attend to own Encourage client to bathe and wear clean clothes.
Feeding Self-care Deficit basic health care needs. Teach client the importance of balanced nutrition.
related to lack of concern
or regard toward self Praise client for each activity done on own.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

Some of the techniques used in anger control include

THE CLIENT WHO IS limiting access to frustrating situations, providing physical
POTENTIALLY VIOLENT outlets for expression of anger or tension (such as punching
bags, large motor activities [sports], and anger journals),

I n today’s society, violence has become increasingly

common and widespread. The media routinely and graphi-
cally reports the numerous violent crimes and acts that occur
and ensuring that a client for whom anger is a problem is
given enough personal space that he does not have to feel
encroached upon by others when he is unable to tolerate
environmental stimuli.
on a daily basis. Nurses may come face to face with angry
clients and their families and significant others and, perhaps,
even angry colleagues. When confronted by someone who is ■ HOMICIDAL INTENT
angry, the natural reaction is to respond in a like manner or,
perhaps, to feel intimidated. In such difficult situations, it is
important to maintain objectivity and not get “hooked” into
the client’s anger and respond in an inappropriate manner.
T he client who is homicidal is planning or threatening to
harm or kill another individual or individuals. It is the
responsibility of health care personnel to attempt to ascertain
Nurses may encounter clients who are verbally aggres- the seriousness of the intent; that is, whether the individual is
sive (prone to saying things in a loud and/or intimidating man- actually threatening someone else or just “blowing off steam.”
ner), physically aggressive (prone to threatening or actually Once aware of an individual’s threat or intent to harm some-
harming someone), or a combination of the two. Mind-altering one else, the nurse must inform the individual(s) at risk of the
substances such as alcohol and phencyclidine (PCP) often potential for harm and/or notify the proper authorities and
increase the risk of aggression. Anger-control assistance is enlist their help. The first step in such a situation is to contact
defined as a nursing intervention aimed at facilitation of the the supervisor and offer an accurate appraisal of the situation.
expression of anger in an adaptive and nonviolent manner.
Anger control includes establishing a basic level of trust and
rapport with the client and using a calm and reassuring manner. ■ SUICIDAL INTENT

P
The nurse should use every means possible to learn from the
client (or his family/friends) those situations that are likely to urposefully taking one’s own life, or suicide, is the ultimate
bring on anger, and should encourage the client to inform the form of self-destruction. Clients who are suicidal often feel
nursing staff when he is feeling tension. Although the nurse has overwhelmed by life events and decide that the only relief will
a responsibility to help the client learn to deal with his anger, come from ending their own lives. Intense feelings of fear, loss,
she also has a clear duty to assess for inappropriate aggression anger, or despair can drive individuals to commit suicide, and the
and to intervene before such aggression is expressed. effects of an attempted or completed suicide can be devastating

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 CHAPTER 17 Mental Illness 595

necessarily mean that the behavior will follow. When confronted

PROFESSIONALTIP with a client’s verbalization of possible suicide, however, it is
always wise to take the client’s expression of intent seriously.
Because suicide is a leading cause of death in the United States,
Assessing for Risk of Violence nurses must know how to evaluate a client for the likelihood of
a completed suicide. It is critical to thoroughly assess the client
• Be aware of those clients with past history of
and attempt to accurately ascertain the degree of danger the
violence and poor impulse control. client is experiencing. Once this is done, take the precautions
• Observe the client’s body language: Notice necessary to maintain the client’s safety (Table 17-7).
changes in behavior, words, or dress.
• Assess for aggressive behaviors, increasing ten-
sion, clenched fists, loud or angry tone of voice, ACTIVELY SUICIDAL
narrowed eyes, and pacing. The actively suicidal client is intent on hurting or killing
• Remember that hostility tends to be contagious. himself and is in imminent danger of doing so. This situation
Do not reciprocate with anger and hostility! requires immediate and appropriate action to protect the
client from potentially fatal self-destructive behavior. If the
client is in a supervised setting, it is the nurse’s responsibility
and long lasting. Nurses must learn to recognize the danger signs to maintain the safety of the client and to inform other staff
of clients at risk for suicide and know the appropriate interven- members of the client’s suicidal intentions. The client at risk
tions to help clients preserve their health and dignity. for self-inflicted injury must be monitored closely (per institu-
Suicide is the eleventh leading cause of death in the United tional policy and the frequency as ordered by the physician).
States, claiming more than 32,000 lives each year (CDC, 2008a). The frequency of client observation is determined by the
The populations at greatest risk are individuals with diagnosed degree of suicide risk and is written as a specific order from the
mood disorders such as Major Depressive Disorder, elders, and physician. Observations of the client are documented. Some
those with serious or life-threatening medical illnesses such as clients must be checked a minimum of once every 15 minutes.
cancer or human immunodeficiency virus. Other clients may require more frequent observation and
monitoring. If the client is actively suicidal and/or homicidal
and is indicating an imminent intent to harm self or others, a
SUICIDAL IDEATIONS specific staff member will be assigned to that client at all times
on a one-to-one basis.
The client experiencing suicidal ideations has thoughts of All pertinent observations such as verbalizations and behav-
hurting or killing himself but may or may not be planning to act iors that indicate self-harm potential should be documented in
on these thoughts. It is important to understand the difference the client’s record. Any changes in the client’s condition should
between thoughts and actions; that is, having a thought does not be reported immediately to the physician. The conversation

Table 17-7 Assessment of Risk for Suicide

The following areas are to be assessed in all potentially suicidal clients:

1. Does the client have a plan to commit suicide?

Example: Client plans to “end it all” after wife Rationale: Some clients may be experiencing thoughts of wishing they
leaves for work on a Monday. were dead or killing themselves, but may not have a plan for doing so.
The client who has a plan for committing suicide is at increased risk.

2. How specific is the plan to commit suicide?

Example: Client states he plans to overdose on Rationale: A specific plan increases the risk of completing a suicide.
sleeping pills.

3. Does the client have access to the means to commit suicide?

Example: Client states he will use his spouse’s Rationale: Easy availability of the means to kill oneself increases the risk
sleeping pills to overdose. of suicide.

4. How lethal is the intended means to commit suicide?

COURTESY OF DELMAR CENGAGE LEARNING

Example: Client states he will “blow his brains Rationale: Some means of suicide are more likely to result in a complet-
out” with a gun. ed suicide. Gunshots are the most common cause of completed suicide.
The lethality of guns makes the potential for a successful intervention
very slim. Intervention in light of means that are less lethal may yield a
more favorable outcome (e.g., overdose, cutting of wrists).

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596 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

with the doctor, as well as any new orders or changes in orders, can be used only when all other avenues for control have been
must also be documented in the client’s record. exhausted. The client must be told what is happening and why.
He must not be left alone; a staff member should be assigned
Medical–Surgical to observe the client, usually from the doorway. Seclusion is
an enforced “time-out,” where the client is removed from the
Management situation only long enough to allow him to calm down, regain
a sense of control, and then reenter the unit.
Medical
The client who is severely agitated, aggressive, actively sui- Therapy Psychotherapy is often indicated and initially may
cidal, and/or homicidal and who is exhibiting or threatening focus on personal and social conditions that bring about and/
violent acts may need to be restrained or placed in seclusion in or perpetuate suicidal thoughts. Cognitive-behavioral therapy
order to be safely contained. The physical holding of someone may be particularly useful, as may techniques to deal with frus-
or use of mechanical restraints severely restricts movement tration and anger. Substance use and abuse are often involved
and can constitute a violation of the client’s rights unless suf- and may require separate outpatient or inpatient interventions.
ficient clinical justification exists. Thus, all of the client’s com-
ments and behaviors plus any nursing interventions must be
documented in the client record per agency policy. This docu- Pharmacological
mentation provides the necessary justification for the use of The severely agitated, aggressive, suicidal, and/or homicidal
restraints or seclusion. In addition, the physician must write a client who is violent or threatening violence may require a medi-
specific, time-limited order that spells out the reason restraints cation with strong anxiolytic (antianxiety) and/or sedative prop-
or seclusion was indicated for use with the client. erties, such as one of the antianxiety agents or a sedative-hypnotic
(Table 17-1). Additionally, the suicidal client who is depressed
Physical Restraints Physical restraints, usually leather straps, may be evaluated for treatment with one of the many available
are used to immobilize a person who is clearly dangerous to antidepressants such as fluoxetine hydrochloride (Prozac), ser-
self or others and who poses sufficient risk of harm. Physical traline hydrochloride (Zoloft), paroxetine hydrochloride (Paxil),
restraints may be applied only under the direction and super- fluvoxamine maleate (Luvox), mirtazapine (Remeron), or one of
vision of a registered nurse (RN) and must comply with state the many others (Tables 17-3, 17-4, 17-5, and 17-6).
laws regarding their use. In almost all cases, there must be a
physician’s order to apply the restraints, and there must be Diet
clearly documented evidence that the restraints were needed.
Some of the observable behaviors indicating that restraints Foods are not restricted because a client is severely agitated,
are necessary include increased motor activity, verbal and/ aggressive, actively suicidal, and/or homicidal, but may be
or physical threats, overresponsiveness to stimuli, and actual restricted depending on the medications being taken. The food
physical assault (Frisch & Frisch, 2010). tray should be inspected for any potentially dangerous objects
such as glassware or silverware. Even plasticware can be broken
Seclusion Seclusion is the process of confining a client to in such a way as to yield a very dangerous weapon for hurting
a single room. The room may be locked or unlocked, and it self or others.
may or may not have furnishings. The purpose of seclusion
is to provide security, to remove the client from a situation of Activity
escalating anger and violence, or to remove the client who is
hypersensitive to environmental stimuli from the stimulation The activity level of the client who is severely agitated, aggres-
of a hospital unit. Seclusion, like the use of physical restraints, sive, actively suicidal, and/or homicidal may need to be
restricted for a period of time in order to maintain the client’s
safety and the safety of others.

PROFESSIONALTIP Nursing Management

Assess the client for suicidal thoughts. If the client has a spe-
Providing a Safe Environment cific plan, evaluate the degree of risk for the client and contact
the physician. Assess the environment for potentially danger-
When a client verbalizes an intention to inflict ous items. Increase the level of client observation.
self-harm, measures must be taken to ensure
the client’s safety. One way is to provide and
maintain a safe, secure environment for the
client. This may require a change in items allowed
NURSING PROCESS
in the client’s surroundings and living space.
For example, a pencil or pen could be used as a
Assessment
dangerous weapon; an empty soda can could be Subjective Data
used to deeply cut the wrists or to seriously injure
The client may argue, yell, curse, and make numerous verbal
someone else; and the broken glass from a bottle threats in a loud voice. The suicidal client may indicate inten-
of make-up could cause great harm. These and tions verbally, nonverbally, or a combination of the two. The
all other potentially dangerous items must be client contemplating suicide may verbalize his thoughts either
removed from the client’s immediate area. directly or indirectly. A direct statement may be something as
straightforward as “I am planning to kill myself.” An indirect

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 CHAPTER 17 Mental Illness 597

PROFESSIONALTIP

No-Suicide Contract
Obtaining a “No-Suicide Contract” from the client is matter what happens clause blocks off this avenue
one way to help reduce the risk of suicide attempts. of escape from the contract.
There are several guidelines to follow in working • Ask the client whether he can make a promise to
through this process: himself that if thoughts of suicide return, he will
• Ask the client whether he is able to make a prom- talk to someone before taking any action. Ratio-
ise to himself that he will not do anything to nale: If the client talks to someone regarding his
harm himself. Rationale: It is important for the thoughts of suicide before he attempts suicide, a
client to make the contract with himself, because successful intervention and suicide prevention are
if the contract is made with someone else, such more likely.
as a nurse, and the client later becomes angry or • Assist the client in developing a detailed plan of
upset with that person, he may then harm himself action regarding those persons he will contact
in order to “get back” at that person. in the event that he again experiences suicidal
• If the client is unable to commit to the No-Suicide thoughts. Include names and phone numbers of
Contract for the rest of his life, work with him on all significant and supportive individuals. Ratio-
establishing a time frame to which he can commit, nale: During a crisis, the suicidal individual is not
for example, 1 week, 24 hours, 8 hours, or some able to think rationally and will behave and act
other time frame. Always meet with the client at in an impulsive manner. Having a well-developed
the end of the allotted time frame and review/ plan of action increases the likelihood that the
renew the contract at that time. Rationale: The suicidal individual can follow these guidelines.
suicidal individual may feel overwhelmed at the • At the bottom of the list, put the name and phone
thought of promising never to harm himself, but number of the local suicide crisis hotline and/or
may be able to sincerely commit for a shorter local emergency number (911). Rationale: Includ-
length of time. ing these numbers ensures that there will always
• Ask the client whether he is able to maintain the be someone available for the suicidal client to talk
No-Suicide Contract no matter what happens. to 24 hours a day, 7 days a week, 365 days a year.
Rationale: Some clients will leave a way out of • Assist the client in putting the No-Suicide Contract
the contract. For example, the suicidal client may in writing and in his own words. Give the client
outwardly make a promise to not commit suicide the original and put a copy in the client’s chart.
but inwardly think “unless something really bad Rationale: When the contract is in writing and the
happens, like if my wife leaves me.” If the wife client has a copy, he will be more likely to follow
then files for a divorce, the client may feel that through with his promise to not commit suicide.
he has “permission” to kill himself. Adding the no

statement might be “I’m not going to be around here any- to use items in the environment, such as books, furniture, or
more” or “Everyone will be better off without me.” a coffee pot, as weapons. A nonverbal signal of possible inten-
tions of suicide may be seen in the client who begins making
Objective Data arrangements for people and pets to be taken care of, putting
The client may exhibit restlessness, pacing, and “poor impulse personal affairs in order, and giving away personal possessions,
control”; may be physically intimidating; and may use or try especially treasured items.

Nursing diagnoses for the client who is severely agitated, aggressive, actively
suicidal, and/or homicidal include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Self-Directed The client will not harm self. Assess for the presence of suicidal thoughts and whether a
Violence related to risk specific plan is present.
factors such as mental Evaluate the degree of risk associated with the client’s verbal-
health, emotional status, ization of suicide intent.
or suicidal plan
Contact the attending physician or psychiatrist and inform of
the client’s intentions and current condition.
(Continues)

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598 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Nursing diagnoses for the client who is severely agitated, aggressive, actively
suicidal, and/or homicidal include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Assess and evaluate the client’s surroundings and environ-
ment for any potentially dangerous items or objects that
could be used for self-harm. Remove or secure any poten-
tially harmful items.
Increase the level of observation so that the client is
frequently monitored.
Assist the client in developing a No-suicide Contract.

Risk for Other-Directed The client will not harm Assess for the presence of homicidal ideations.
Violence related to risk anyone. If the client is verbalizing a plan to harm someone, immediately
factors such as history of notify the proper authorities so they can alert this individual.
violence against others, sui-
cidal behavior, impulsivity

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Suicidal Client with Major Depression

A.J. is a 27-year-old woman who was brought to the emergency department of a county hospital by
ambulance after a serious suicide attempt via ingesting a bottle of insecticide. After being treated in the
emergency room, she spent 2 days in the intensive care unit (ICU) and then was transferred to a locked
adult inpatient psychiatric unit for evaluation and treatment. A.J. reports she became suicidal following
the recent ending of a 4-year relationship with her boyfriend and decided to take her life because she felt
“completely hopeless,” that “there was nothing left to live for,” that “no one would miss her” if she were
dead, that she “would never be loved,” and that she “could never be happy again.” Before the suicide at-
tempt, A.J. reports that she had not been eating, had only been sleeping 1 to 2 hours per night, and had
been crying almost continuously throughout the day. Since admission to the psychiatric unit, A.J. has been
started on sertraline (Zoloft).
NURSING DIAGNOSIS 1 Risk for Self-Directed Violence related to recent loss, feelings of abandon-
ment, and impulsive behavior as evidenced by suicide attempt of drinking bottle of insecticide, verbaliza-
tions that “there was nothing left to live for” and that “no one would miss her” if she were dead
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Depression Level Self-Esteem Enhancement
Suicide Self-Restraint Coping Enhancement

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

A.J. will verbalize that she is no Assist A.J. in developing a No- May help deter self-destructive
longer at risk of harming herself. Suicide Contract. Obtain in writing behavior in the future.
if possible, make a copy for her
chart, and give her the original.
Explore with A.J. factors that con- Can be the first step in preventing
tributed to her becoming suicidal. another attempt.

(Continues)

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 CHAPTER 17 Mental Illness 599

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
Encourage A.J. to verbalize her Current feelings of loss and aban-
feelings related to the recent donment are often magnified
break-up and to explore any un- and intensified by unresolved past
resolved past issues that this loss situations and circumstances that
might have triggered. were never effectively handled.
Explore with A.J. her usual meth- Can lead to a better understand-
ods of coping with stressful situ- ing of those behaviors that must
ations and whether these have be changed.
been effective for her.
Assist A.J. in identifying and then Assists the client in recognizing
developing stress-management alternate methods of managing
methods as alternatives to at- stressful situations.
tempting suicide.
Assist A.J. in developing a Plans to prevent suicide must be
suicide-prevention plan and in developed ahead of time, be-
identifying supportive individuals cause individuals contemplating
and resources that she can turn suicide are impulsive and unable
to in the event that she begins to to problem solve or think clearly.
again have suicidal thoughts. They may, however, be able to
follow through with a previously
defined plan of action.
Teach A.J. about possible side Medication education is an inte-
effects associated with sertraline gral part of treatment.
(Zoloft), such as nausea and GI
upset, and encourage her to have
something to eat prior to taking
this medication.
Emphasize the importance of tak- If medications are discontinued
ing this medication as prescribed prematurely, symptoms usually
and not stopping the medication reappear and are often much
on her own, even if she starts to more serious.
feel better and thinks that she no
longer needs it.
Encourage A.J. to keep a journal Writing in a journal can be a safe
to reflect on her thoughts and and effective method of identi-
feelings. fying, expressing, and releasing
feelings and emotions.
Encourage A.J. to keep follow-up Recommended to evaluate effec-
appointments for medication to tiveness and to monitor for any
monitor progress. side effects.
Assist A.J. in setting up an Recommended after a suicide
appointment for outpatient coun- attempt in order to address the
seling/therapy upon discharge underlying issues and to prevent
per recommendation from the future attempts.
treatment team. Encourage A.J.
to keep counseling appointments.
(Continues)

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600 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

SAMPLE NURSING CARE PLAN (Continued)

EVALUATION
At the time of discharge from the adult inpatient psychiatric unit, A.J. was no longer actively suicidal
or intent upon harming herself. She still had occasional suicidal ideations; however, she did not feel
compelled to act on them. She had made a promise to herself that she would never try to kill herself
again no matter what happened, and that if those thoughts returned, she would find someone to talk
to before she did anything. She also had developed a written list of friends and relatives she could call
if she again experienced thoughts of suicide.

NURSING DIAGNOSIS 2 Hopelessness related to feelings of loss about her life and future as evi-
denced by verbalizations of feeling: “completely hopeless,” that she “would never be loved,” and that
she “could never be happy again”
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Depression Control Suicide Prevention
Mood Equilibrium Patient Contracting

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

A.J. will be less hopeless as indi- Develop a therapeutic nurse–client Fosters the development of a
cated by verbalizations of plans relationship with A.J. using the therapeutic nurse–client relation-
for her future components of trust, rapport, re- ship.
spect, genuineness, and empathy.
Encourage A.J. to become in- Helps distract the mind from a
volved in activities on the unit, preoccupation with losses, over-
for example, interacting with whelming feelings of depression,
staff and other clients and attend- and suicidal ideations.
ing and participating in therapy
groups and recreational activities.
Provide things for A.J. to do Provides time to allow for
when she is feeling down, for something to shift for her, to see
example, go for a walk with the the situation as not so utterly and
staff, read a newspaper or book, permanently hopeless or for her
or play a game. to begin to feel better and think
differently once she has started
responding to medication.
Assist A.J. in identifying the Changing the way a person thinks
irrational beliefs or thoughts that by replacing irrational thoughts
she is having, for example, when with rational or healthier ones,
she says no one will ever love or will change the way the person
want her again. feels.

EVALUATION
A.J. continued to have fleeting thoughts of hopelessness as far as ever having another significant relation-
ship or being in love again; however, she now was beginning to catch herself and could identify these
thoughts as being irrational and negative in nature and not helpful to her in any way.

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 CHAPTER 17 Mental Illness 601

lives with minimally debilitating symptoms through psycho-

THE CLIENT WHO social treatments.
IS PSYCHOTIC The goals of psychosocial treatment can be divided
into three categories: clinical and family support services,

P sychosis is a state wherein an individual loses the ability to

recognize reality. A psychotic person may experience hal-
lucinations, wherein he hears voices or sees images of persons
rehabilitative services, and humanitarian aid/public safety.
Clinical support involves outpatient management and fam-
ily/community services. Rehabilitation involves increasing
clients’ capacities, both for social interactions and for produc-
or things that others cannot see or hear. A psychotic person
tive activity (including gainful employment, when feasible).
is frequently unable to care for basic needs of safety, security,
Humanitarian interventions are those efforts that maximize
nutrition, and so on. Such an individual is hospitalized for his
an individual’s independence and quality of life within the
own safety and to initiate treatment (usually involving some
bounds of the mental disability. Public safety involves balanc-
form of medication) to bring the symptoms under control. A
ing personal liberty with the recognition that some social
psychotic person may slip into and out of reality.
control may be needed to prevent harm, both to the individual
Psychosis can be a component of several illnesses, includ-
and to society.
ing Schizophrenia and Bipolar Disorder.
Pharmacological
■ SCHIZOPHRENIA The most commonly prescribed classification of medications

T
for the client experiencing schizophrenia is the antipsychotics
he client with schizophrenia can be very difficult to under- (Tables 17-8 and 17-9). This group of medications is given
stand and treat because the symptoms of schizophrenia to reduce the signs and symptoms of psychosis, with a long-
can be confusing and frightening to caregivers. Clients with term goal of the client eventually being symptom free. If this is
schizophrenia frequently have belief systems that have become not possible, the goal is to reduce symptoms to a manageable
distorted, so that they hold firmly to false ideas or delusions, level.
even when presented with evidence to the contrary. When con- Because several side effects are associated with the antip-
fronted with an opposing belief system, they may become even sychotics, client teaching is an important part of the nurse’s
more entrenched in their mistaken views and begin to believe role. In addition to common side effects, some antipsychotic
others are “against them,” when, in fact, they are not. This medications also have the potential for causing adverse reac-
makes them even more paranoid and suspicious, adding to their tions such as extrapyramidal symptoms (EPS), tardive dyski-
already distorted views of reality. As a result, these individuals nesia (TD), and neuroleptic malignant syndrome (NMS).
are often struggling to determine the difference between that One of the most important factors in symptom manage-
which is real and that which is unreal or delusional. ment for schizophrenia is medication compliance. In most
Hallucinations can occur in relation to any of the five cases, individuals who are schizophrenic must take some type
senses (hearing, sight, touch, taste, and smell), but the most of antipsychotic medication for the remainder of their lives. Cli-
common types of hallucinations are auditory and visual. Indi- ents suffering from schizophrenia are often extremely resistant
viduals experiencing auditory hallucinations hear someone to taking their medications as prescribed and usually require
talking to them, when, in reality, no one is. The voice may be multiple repeat hospitalizations for stabilization. Multiple rea-
that of someone the individual recognizes, or the voice may be sons exist for noncompliance, one being the client’s denial of
unknown to the person. If the voice or voices are comforting, the diagnosis or the illness or of the seriousness of the illness. As
the individual will be very resistant to “giving them up.” Most a result of denial, the individual with schizophrenia resists tak-
of the time, however, the voices are derogatory in nature, tell- ing medication, because to the client, taking medication equates
ing the person that there is something wrong with him. to acceptance of having a serious mental disorder. Clients may
The individual experiencing a visual hallucination per-
ceives or sees someone or something that is not actually there.
Depending on the nature of the hallucination and whether the
individual perceives it as threatening, the situation can be very CLIENTTEACHING
frightening. Schizophrenia
The most serious type of hallucination is referred to as
the command hallucination, which occurs when the voice Family involvement is important for all clients, but
or voices tell the individual to harm himself or someone else. it is especially critical for the client with schizophre-
For example, the voices may tell the individual to jump off a nia. Because the client may be too ill or confused to
bridge or building, step in front of a moving motor vehicle, be trusted to take medications reliably, it becomes
or take an overdose of medication. These hallucinations are the responsibility of family members to help ensure
extremely dangerous because the demands are so strong that medication compliance. Most hospital readmissions
the individual is very likely to act on them.
for the client with schizophrenia are a result of

Medical–Surgical
noncompliance with the prescribed medication regi-
men. If the family understands the important role
Management psychotropic medications can play in preventing dec-
ompensation (a return of the psychiatric symptoms)
Medical and subsequent hospital readmission, the client has
At this time, there is no cure for schizophrenia; however, it is a much better chance of remaining stabilized.
possible for some clients with schizophrenia to lead functional

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602 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Table 17-8 Atypical Antipsychotics

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS
clozapine Clozaril Agranulocytosis, angina, constipation, dizziness, orthostatic hypotension,
increased salivation, leukopenia, NMS, drowsiness, seizures, tachycardia,
weight gain

olanzapine Zyprexa Agitation, acute renal failure, amblyopia, constipation, CVA, dizziness, dry mouth,
headache, NMS, orthostatic hypotension, restlessness, rhinitis, sedation, seizures,
tachycardia, TD, tremors, weakness, weight gain

quetiapine Seroquel Dizziness, headache, NMS, seizures, TD, weight gain

fumarate

risperidone Risperdal Acute renal failure, constipation, cough, decreased libido, diarrhea, dizziness,
dry mouth, dysmenorrhea/menorrhagia, headache, increased dreams, increased
sleep duration, insomnia, itching/skin rash, MI, nausea, NMS, pharyngitis, rhinitis,
sedation, visual disturbances
Data from Delmar Nurse’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Table 17-9 Phenothiazines (Antipsychotics)

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS
chlorpromazine, Thorazine Agranulocytosis, blurred vision, constipation, dry eyes, dry mouth, hypotension,
hydrochloride laryngeal edema, NMS, photosensitivity, sedation, TD

fluphenazine Prolixin Agranulocytosis, EPS, photosensitivity, TD

hydrochloride

thioridazine hydro- Mellaril Agranulocytosis, blurred vision, constipation, dry eyes, dry mouth, hypotension,
chloride NMS, photosensitivity, sedation, TD
Data from Delmar Nurse’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

also become noncompliant after a period of time on medica-

CLIENTTEACHING tion; once they start to feel better, they think the medication is
Adverse Reactions to Antipsychotic no longer needed and stop taking it. After a short time of being
Medications off the prescribed medication, however, most individuals with
schizophrenia will experience a return or significant worsening
• Extrapyramidal side effects: a common adverse of their previous symptoms.
reaction of some antipsychotic medications Probably the most common reason for medication non-
(especially the older ones) involving muscle compliance, however, is the number of troublesome side
rigidity and involuntary muscle movements; effects and potentially dangerous adverse reactions histori-
reversible if the dose is lowered or an anti- cally associated with antipsychotic medications. Fortunately,
newer antipsychotic medications are now available that have
Parkinson agent is administered
fewer side effects and are much better tolerated. Even with
• Tardive dyskinesia: irreversible reaction to anti- the advent of these newer and more effective medications,
psychotics (usually associated with high doses however, many individuals are unable to benefit from them
over a long period) consisting of involuntary because of the high cost and the difficulties sometimes associ-
muscle and body movements ated with accessing these medications.
• Neuroleptic malignant syndrome: a rare and
potentially fatal reaction to antipsychotic
medications characterized by a very high fever,
Diet
severe muscle stiffness, and changes in senso- Some of the antipsychotics such as clozapine (Clozaril),
olanzapine (Zyprexa), quetiapine fumerate (Seroquel), and
rium progressing to coma
risperidone (Risperdal) can cause weight gain over time.
For the individual who has schizophrenia and its multiple

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 CHAPTER 17 Mental Illness 603

CLIENTTEACHING CLIENTTEACHING
Phenothiazines Atypical Antipsychotics
Be sure to instruct each client taking a phenothiazine Be sure to instruct each client taking an atypical
medication in the following: antipsychotic medication in the following:
• Do not drink alcohol while on the medication. • Do not drink alcohol while taking the medica-
• Do not take any other medications unless pre- tion.
scribed by your physician. • Do not take any other medications, prescription
• Do not stop taking the medication abruptly. or OTC, unless prescribed by your physician.
• The ability to drive and/or operate heavy • Do not stop taking the medication without
machinery may be impaired while taking the authorization from your physician.
medication. • Do not stop taking the medication abruptly.
• Be aware of possible side effects of the medica- • The ability to drive and/or operate heavy
tion. machinery may be impaired while taking the
• Increase fluid intake to minimize the side effects medication.
of dry mouth and constipation. • Rise slowly from a lying position to prevent diz-
• Increase dietary fiber to minimize the side effect ziness and a sudden drop in blood pressure.
of constipation. • The medication is contraindicated during preg-
• Rise slowly from a lying position to prevent diz- nancy and lactation. Reliable contraception
ziness and a sudden drop in blood pressure. should be utilized while taking the medication.
Female clients should advise their physicians
• These medications are contraindicated during
immediately if they suspect they are either
pregnancy and lactation. Female clients should
pregnant or planning to become pregnant.
advise their physicians immediately if they are
either pregnant or planning to become pregnant. • Be aware of the potential side effects of the
medications.
• Wear sunscreen and protective clothing while
outdoors, as the medication increases suscepti- • Notify your physician immediately of unex-
bility to sunburn. plained fever, sore throat, bleeding, bruising, or
petechiae.
• Some of the side effects may diminish in inten-
sity after an initial period of adjustment. • Wear sunscreen and protective clothing while
outdoors, as olanzapine (Zyprexa) and risperidone
• The medication may increase your risk of devel-
(Risperdal) increase susceptibility to sunburn.
oping EPS, TD, and NMS.
• Avoid temperature extremes if taking olanzap-
ine (Zyprexa), quetiapine fumerate (Seroquel),
or risperidone (Risperdal), as the body’s ability
associated problems, weight gain can constitute yet one to regulate internal temperature is affected by
more stressor. Teaching for the client who is at risk for gain- these medications.
ing weight must therefore emphasize the importance of • Utilize good oral hygiene in conjunction with
being cognizant of and conservative with regard to caloric sugarless candy or gum to minimize the discom-
and fat intake, avoiding a sedentary lifestyle, and increasing forting side effect of dry mouth associated most
physical activity. frequently with clozapine (Clozaril) and olan-
zapine (Zyprexa).
• Beware of associated risks including EPS, NMS,
and a high risk of agranulocytosis and seizures
PROFESSIONALTIP with clozapine (Clozaril); EPS, TD, and NMS with
olanzapine (Zyprexa), quetiapine (Seroquel),
Refrain from Making Judgments and risperidone (Risperdal); and seizures with
olanzapine (Zyprexa) and quetiapine fumerate
Changing the words we use may help the client and
(Seroquel).
family feel less defensive and may open the door
for more effective communication. One example • Treatment with clozapine (Clozaril) requires
of an often-used term that carries negative weekly white blood cell (WBC) monitoring to
connotations is noncompliance. Ward-Collins (1998) assess for onset of agranulocytosis. Medication
encourages nurses to consider using another term is dispensed in 7-day increments to maintain
such as nonadherence, which does not carry the policy compliance and prevent this potentially
same degree of negative connotations. life-threatening occurrence.

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604 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Activity NURSING PROCESS

Clients with schizophrenia tend to be tired and lethargic,
probably because of multiple factors including the disease
process and, possibly, the sedative properties associated
Assessment
with some of the antipsychotics, especially some of the Subjective Data
older ones such as chlorpromazine (Thorazine) and thior- The client may be very frightened, confused, and have disor-
idazine (Mellaril). ganized thought processes, using a nonsensical combination
of words that is meaningless to others (word salad), talk
out loud even when no one is present, or respond to internal
stimulation or hallucinations.
Nursing Management
Carefully observe the client’s behavior. Listen to the client Objective Data
but neither agree nor disagree with what the client is say- The client may be isolated, withdrawn, experience great difficulty
ing. Accurately document what is seen and heard. Include in any type of social interaction or situation, and stay in bed and
the family in client care. Encourage the client to perform sleep. Thus, the client may require a great deal of assistance and
ADLs. encouragement to perform ADLs and complete basic hygiene needs.

Nursing diagnoses for the client with schizophrenia include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Sensory Per- The client will experience a Assess for the presence of hallucinations.
ception ( Visual, Auditory ) decrease in the intensity and Assist the client in beginning to exert some control over the
related to altered sensory frequency of symptoms. hallucinations.
perception
Educate the client about ways to decrease the intensity and
power of the hallucinations.

Deficient Knowledge The client will verbalize an Educate the client and family about the disorder of Schizo-
related to medication understanding of the disorder phrenia, the need for antipsychotic medications, and the
therapy and the ongoing need for importance of continuing the prescribed medication regimen.
medications.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

day. There are also several degrees of both depression and

■ BIPOLAR DISORDER mania that the individual can experience. As is the case with

B
depression, an individual can experience mild, moderate, or
ipolar Disorder (previously known as manic–depressive severe mania. The degrees of mania range on a continuum
disorder) is characterized by wide fluctuations in mood from hypomania (a mild form of mania without significant
(the way an individual reports feeling, e.g., depressed, elated, impairment) to severe or delirious mania (DBSA, 2006).
happy, sad) and affect (the objective or outward manifesta- An individual in the depressed phase of bipolar disorder
tion of the way an individual is feeling). Nearly 6 million will manifest the same signs and symptoms as an individual
Americans have bipolar disorder (DBSA, 2009). Bipolar dis- with depression. The client in the manic phase of bipolar
orders are a personal and public health concern with as many disorder may be very irritable and agitated and can be intimi-
as 19 % of bipolar individuals dying from suicide, and bipolar dating toward others, both verbally and physically. The client
disorder ranking sixth as a leading cause of disability in the exhibiting manic behavior is often hyperactive, unable to sit
United States (Antai-Otong, 2008). In addition to having a down or remain still, and may display a euphoric (being
wide range of both affect and mood, the individual with bipo- elated out of context to the situation) affect and mood. Once
lar disorder may experience fluctuations between depression in the manic phase of illness, clients will often exhibit behav-
and mania (extremely elevated mood with accompanying iors incongruent with their usual personalities. For example,
agitated behavior). The client with bipolar disorder may expe- the manic client may dress in a flamboyant and provocative
rience these fluctuations in mood and affect in varying degrees manner; spend money and buy things in a very lavish fash-
and over varying time frames. For example, an individual may ion; and become sexually promiscuous and engage in risky
experience changes in mood and affect every few years, at cer- behaviors that would otherwise be out of character. After a
tain times of the year, every few months, every few weeks, or while, the client may experience a great deal of conflict in
even every few days. The alterations in mood between depres- social, familial, and personal relationships. It often becomes
sion and mania are often referred to as cycling. Individuals the responsibility of a significant other or family member to
who suffer what is known as rapid cycling may experience seek professional assistance for the individual. This already
multiple swings between depression and mania in the same difficult situation is compounded by the fact that the client

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 CHAPTER 17 Mental Illness 605

Table 17-10 Mood Stabilitzer: Antimanic

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS SIGNS AND SYMPTOMS OF
TOXICITY
lithium carbonate Eskalith, Litho- Abdominal pain, acneiform eruption, Ataxia, change in level of orienta-
nate anorexia, arrhythmia, bloating, diarrhea, tion, confusion, diarrhea, drowsi-
dizziness, drowsiness, EKG changes, ness, excessive urination, lack of
fatigue, folliculitis, GI upset, headache, coordination, muscle weakness,
hypothyroidism, impaired memory, irritability, tremors, vomiting
leukocytosis, muscle weakness, nausea,
polyuria, seizures, tinnitus, tremors

Data from Delmar Nurse’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

in the manic phase of bipolar disorder is frequently in denial client is stabilized on the medication. Blood should then be
about the illness, does not perceive the erratic behavior as drawn monthly for as long as the client is taking the medication
problematic, and enjoys the “high” created by the disorder. As (Spratto & Woods, 2008). Before initiating lithium therapy,
a result, the individual often refuses any type of help, and the a 24-hour urine creatinine clearance test is done to evaluate
family may be required to seek involuntary hospitalization in the functioning of the kidneys and their ability to adequately
order to obtain the much-needed treatment. excrete the lithium.

Medical–Surgical Diet
Management Because lithium is a salt that is chemically similar to sodium
chloride (table salt), lithium and sodium compete for
Medical
The severely agitated client in the manic phase of bipolar Table 17-11 Mood Stabilizers:
disorder may need to be secluded and/or restrained in order
to protect against self-inflicted injury and/or the risk of injury
Anticonvulsants
to others. GENERIC TRADE POTENTIAL SIDE
Psychotherapy may be helpful to the client experiencing NAME NAME EFFECTS
bipolar disorder, but it is not recommended as the only inter- carbamazepine Tegretol Agranulocytosis, aplastic
vention. These clients typically require some type of medica- anemia, ataxia,
tion management for the remainder of their lives in order to
drowsiness, drug-
function adequately.
induced hepatitis,
thrombocytopenia
Pharmacological valproic acid Depakene Depression, dizziness,
The drug of choice for treatment of bipolar disorder is lithium indigestion, hepatotoxi-
carbonate (Lithonate) (Table 17-10). Lithium is a naturally city, leukopenia, nausea,
occurring salt that has proven highly effective for many indi- thrombocytopenia,
viduals in managing the severe mood swings associated with vomiting, weight gain
bipolar disorder. Lithium is referred to as a “mood stabilizer,”
meaning that it helps level or even out the wide mood swings Data from Delmar Nurse’s Drug Handbook 2010 Edition, by G. Spratto
associated with the disorder; however, some individuals either and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.
cannot tolerate lithium therapy or become resistant to its ther-
apeutic effectiveness after a period of time. Fortunately, some
other medications are often prescribed for clients who cannot
take lithium. These include the anticonvulsants valproic acid LIFE SPAN CONSIDERATIONS
(Depakene) and carbamazepine (Tegretol) (Table 17-11) and
the anxiolytic/anticonvulsant clonazepam (Klonopin). Lithium Use in Older Adults
Lithium has a very narrow range of therapeutic effective-
ness. The amount of lithium the individual has available and Because older adults have a reduced creatinine
whether this level is appropriate is measured by a blood test clearance, they are at greater risk for developing
called serum lithium level. The acceptable therapeutic range toxicity while taking lithium. Use caution in
for the serum lithium level is 0.4 to 1.0 mEq/L; however, the older adult because lithium is more toxic
the value may vary slightly depending on the laboratory that to the central nervous system. The older adult
is performing the test (Spratto & Woods, 2008). A lithium may also develop a lithium-induced goiter and
level that is too low will not produce any benefit, and one that hypothyroidism (Spratto & Woods, 2010).
is too high may be toxic, or poisonous. It is therefore critical
that the serum lithium level be obtained every 5 days until the

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606 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

CLIENTTEACHING CLIENTTEACHING
Lithium Anticonvulsants
Be sure to instruct each client taking lithium in the Be sure to instruct each client taking an anticonvul-
following: sant medication in the following:
• Do not drink alcohol while taking this medica- • Do not drink alcohol while taking the
tion. medication.
• Do not take any other medications, prescribed • Do not take any other medications, prescribed
or OTC, unless authorized by your physician. or OTC, unless authorized by your physician.
• Do not stop taking this medication without • Take the medication exactly as prescribed.
authorization from your physician. • Do not stop taking the medication without
• Female clients should utilize a reliable form authorization from your physician.
of contraception while taking this medication. • Do not stop taking the medication abruptly.
Immediately inform your physician if pregnancy
• The medications are contraindicated during
is suspected.
pregnancy and lactation. Female clients should
• Drink 2,000 to 3,000 mL of fluid (10–12 glasses) advise their physicians immediately if they are
per day. either pregnant or planning to become
• Maintain a consistent level of salt in the diet. pregnant.
• The ability to drive or operate heavy machinery • Carbamazepine (Tegretol) can impair the
may be impaired while on this medication. effectiveness of hormonal forms of contra-
• Serum lithium level must be checked at sched- ception. Female clients should practice an
uled intervals throughout therapy. alternate form of birth control while on this
• Be aware of signs and symptoms of lithium medication.
toxicity. • The ability to drive or operate heavy machinery
may be impaired while on the medication.
• Laboratory tests monitoring complete blood
count (CBC), platelet count, bleeding time, and
absorption at receptor sites. This relationship is inversely hepatic functioning must be performed periodi-
proportional; thus, any changes in the body’s sodium level cally throughout therapy.
will directly affect lithium level. Adequate fluid intake is • Notify your physician immediately of unex-
very important for the client on lithium therapy. It is recom- plained fever, sore throat, bleeding, bruising, or
mended that the client taking lithium consume a minimum of petechiae.
2,000 to 3,000 mL of water per day. Because of the stimulat-
ing effects of caffeine, clients taking lithium should avoid any • Serum level must be checked at scheduled inter-
beverages containing caffeine. vals throughout therapy.

Activity
The balance of sodium chloride to lithium can also be of both fluid and electrolytes in order to prevent a sudden
affected by the client’s level of activity. An increase in activ- increase in the lithium level.
ity, especially in hot and/or humid conditions when exces-
sive perspiration is likely, can deplete the client’s sodium
level, thereby causing a drastic increase in lithium level and, Nursing Management
potentially, lithium toxicity. A sudden increase in a client’s Include the family in client education about the disease
activity level requires close monitoring and replacement process, illness progression, medications, and importance

CASE STUDY
Bipolar Disorder
A 28-year-old male client is admitted to the psychiatric unit with a diagnosis of Bipolar Disorder. He is unable to
sleep, in constant motion, very talkative, exaggerating and glamorizing life events, and inappropriately talking
about sexual promiscuity to other clients.
1. The client is exhibiting which phase of bipolar disorder?
2. The drug of choice for treatment of bipolar disorder is?
3. List two types of treatment for bipolar disorder.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 17 Mental Illness 607

of taking the medications as prescribed (even if the client’s quite loud, flamboyant, and grandiose in verbalizations and
condition improves dramatically). Emphasize the need to manifest very quick and pressured speech (rapid, intense
keep follow-up appointments and to have lab work done for speech).
lithium level. Encourage the family to help the client maintain
a regular eating and sleeping schedule.
Objective Data
The client may be sleeping very little or not at all and may not
NURSING PROCESS be eating or drinking, if in the manic phase. The client may at
times be very irritable, agitated, quick to anger, and, possibly,
Assessment violent. Clients with bipolar disorder often have extreme dif-
ficulty in interpersonal and social relationships because they
Subjective Data have no personal boundaries. They may also be invasive and
The client may deny having a problem or may view the intrusive in their interactions with others, both verbally and
problem as residing in other people. The client may also be physically.

Nursing diagnoses for the client with bipolar disorder include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Sleep Pattern The client will sleep 6 hours Provide a quiet, peaceful environment. Decrease external
related to sensory altera- per night. stimulation and environmental distractions.
tions Teach client relaxation exercises.
Noncompliance (medi- The client will demonstrate Educate the client and family about the disease process and
cation and treatment increased compliance with the progression of the illness over time, prescribed medica-
regimen) related to health medication and treatment. tion, indications for use, dosage, times, and any possible side
beliefs effects or untoward reactions, and the importance of taking
the medication as prescribed.
Teach the client to continue taking medication and to not miss
doses even if the condition improves dramatically.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

continue well into adulthood. Individuals with ADHD are

THE CLIENT REQUIRING extremely sensitive to their environments and surroundings
SPECIAL CONSIDERATION and respond immediately to any type of stimuli or distraction
that most individuals would not even notice.

S everal disorders require special attention and consider-

ation on the part of the nurse. These include disorders
commonly associated with childhood and adolescence and PROFESSIONALTIP
with individuals who have been violated in some manner, such
as via neglect and/or abuse.
Token-Economy System
■ ATTENTION-DEFICIT/ A token-economy system is a form of behavior
HYPERACTIVITY DISORDER modification used to shape a client’s behavior over

T
time. The client receives a “token” (poker chips
he DSM-IV identifies 18 diagnostic criteria for Attention- work well) each time an appropriate or desired
Deficit/Hyperactivity Disorder (ADHD) that fall under behavior is exhibited. In the classroom, the desired
the categories of inattention, hyperactivity, and impulsivity behavior might be working 15 minutes on a math
(APA, 2000). There are three varieties of Attention-Deficit/ assignment; at home, it might be picking up dirty
Hyperactivity Disorder listed in the DSM-IV: Attention- clothes from the floor. Receiving the token is a
Deficit/Hyperactivity Disorder, Predominantly Hyperactive-
form of positive reinforcement for the client and
Impulsive Type; Attention-Deficit/Hyperactivity Disorder,
provides immediate gratification. At the end of a
Predominantly Inattentive Type; and Attention-Deficit/
Hyperactivity Disorder, Combined Type. The child with designated period, the client may “cash in” earned
ADHD may exhibit one or more of these behaviors in any tokens for a prize (game, puzzle) or a special
combination (inattention, hyperactivity, and impulsivity). privilege (going to get an ice cream). The cashing
The problematic behaviors associated with these disorders in of tokens emphasizes the concept of delayed
vary in severity for each individual. Once thought to be a gratification, which in turn teaches patience.
disorder only of childhood, it is now known that ADHD may

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608 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

PREDOMINANTLY LIFE SPAN CONSIDERATIONS

HYPERACTIVE-IMPULSIVE TYPE
Hyperactivity is the hallmark feature of Predominantly ADHD
Hyperactive-Impulsive Type ADHD, which is usually diag- In the past, it was believed that most children
nosed in childhood when the symptoms first manifest. The would outgrow ADHD. Today, it is known that
pediatric client with ADHD may be referred for evaluation symptoms of ADHD can continue into adulthood
and treatment by parents or teachers because of impulsive (Antai-Otong, 2008).
and disruptive behavior in the classroom and/or at home. In
many cases, there seems to be a familial or possible genetic
link, as seen in health histories, which often reveal a parent or
immediate family member as having had a similar problem as will require assistance in developing an effective behavior-
a child. modification program, such as a token-economy system that
rewards desired behaviors, to help manage some of the child’s
problematic behaviors.
PREDOMINANTLY INATTENTIVE
TYPE Pharmacological
In some children with ADHD predominantly inattentive The central nervous system (CNS) stimulants, which include
type, the symptom of hyperactivity is not always present. methylphenidate hydrochloride (Ritalin), pemoline (Cylert),
The children have problems primarily with attention span. dextroamphetamine sulfate (Dexedrine), and amphetamine
The inattentive child cannot maintain attention on one task, sulfate (Adderall), are usually prescribed to treat ADHD
does not appear to listen when spoken to, and is easily dis- (Table 17-12). When one of the CNS stimulants is given to
tracted and forgetful. someone with ADHD, however, it has the opposite effect,
or paradoxical reaction. Thus, instead of making someone
with ADHD more hyperactive, it actually helps calm him.
COMBINED TYPE Because most of the symptoms of the child with ADHD, such
as hyperactivity and the inability to concentrate and remain
Children with ADHD of the combined type exhibit symp- on task, are manifested in the classroom, any improvement
toms of hyperactivity, impulsivity, and inattention. The char- will likely first be noted in this setting. When a child begins
acteristics must typically be exhibited for a period of at least 6 a new medication, it is vitally important that the family
months in order to qualify for the diagnosis. communicate openly with the child’s teacher to ensure close
monitoring of the child’s response to medication. The child
Medical–Surgical with ADHD who has been hyperactive, unable to stay on
task, or complete assignments before receiving medication
Management may now be less disruptive in the classroom and better able
to remain on task and complete assignments. In addition,
Medical the medication can be a useful adjunct to facilitate the child’s
Counseling and therapy are often recommended to the cli- ability to develop and strengthen internal mechanisms for
ent and family to assist in managing the child. The parents improving behavior.

Table 17-12 Central Nervous System Stimulants

GENERIC NAME TRADE NAME POTENTIAL SIDE EFFECTS
dextroamphet- Dexedrine Anorexia, headache, hyperactivity, hypertension, insomnia, palpitations, physical
amine sulfate and psychological dependence, restlessness, tachycardia, tolerance, tremors,
urticaria, weight loss
amphetamine Adderall Anorexia, hyperactivity, insomnia, palpitations, physical and psychological depen-
sulfate dence, restlessness, tachycardia, tremors
methylphenidate Ritalin Anemia, anorexia, hyperactivity, hypertension, insomnia, leukopenia, physical and
hydrochloride psychological dependence, restlessness, skin rash, suppression of weight gain,
tolerance, tremors
pemoline Cylert Insomnia, anorexia, aplastic anemia, decreased growth, drug-induced hepatitis,
nausea, physical or psychological dependence, seizures, stomachache, tolerance,
weight loss
atomoxetine Strattera Fatigue, decreased appetite, aggression, nausea, vomiting, postural hypotension
hydrochloride

Data from Delmar Nurse’s Drug Handbook 2010 Edition, by G. Spratto and A. Woods, 2010, Clifton Park, NY: Delmar Cengage Learning.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 17 Mental Illness 609

Teaching the client and family about the prescribed

medication is very important, as there are some common side PROFESSIONALTIP
effects associated with the CNS stimulants, such as insomnia.
To help decrease the risk of insomnia, these medications
are usually given in the morning at breakfast, and if more is CNS-Stimulant Abuse
needed, another dose is given again at lunchtime. In some
cases, a late-afternoon dose may be needed after school; Another consideration often overlooked in terms of
however, this decision must be made very cautiously, because the CNS stimulants is the risk for abuse because of
the later in the day that the dose is given, the greater the risk of the strong addictive potential of these medications.
insomnia that night for the child. Not only is the client with ADHD at risk for abusing
The client on CNS stimulants must be monitored for any these medications, but sometimes the client
vocal or motor tics, which might indicate the development of “shares” prescribed medication with schoolmates
Tourette’s syndrome. The CNS stimulant should be discontin- and friends interested in drug experimentation.
ued immediately if these symptoms are noted. Another problem that may be encountered is abuse
of the prescribed medication by a family member
Diet with a substance-abuse problem.
One potential problem associated with the CNS stimulants
is that of decreased appetite, which can become serious if the
child begins losing weight as a side effect of the medication. If
this occurs, the medication may be given immediately after a
meal to decrease the chance of appetite suppression. The family CLIENTTEACHING
can adjust the timing and amount of food intake, such as eating
larger meals later in the day, when the effects of the medication CNS Stimulants
have worn off, or having a larger snack in the evening before For each client taking a CNS-stimulant medication,
bedtime. instruct the client or, if the client is too young to
The role and importance of diet in the management of understand or reliably carry out the instructions,
ADHD continues to be highly controversial; however, some data
the client’s caregivers in the following:
supports the restriction of certain foods as an effective method
of managing this disorder. Foods that contain sugar and caffeine • Take the medication only as prescribed.
are sometimes recommended to be excluded from the diet of • Do not take any other medications without phy-
the child with ADHD. The theory behind this recommenda- sician approval.
tion is that sugar and caffeine tend to energize and increase • Be alert for decreased appetite and adjust meals
any child’s activity level, and in the case of some children with and mealtimes accordingly.
ADHD, this effect seems to be even more accentuated. Another
controversial issue surrounding the significance of diet is that of • Do not take any doses after 5 p.m. because
food sensitivities and allergies. Food allergies sometimes mani- doing so will increase the risk of insomnia.
fest in symptoms such as irritability and hyperactivity, which • Obtain periodic liver function tests if taking
may then be confused or misdiagnosed as ADHD. pemoline (Cylert).
• Obtain periodic CBC, platelet count, and differ-
Activity ential if taking methylphenidate (Ritalin).
The child with ADHD will usually respond best to a highly • Limit caffeine intake.
structured environment, which includes clear expectations
and firm, consistent limits as well as appropriate consequences
for unruly and disruptive behaviors. For example, a “time-out”
may be used when the child must be temporarily removed behaviors and feeling like a failure, especially in the class-
from a setting or the environment. room. After only a single dose of medication, however, the
child sometimes states a noticeable difference in the ability to
Nursing Management
remain centered and focused.

Monitor growth (height and weight) and development. Objective Data

Explain to the client what comprise acceptable behaviors. Although usually described as being hyperactive, unable to
Provide positive reinforcement for appropriate behavior. concentrate, unable to focus, and unable to remain on task,
Teach the client and family about prescribed medications. children with ADHD may sometimes be able to concentrate
and remain quite attentive and focused. This usually hap-
pens in situations that the child enjoys and sometimes in
NURSING PROCESS situations that are new to the child. It can be quite frustrat-
ing for parents to bring in their child for an evaluation or
Assessment screening, only to have the child not exhibit any of the usual
problematic behaviors. The knowledgeable practitioner or
Subjective Data evaluator will be aware of what is happening and will obtain
The child or adolescent frequently verbalizes feeling “bad” the necessary information from the parental report of the
about being unable to control hyperactive and disruptive child’s health history.

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610 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Nursing diagnoses for the child with ADHD include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Knowledge The child and parents will Educate the child and family about the disorder, including
(medications and disease verbalize an increased signs and symptoms, about the medication, including indica-
process) related to new understanding of the tions for use, dosages, when to take the medication, possible
diagnosis of disorder and disorder. side effects, and the benefits that can be expected with the
treatment regimen The child and parents will particular medication.
verbalize an understanding Emphasize the importance of taking the medication as
about the role medications prescribed.
can play in treatment.
Impaired Social Interaction The child will demonstrate Explain to the child those behaviors that are acceptable. Ob-
related to unaccepted an increase in appropriate serve the child in social situations with peers.
social behaviors peer interactions. Provide positive reinforcement for demonstration of appro-
priate behaviors. Immediately intervene when unacceptable
behaviors are observed.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

form of elder abuse prevention laws (AoA, 2003). Adult

■ NEGLECT AND/OR ABUSE abuse and protection laws are based on the legal premise

T
that society (represented by the state) has the authority to
here are many types of neglect (a situation wherein act in a parental capacity for persons who are unable to care
a basic need of the client is not being provided) and for and protect themselves and thus prevent them from suf-
abuse (an incident involving some type of violation to fering from abuse, neglect, or exploitation by those respon-
the client). Neglect can be quite evident, such as a lack of sible for their care or from self-abuse (Frisch & Frisch,
adequate food, clothing, or shelter, or less tangible, such as 2010). The purposes of adult protection service laws are to
emotional neglect or an absence of nurturing. Abuse can facilitate the identification of functionally impaired elders
be physical, emotional, psychological, financial, or sexual who are being abused, neglected, or exploited by others;
in nature, or any combination of these. Abuse can also take to encourage expeditious reporting; and to extend protec-
the form of domestic violence, which is aggression and tive services while protecting the rights of the abused. In
violence involving family members. Neglect and abuse often most states, the adult protective services (APS) agency is
go hand in hand. the principal agency designated to receive and investigate
A client experiencing neglect or abuse is usually depen- allegations of elder abuse and neglect. In most jurisdictions,
dent on another individual for the meeting of basic care and the county departments of social services maintain the APS
needs. In many neglectful or abusive situations, the clients unit.
are vulnerable individuals such as children, adolescents, or The National Elder Abuse Incidence Study of 1996
elders. Others who are neglected or abused include individu- found that almost 450,000 persons age 60 and older expe-
als with some type of illness or incapacitation. Neglect and rienced abuse and/or neglect in domestic settings. Only
abuse can take many shapes and forms, ranging anywhere 16% were reported to APS; that is, less than 1 of 5 cases
from mild cases to situations so severe that death is the end were reported. Persons age 80 and older were abused and
result. neglected two to three times their proportion of the elderly
population.

ELDER ABUSE AND

NEGLECT
Elder abuse became nationally recognized in 1981 after LIFE SPAN CONSIDERATIONS
the House Select Committee on Aging issued its landmark
report Elder Abuse: An Examination of a Hidden Problem. Teen Dating Violence
The committee found that elder abuse was simply “alien to
the American ideal.” Because it is such a difficult concept to Teen dating violence is a serious public health
come to grips with, even abused elders are reluctant to admit concern in the United States. Three common types
that their loved ones have abused them. of dating violence are physical, emotional, and
The committee defined the following types of elder sexual. Approximately 10% of students report
abuse: physical, passive physical, financial, psychological, being physically hurt by a boyfriend or girlfriend in
sexual, and violation of rights. There is no federal legisla- the past 12 months (CDC, 2008b).
tion to protect elders from abuse, neglect, or exploitation.
All 50 states, including the District of Columbia, have some

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 CHAPTER 17 Mental Illness 611

Physical

Violation of Rights Passive Physical

Elder Abuse

Sexual Financial

COURTESY OF DELMAR CENGAGE LEARNING

Psychological

Figure 17-4 Types of Elder Abuse

DOMESTIC VIOLENCE PROFESSIONALTIP

Domestic violence is a pattern of controlling behavior and
assaults, including physical, sexual, and psychological attacks
and economic control, that adolescents and adults use against Caring for the Abused Client
their intimate partners. It is common and lethal, affecting When questioning clients about the possibility of
people of all ages, cultures, religions, sexual orientations, edu- interpersonal violence or sexual assault, the nurse
cational backgrounds, and income levels. must quickly develop a rapport and create an
Domestic violence occurs in relationships where conflict environment indicating that personal experiences
is the continuous result of power inequality between partners.
are acceptable topics to discuss. This allows
One of the partners is afraid of and harmed by the other. In all
cultures, the perpetrators are most often men and the victims them the opportunity to express their fears and
are most often women (National Coalition Against Domestic concerns. This can be done by:
Violence [NCADV], 2005). • Treating them with dignity and concern.
In all states, domestic violence is a crime, but the laws • Giving priority to them over nonemergency
in each state are a little different. The nurse is responsible clients.
for knowing the laws, especially mandatory reporting, about • Placing them in quiet and private areas.
domestic violence in the state of employment. Each state
has a coalition against domestic violence, which are valuable • Not leaving them alone.
resources. The National Domestic Violence Hotline is 800- • Speaking quietly and in a nonjudgmental
799-7233 (SAFE). manner.
• Using active and empathic listening skills.
• Not acting shocked or surprised at the details of
CRITICAL THINKING their experiences.
• Reassuring them that the abuse was not their
Domestic Violence
fault.
What are your feelings about domestic violence? • Explaining any delays in treatment.
How would you react to a client who was a victim • Asking permission to call family members, friends,
of domestic violence? Would you be able to respond or in the case of rape, rape crisis advocates.
appropriately? What if the client refuses your • Providing information about community
attempt to assist her to leave the abusive situation? resources.

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612 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

RAPE Medical–Surgical
Rape is a legal term, not a medical entity. It is a crime of vio- Management
lence. Rapists use sexual violence to dominate and degrade Medical
their victims and to express their own anger. It is not an act
Planning care for survivors of neglect and abuse and their
of lust or an overzealous release of passion done to satisfy a
families requires input from the clients and a survey of their
sexual urge (Frisch & Frisch, 2010).
resources to ensure that care is in line with their expectations
There are three basic types of rape: (1) rape by a per-
and commitments. Nursing interventions directed at primary
son known to the survivor, for example, father, former and
prevention of interpersonal violence are those that reduce
current friends (date rape), neighbors, partner or separated
or control the causative factors associated with interpersonal
partner, dissatisfied clients of prostitutes; (2) gang rape;
violence and sexual assaults. By identifying families at risk for
and (3) stranger-to-stranger rape. The latter, which women
abuse, nurses can help the family plan efforts to modify those
fear the most, follows an identifiable pattern. Such rapists
risk factors.
look for women who are vulnerable, even though they differ
on defining who is vulnerable. They might attempt to rape
elders, people who are developmentally, physically, or men- Health Promotion
tally challenged, or intoxicated people. They might look for
environments that are easy to enter and relatively safe (e.g., Primary prevention includes empowering survivors of abuse
women’s bedrooms) and where they will not be interrupted. by helping them learn to care for and protect themselves
They often select their victims long before they approach from the imposition by others. For example, children can be
them and repeat the same pattern of victim selection over taught in health care settings or schools those things to do if
and over again. All types of rape can be an emotionally ter- they are being abused. It also includes changing the family’s
rorizing experience for the survivors. perceptions of violence as an acceptable mode of conflict
resolution.
Provide anticipatory guidance. For example, by antici-
pating the challenges of toddlerhood, acknowledge that this
can be a difficult period for parents and provide practical
PROFESSIONALTIP advice about constructive discipline. Teach college freshmen
about date rape and to avoid vulnerable situations. Encourage
families with dependent elderly members to use respite care
Interviewing the Survivor of Abuse or services and day care programs. Such support and anticipatory
Violence guidance can enhance the family’s and client’s competence
and diminish the likelihood of violence or abuse.
The type of questions will depend on the type
of violence and whether survivors have told you
they have been abused. If they have told you Nursing Management
they have been abused, you must ask specific Know the mandatory reporting laws in your state of employ-
questions about the abuse. If they have not, you ment. When assessing clients, ask about bruises, scars, and
must ask more open-ended questions to allow burns when seen. Provide anticipatory guidance for challeng-
them to disclose sensitive information. Generally ing events in a client’s family life that will enhance the family’s
speaking: competence and diminish the probability of abuse or violence.
• Inform the client that it is necessary to ask some
very personal questions.
• Use language appropriate for the age and NURSING PROCESS
Assessment
developmental level of the survivor.
• Use conversational language or street
language. Subjective Data
• Keep questions simple, nonthreatening, and There is no comprehensive assessment tool that offers conclu-
direct. sive evidence that neglect, abuse, or violence has occurred. Act
• Pose questions in a manner that permits brief like detectives when assessing clients, given that clients or their
answers. abusers will rarely admit to abuse or violence. Make direct obser-
vations of the client and family members (e.g., Does the child
• Indicate sensitivity to and acceptance of the
seem afraid of the caregiver? Does the caregiver hit the child?).
client’s state of confusion. These observations are clues that more probing is necessary.
• Avoid using leading statements that can distort To properly assess survivors of abuse, the symptoms
the client’s report. that are commonly seen in interpersonal violence and sexual
• Do not criticize the client’s family. assaults and the common characteristics of the abusers must
be known. Many of the symptoms are subjective, so the health
• Do not promise not to report the abuse; indi-
care team must piece together the evidence to ascertain
cate that you are required by law to report the whether interpersonal violence has occurred or clients are
abuse. at risk for violence. Psychological abuse is a particularly dif-
ficult area to assess because emotional relationships are very

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 CHAPTER 17 Mental Illness 613

culture bound, and words and emotions that may be harmful them. A traumagram, or body map (a drawing of the front and
in one family are not necessarily so in another family. back of a nude human figure), is generally used to mark the
location of all visible injuries. Each state has legally mandated
procedures for collecting evidentiary material, and it is a nurs-
Objective Data ing responsibility to be sure that the legal “chain of evidence”
A more extensive examination is warranted when the history pertaining to collection of forensic samples is unbroken. The
or behavioral symptoms indicate interpersonal abuse. Clients medical record should document the injuries and nursing and
need to have physical examinations to assess the extent of their medical treatment that may serve as legal evidence of the client’s
injuries and to collect forensic evidence to prove who assaulted condition.

Nursing diagnoses for the client experiencing neglect or abuse include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Interrupted Family Process- The client will not experi- Provide support for the client.
es related to neglect ence any further Neglect. Document the evidence of neglect with which the client
presents via written observations, laboratory reports, and/or
pictures, if indicated.
Report the case of neglect to the proper authorities: police,
child protective services (CPS), APS, and any others that
might be indicated.

Fear related to abuse The client will verbalize be- Reassure the client that the client is in a safe place and that
ing less fearful. you are there to help in any way that you can.
Provide emotional support to the client in a nonjudgmental
manner.

Risk for Injury related to abu- The client will not experi- Address the client’s safety needs and attempt to assess
sive home life ence any further injury or whether abuse is occurring.
abuse. If you suspect that abuse is occurring notify your supervi-
sor so the proper authorities can be notified (Ladebauche,
1997).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

stop eating. Clients often experience guilt and depression after

■ EATING DISORDERS a binge.

E ating disorders include anorexia nervosa and bulimia

nervosa. Anorexia nervosa is characterized by self-imposed
starvation by restricting caloric intake and compulsive exer-
Medical–Surgical
Management
cising. Bulimia nervosa is characterized by periods of binge
eating of up to 10,000 calories at one time followed by self- Diet
induced vomiting and other forms of purging such as laxative During severe cases, clients may be admitted for enforced
and diuretic abuse. In bulimia nervosa, the client’s weight is feeding, including the placement of a feeding tube or TPN, IV
normal or above normal. In anorexia nervosa, body weight is fluid rehydration, and electrolyte replacement. Clients need to
low and keeps getting lower. Most clients with these disorders be monitored for refeeding complications such as pancreatitis
are female and younger than age 30. and gastric dilation. Small quantities are given at first, and very
Complications can be serious and include cardiac abnor- gradually the amount is increased.
malities such as bradycardia, hypotension, arrhythmias, CHF,
and cardiovascular collapse; oral and esophageal erosions and
dental caries from vomiting; renal abnormalities that affect the Other Therapies
kidney’s ability to filter urine; skin rashes from malnutrition; Treatment is primarily psychiatric, involving the client and
and bruising from vomiting. family, and is typically done on an outpatient basis.
Clients with anorexia nervosa tend to be high achievers,
perfectionists, have a distorted body image in that they see
themselves as fat, and are rigid and ritualistic. Nursing Management
Bulimia nervosa occurs more frequently than anorexia Monitor weight, calorie intake, I&O, and exercise program.
nervosa, with clients experiencing a fear of not being able to Assess behavior around mealtime. Administer IV fluid and

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614 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

electrolyte replacement. Check vital signs and laboratory test Objective Data
results.
Clients with anorexia nervosa are underweight, usually lost
over a short period of time, reluctant to eat with others, move
NURSING PROCESS food around the plate without eating it, hypotensive, have
heart irregularities, and altered thinking patterns.
Assessment Clients with bulimia nervosa have normal weight, tooth
erosions and dental caries, puffy face, callused knuckles, bro-
Subjective Data ken blood vessels in the eyes and face, reluctance to eat with
Clients with either anorexia nervosa or bulimia nervosa may others, and going to the bathroom immediately after eating.
verbalize feelings of helplessness and being out of control, and Laboratory analysis will include a CBC, which may show low
may exhibit low self-esteem. They may also have overprotec- Hgb, Hct, and platelets; electrolytes, which may show low sodium,
tive parents. Clients with anorexia nervosa may also describe potassium, and chloride; an SMA-22 that shows low protein,
bad dreams and cold intolerance. phosphate, and magnesium; and elevated BUN.

Nursing diagnoses for a hospitalized client with anorexia nervosa or bulimia

nervosa include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: The client will demonstrate in- Weigh daily. Monitor calorie intake. Monitor I&O every
Less than Body Require- creased consumption of nutrients shift.
ments related to psycho- as evidenced by weight gain daily Administer IV rehydration, electrolyte replacement, and
logical restriction of food and improved laboratory values. TPN or tube feedings as ordered.
intake, excessive activity
Monitor behavior at and around meal time, such as
going to the bathroom right after eating.
Monitor exercise patterns.

Risk for Deficient Fluid The client’s intake and output will Monitor I&O every shift and bowel movements for diar-
Volume related to inad- be approximately equal by the rhea (a sign of continued laxative abuse).
equate intake of liquids, fourth hospital day. Monitor laboratory reports for electrolyte levels as
self-induced vomiting, The client’s electrolytes will be within ordered.
laxative and diuretic use normal limits, by the third hospital Administer IV fluid and electrolyte replacement as
day. ordered.
The client’s fluid intake will be at
least 2,000 mL per day.

Ineffective Coping (Indi- The client will verbalize feelings Provide opportunities for the client to express feelings
vidual) related tomatura- regarding disease process and regarding hospitalization.
tional crisis andattempt- hospitalization, by discharge. Encourage client to identify coping mechanisms and
ing to control environment The client will identify current strengths.
coping strategies, by discharge. Give positive feedback regarding identified personal
The client will identify personal strengths.
strengths, by discharge.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SUMMARY

• The components of a therapeutic nurse–client relationship • The individual with schizophrenia may be out of touch with
include trust, rapport, respect, genuineness, and empathy. reality and influenced by delusions and/or hallucinations.
• An individual’s anxiety level may range anywhere from • Individuals with bipolar disorder may experience wide
mild to panic level. mood swings ranging from depression to mania.
• The nurse often encounters clients and/or family • Neglect and abuse can occur among any age group.
members who are angry, aggressive, homicidal, and/or • Anorexia nervosa and bulimia nervosa are psychological
suicidal in the midst of a crisis situation. disorders affecting mostly women. Severe nutritional
• The depressed individual must be evaluated for risk of imbalances can occur leading to serious effects on the
suicide. cardiovascular system.

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 CHAPTER 17 Mental Illness 615

REVIEW QUESTIONS
1. The client who is experiencing severe or panic level statements indicates that further teaching is
anxiety should: needed?
1. be left alone to calm down. 1. “I should take the medication on an empty
2. be taught new information. stomach.”
3. never be left alone. 2. “Paxil can cause drowsiness.”
4. be given an antidepressant immediately. 3. “I cannot drink alcohol while taking Paxil.”
2. A nurse who is aware of a client’s plan to kill 4. “I should put on sunscreen when outside because
someone else should: I will be more susceptible to sunburn.”
1. do nothing; it is not her responsibility. 7. The nurse is assessing a client admitted to the
2. contact the physician and alert the proper psychiatric unit with a diagnosis of Bipolar Disorder
authorities. The nurse can expect the client to exhibit all but
3. discourage the client from following through with which of the following behaviors?
the plan. 1. Conflict in relationships.
4. continue preparing the client for discharge per 2. Sexual promiscuousness.
orders in the chart. 3. Euphoria.
3. Components of a therapeutic nurse−client 4. Drug seeking behavior.
relationship include: (Select all that apply.) 8. Before the administration of MAOI antidepressant
1. genuineness. medication to a client with depression symptoms, it
2. rapport. is imperative for the nurse to teach the client which
3. independence. of the following?
4. trust. 1. It is safe to drink alcohol while taking this
5. mild anxiety. medication.
6. respect. 2. Over the counter medications can be taken with
4. A client experiencing panic level anxiety informs the MAOIs.
nurse that she is hearing the voice of her deceased 3. Avoid all foods containing tyramine.
husband and wants it to stop. The most appropriate 4. MAOIs do not affect blood pressure.
nursing action is to: 9. A 45-year-old female client is diagnosed with
1. provide constant reassurance, monitoring, and depression. An appropriate nursing intervention for
supervision. working with this client is:
2. apply wrist restraints. 1. to allow plenty of alone time to think through issues.
3. place all four bed side rails up. 2. to provide at least 14 hours of sleep time each day.
4. medicate the client with a sedative and supervise 3. to encourage her to engage in any type of physical
for safety. activity.
5. The nurse notices that a client on your unit is giving 4. to do her activities of daily living for her since she
away prized personal possessions to his family and cannot.
friends. This action is indicative of: 10. The nurse is assessing a client admitted with
1. a client that is schizophrenic. schizophrenia. The nurse can expect to observe
2. a client that is contemplating suicide. which of the following signs and symptoms?
3. a client that is experiencing excessive anxiety. 1. Able to care for basic needs.
4. an anorexic client that is recovering. 2. Alert and oriented.
6. A client has an order for Paxil 12.5 mg one tablet 3. Speech clear and appropriate.
every morning. Which of the following client 4. Delusional.

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RESOURCES
Administration on Aging (AoA), http://www.aoa.gov National Association of Anorexia Nervosa and
American Anorexia/Bulimia Association, Associated Disorders, http://www.anad.org
http://www.aabainc.org National Center on Elder Abuse, http://www.ncea.aoa.gov
American Psychiatric Association, http://www.psych.org National Coalition against Domestic Violence
American Psychiatric Nurses Association, (NCADV), http://www.ncadv.org
http://www.apna.org National Domestic Violence Hotline, http://www.ndvh.org
Anxiety Disorders Association of America, National Eating Disorders Association,
http://www.adaa.org http://www.nationaleatingdisorders.org
Depression and Bipolar Support Alliance, National Institute of Mental Health,
http://www.dbsalliance.org http://www.nimh.nih.gov
Family Violence Prevention Fund (FVPF), Parents Anonymous, The National Organization,
http://www.endabuse.org http://www.parentsanonymous.org
National Alliance for Research on Schizophrenia and Recovery, Inc.: The Association of Nervous and Former
Depression (NARSAD), http://www.narsad.org Mental Patients, http://www.recovery-inc.com
National Alliance for the Mentally Ill (NAMI), Victims of Incest Can Emerge Survivors (VOICES),
http://www.nami.org http://www.healthywomen.org
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 CHAPTER 18
Substance Abuse

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of substance abuse:
Adult Health Nursing
• Respiratory System • Sexually Transmitted Infections
• Gastrointestinal System • The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Differentiate among dependence, abuse, and intoxication.
• Describe issues related to drug testing.
• Discuss substances frequently abused.
• Use assessment skills to identify possible substance abuse.
• Describe nursing interventions in working with substance abusers.
• Describe stages of alcoholism and the impact on the individual, family, and
society.
• Discuss medications frequently used in the treatment of substance abuse.
• Describe an impaired nurse.
• Identify goals of programs for impaired nurses.

KEY TERMS
abuse detoxification reverse tolerance
addiction hallucination substance
behavioral tolerance intoxication synesthesia
codependent Johnsonian intervention teratogenic
confabulation misuse tolerance
cross-tolerance opisthotonos withdrawal
dependence relapse

617

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618 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

marijuana flooded the market. The Marijuana Tax Act of 1937

INTRODUCTION was intended to raise revenue, identify the persons involved
Substance use has taken place for many centuries. It is not a in its use, and discourage the recreational use of marijuana.
new problem for society. A substance is a drug, legal or illegal, Marijuana was removed in 1941 from the official list of drugs
that may cause physical or mental impairment. With the great U.S. physicians could prescribe. World War II disrupted supply
increase in world population, there are more people involved routes of drugs from Asia and Europe, and large-scale drug use
in substance abuse. Today’s speed of travel and communica- disappeared in the United States.
tion has facilitated the broad distribution of substances. The 1960s, saw drug use move into the mainstream of life
Many street drugs are “cut” (mixed) with substances that in the United States. Drugs were used as a form of relaxation.
should not be consumed, such as talcum powder, rodent exter- The Comprehensive Drug Abuse Prevention and Control Act
minating powder, or even strychnine. The purity (strength) of was passed in 1970; it is commonly referred to as the Con-
the drug is then not known and overdose easily occurs. Fatali- trolled Substance Act. This act regulates the manufacture, dis-
ties can occur from the substance with which the drug is cut. tribution, and dispensing of controlled substances. To enforce
In the United States, substance disorders affect males and the provisions of this act, the Drug Enforcement Administra-
females, all ethnic groups, and persons of all levels of educa- tion (DEA) was organized.
tion and income. From the newborn to the elderly, all ages can There are five classifications or schedules of controlled
be affected. substances. The categories are based on the drugs’ potential
Substance disorders may be classified as intoxication, to cause psychological and/or physical dependence, and also
abuse, or dependence (addiction); definitions are based on on their potential for abuse. Table 18-2 identifies and explains
the criteria presented in the American Psychiatric Association’s the five schedules.
Diagnostic and Statistical Manual of Mental Disorders, fourth In the 1980s, marijuana and other drug use declined,
edition (DSM-IV). The reversible effect on the central ner- especially among high school students. Cocaine and its deriva-
vous system (CNS) soon after the use of a substance is termed tive, crack, were the new drugs of choice. The increased supply
intoxication. Abuse is the misuse, excessive, or improper use hooked many people into heavy drug use. The early 1990s saw
of a substance, the abstinence of which does not cause with- an increase in the use of all substances. Adolescent illicit drug
drawal symptoms. Dependence (addiction) is reliance on a use is decreasing for almost all of the specific types of drugs.
substance to such a degree that abstinence causes functional Combined data for 8th, 10th, and 12th graders show an over-
impairment, physical withdrawal symptoms, and/or a psycho- all decline in illicit drug use by 24% between 2001 and 2007
logical craving for the substance. (NIDA, 2008g).
According to the National Institute on Drug Abuse
(NIDA, 2008h), substances interfere with normal brain func-
tion, inducing powerful feelings of pleasure and having long- FACTORS RELATED TO
term effects on brain metabolism and activity. At some point,
changes in the brain turn substance abuse into addiction, a
SUBSTANCE ABUSE
chronic, relapsing illness. Table 18-1 shows diagnostic criteria Many factors interact to influence a person’s substance abuse.
for abuse and dependence. Many people who have stopped substance abuse relapse
(return to a previous behavior or condition) because of these
same factors. These factors may be categorized as individual,
HISTORICAL PERSPECTIVES family, lifestyle, environmental, and developmental.
Nearly 6,500 years ago, ancient Egyptians used opium for
pain relief. Later they used it for recreation when they discov- Individual Factors
ered it provided anxiety relief, a pleasurable experience, and Genetic factors are being researched as a possible reason for a
an escape from reality. Drug problems began in the United person’s susceptibility to substance abuse. Research suggests
States with the Civil War in 1861. Wounded soldiers were that variations in the intensity of the flow of neurotransmitters
given their own supply of morphine. Its use was uncontrolled. may cause certain individuals to be more susceptible to addic-
Dependence-producing drugs such as cocaine, heroin, and tion. The personality traits of sensation seeking and being
morphine were given freely to clients by doctors. Patent medi- impulsive may make it easier for the person to experiment
cines, many containing alcohol, cocaine, and heroin, were said with substances.
to cure almost any ailment a person might have.
The Pure Food and Drug Act of 1906, requiring accurate
labeling of drugs, was the first measure designed to control Family Patterns
drugs in the United States. In 1914, The Harrison Act made Substance abuse, especially in the adolescent, seems to be
the use of certain narcotics illegal. Physicians then became related to family relationships. Close family relationships, with
unwilling to give individuals these drugs, and drug use actu- the parents involved in their children’s activities, appear to dis-
ally increased as those persons already using drugs turned courage substance abuse. Families with positive relationships
to illegal markets for a supply. In 1919, Congress passed the between parents and children generally have less use of illicit
19th Amendment to the Constitution declaring the making drugs. Parent–child interactions that show a lack of close-
and selling of alcohol illegal. Prohibition lasted until 1933, ness, lack of involvement in the children’s activities, lack of or
when the 19th Amendment was finally repealed because inconsistent discipline, and low aspirations for the children’s
it had not controlled drunkenness or alcoholism as it was education contribute to the prediction of substance abuse by
intended. the children.
Many medical, law enforcement, and legislative efforts Families of adolescent substance abusers generally have
in the 1930s slowed narcotic abuse and addiction. Then negative communication patterns. That is, there is a lack

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 CHAPTER 18 Substance Abuse 619

Table 18-1 Diagnostic Criteria for Substance Dependence and Abuse

SUBSTANCE DEPENDENCE
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or
more) of the following, occurring at any time in the same 12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal
from the specific substances)
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple
doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of
substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological prob-
lem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition
of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol
consumption)

SUBSTANCE ABUSE
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one
(or more) of the following, occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated
absences or poor work performance related to substance use; substance-related absences, suspensions, or expul-
sions from school; neglect of children or household)
(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a
machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused, or exac-
erbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical
fights)
B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 2000 American Psychiatric Association.

Table 18-2 Schedules of Controlled Substances

Schedule I (C-I) High abuse and dependence potential. No accepted medical use in the United States. Includes
heroin, mescaline, LSD, marijuana, and other hallucinogens and certain opiates. Can be obtained
legally for limited research programs.

Schedule II (C-II) High abuse and dependence potential. Have currently accepted medical use. Includes narcotics,
barbiturates, and amphetamines. Obtained only with physician’s prescription, nonrefillable.

Schedule III (C-III) Less abuse potential, moderate dependence likely. Includes nonbarbiturate sedatives and some
COURTESY OF DELMAR CENGAGE LEARNING

narcotics in limited doses. Prescription refills good for 6 months. Fewer controls than for Schedule II.

Schedule IV (C-IV) Even less abuse potential, limited dependence likely. Includes some sedatives and antianxiety agents
and nonnarcotic analgesics.

Schedule V (C-V) Limited abuse potential. Includes cough medicines containing codeine and antidiarrheals. May be sold
over-the-counter in pharmacies to persons over 18 years old. A record is kept of the buyer’s name.

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620 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

of praise and a great deal of blaming and criticism. Often not accepting the consequences of behavior, and seeing
there are unreal expectations of the children by the parents, oneself as a victim of circumstances. Individuals who do not
inconsistent or unclear behavioral limits, and a pattern of self- view themselves as empowered may choose substance use as a
medication by family members. means of gratification.

Lifestyle PREVENTION
All dimensions of a person’s life that influence how that person
lives are termed lifestyle. First is the physical dimension, which Prevention of substance abuse must be a proactive process
includes food, clothing, shelter, and health care. The second to empower people to constructively confront stressful situ-
is the social dimension, which includes friends, organizations, ations in adaptive ways. There are three levels of prevention.
and activities with others. Third is the intellectual/emotional Primary prevention focuses on preventing the initial use or
dimension, including education, parental support of educa- preventing further uses that may lead to abuse or dependence.
tion, self-esteem, and how the individual is treated by others. This is usually aimed at school-age children. Children need to
The fourth dimension is spiritual and includes a belief in a hear the message that drugs are not good for them. Education
“higher being,” caring and compassion for others, and being in about substances and their effects must also emphasize per-
touch with the inner self. Substance use, abuse, or dependence sonal, social, and health risks. Children need role models to
may be the coping mechanism used by an individual who has teach them how to cope with life without drugs, to resist social
problems in any dimension of lifestyle. and peer pressure, and to make effective decisions.
Secondary prevention focuses on preventing ongoing use
Environmental Factors from becoming a situation of abuse or dependence. If abuse
is already evident, the focus is to return the client to a state of
Many environmental factors may encourage or predispose abstinence or at least reduced use.
an individual to substance abuse. The social environment Tertiary prevention focuses on returning the client to a
in which persons find themselves, the groups, clubs, gangs, drug-free state. If this is not possible, the goal is then to pre-
sororities, fraternities, and other organizations influence the vent physical and psychosocial problems from getting worse.
acceptance or rejection of substance abuse. Stresses in a per-
son’s life, including accidents, disabilities, illnesses, stressful
family relations, frequent job changes, divorce, death, or pre-
carious financial conditions may be too much for that person
DIAGNOSTIC TESTING
to handle. The maladaptive coping of substance abuse offers Clients who have a problem with substance abuse or depen-
temporary relief. Because the symptoms of the stressors are dence often have abnormal liver function tests and electrolyte
reduced, substance abuse is reinforced. levels. Diagnostic criteria for specific substance-related disor-
Social traditions, especially in the use of alcohol, may open ders can be found in DSM-IV.
the door for abuse in certain individuals. Examples of these Tests may be done with either a blood or urine specimen.
social traditions are having wine with meals, making toasts at A positive test indicates only that the person has been exposed
weddings and other celebrations, serving “holiday cheer,” and to the substance. It does not indicate abuse, addiction, or
going to “happy hour.” For some individuals, these situations intoxication (except alcohol). Positive screening tests should
may predispose them to alcohol abuse or dependence. be confirmed by a more specific test using a different process.
Peer activities, especially during adolescence, may result Drugs for which tests can be done include alcohol, benzodi-
in substance abuse. Even adults often feel they must go along azepines, barbiturates, cocaine, crack, amphetamines, opiates,
with certain activities, such as drinks after work or cocktail synthetic narcotic analgesics, marijuana, and PCP.
hour, to get ahead in their careers. Urine is usually the body fluid tested because it is eas-
Some occupations, like health care, seem to be more ily obtained and tested. When obtaining a urine specimen
associated with substance problems than others. Physicians for drug screening, the client should be observed to prevent
and nurses, particularly, have access to many substances that adulteration of the specimen by the client, such as substituting
can be abused. another person’s drug-free urine. A “chain of custody” is main-
tained by having each person who handles the specimen sign
Developmental Factors an attached paper until the specimen has been tested.
Detection of a substance depends on the amount used
Many individuals have not had good role models in their lives. and the time since last used. Most substances are detectable
They have not learned to identify with others and do not for less than 7 days. Chronic marijuana use, however, may be
understand that their behavior affects others. Not learning detected for up to 30 days. Barbiturates, amphetamines, and
the skills and attitudes of problem solving leaves individuals opiates are detectable for less than 2 days and alcohol less than
unable to apply personal resources to situations, and escape 1 day. A false negative may result if the client’s drug level falls
seems the only answer. Substances provide that escape. below the threshold of sensitivity for the test.
Learning the intrapersonal skills of self-discipline, self- Positive results for reasons other than substance abuse
control, and self-assessment helps the individual cope with can occur. This is called a false positive. Poppy seeds may give
tension and stress. These skills also work to prevent dishon- a positive result for opiates for up to 60 hours after ingestion.
esty with self, inability to defer gratification, and low self- Using a Vicks® inhaler or over-the-counter diet aids may give a
esteem. A lack of interpersonal skills results in dishonesty with positive result for amphetamines. The client should be asked
others, resistance to feedback, and inability to share feelings about the use of these items.
and give or accept help. Not learning to take responsibility or Breath specimens can be used to determine alcohol levels.
adapt one’s behavior to a situation results in irresponsibility, Law enforcement officials do this with the breathalyzer tests.

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 CHAPTER 18 Substance Abuse 621

If hair is not cut, hair analysis can detect cocaine and heroin CRITICAL THINKING
use for up to a year or more after the person has used the drug.
Testing meconium (first stools) from a newborn can detect Attitude toward Substance Abusers
illicit drug use by the mother during pregnancy.
What is your attitude toward substance abusers?

TREATMENT/RECOVERY How would you respond to a client who is a sub-

stance abuser? Discuss with your classmates.
Treatment depends on many factors, including the amount
and frequency of substance use, age, health, diet, and overall
lifestyle of the individual. Infection from the use of unsterile
needles and/or tissue or organ damage caused by the sub- Elderly persons are more commonly addicted to pre-
stance used, such as lung damage from smoking crack or mari- scription medications, especially minor tranquilizers and
juana or using inhalants, will also require treatment. sleeping pills. Alcohol may be used by the elderly to soothe
Recovery requires abstinence along with intrapersonal and feelings of isolation and loneliness. Depression and paranoia
interpersonal changes. Most individuals need professional treat- may be misidentified as senility rather than a problem with
ment and participation in a self-help program. There are four alcohol.
areas of recovery: physical recovery, psychological and behav- Moderate consumption of alcohol may have been influ-
ioral recovery, social and family recovery, and spiritual recovery. enced by Mothers Against Drunk Driving (MADD) and
Physical recovery means eliminating the substance from Students Against Destructive Decisions (SADD) (founded as
the body. This is termed detoxification. If the client cannot Students Against Driving Drunk). Laws that make bars and
stop using the substance or if withdrawal symptoms are pres- individuals liable if they let guests leave and drive while drunk,
ent, admission to a detoxification unit is usually necessary. called social host laws, and famous people like Betty Ford and
After detoxification, treatment must focus on restoring the Liza Minelli sharing with the public their illness and recovery,
client’s physical health and dealing with the cravings for the are other influences.
substance now removed from the client’s body. It helps if envi- The National Institute on Drug Abuse (2008h) report on
ronmental cues such as drug paraphernalia and alcohol bottles the ongoing study of illicit drug use among 8th-, 10th-, and
or cans are removed. 12th-grade students shows a decrease in use.
Psychological and behavioral recovery becomes evident
when the client no longer denies the problem and accepts the
inability to consistently control the substance abuse. The client CNS DEPRESSANTS

C
will have developed a desire for abstinence and accepted the
need for long-term recovery and support. Emotional stability entral nervous system depressants usually decrease the
will be restored when the client learns to cope with uncomfort- heart and respiratory rates as well as voluntary muscle
able emotional states without the use of the abused substance. responses. Substances in this category include alcohol, benzo-
Social and family recovery occurs when the client no diazepines, and marijuana.
longer denies the impact on the family and makes amends
to family members and significant others who have been ■ ALCOHOL

L
negatively affected by the substance abuse. The client works to
improve family relationships and develops a recovery support ow doses of alcohol depress areas of the brain that are
system. Also, the client learns to resist social pressures to use inhibitory, causing diminished self-control and impaired
alcohol or other drugs and participates in healthy leisure-time judgment. Continued alcohol ingestion may cause uncon-
activities. The client’s family should also attend a program for sciousness and even death. According to the National Institute
recovery. If a client returns to a dysfunctional family, it may be on Alcohol Abuse and Alcoholism (NIAAA) (2006), 39.5%
difficult for the client to maintain recovery. of all traffic crash fatalities were alcohol related.
Spiritual recovery is attained when the client has resolved The active ingredient in alcoholic beverages is ethanol.
the feelings of guilt and shame and developed a meaning for Depending on the alcoholic beverage consumed, varying
life and a relationship with a higher power. amounts of ethanol are ingested (Figure 18-1). It is metabo-
lized at an average rate of 10 mL/hr. Table 18-3 shows the
alcohol content in some beverages.
SUBSTANCE USE PATTERNS One ounce of alcohol provides 200 Kcal but no other
nutrients. It is not converted to glycogen. The blood alcohol
Patterns of substance use have changed throughout the years. level depends on the size of the person, the amount ingested,
Coffee (caffeine) and cigarettes (nicotine) are legal in our and the time since ingestion. Most states have set the legal
society and widely used. Although many people still drink limit for blood alcohol while driving a motor vehicle at 0.08%,
coffee, more are using decaffeinated coffee. Cigarette use has but driving skills are affected at a much lower level.
decreased in the older population as the addictive nature and
negative effects of nicotine have become more evident; how-
ever, cigarette use has increased in the adolescent population. Incidence
The substance of choice is alcohol, which is legal and Several national surveys have found that approximately two-
easily obtained. Many high school seniors have been drunk thirds of the population has more than an occasional drink.
and some are already regular drinkers. There are still more Men are likely to drink more frequently and in greater quantity
alcoholic men than women, but the number of identified than women. Some alcoholics drink little or nothing in public
women alcoholics is increasing. or with friends. They are “at home” or “hidden” alcoholics and

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622 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Associated Problems/
Disorders
Excessive and prolonged alcohol intake can affect numerous
body systems.

Liver Deterioration
Chronic alcohol abuse causes three distinct diseases of the
liver: fatty liver, an accumulation of triglycerides in the liver

COURTESY OF DELMAR CENGAGE LEARNING

caused by obesity, excessive alcohol consumption, and certain
drugs; alcoholic hepatitis, an acute toxic liver injury from excess
alcohol consumption; and cirrhosis, a chronic degenerative
liver disease that can be caused by alcohol consumption. Fatty
liver is reversible, but alcoholic hepatitis and cirrhosis are
not. Liver cells will not function once the scar tissue of cir-
rhosis develops. In 2005, 45.9% of deaths from cirrhosis of the
liver were related to alcohol consumption (NIAAA, 2008a).
Figure 18-1 Each of these drinks contains approximately Esophageal varices are associated with cirrhosis and could
the same level of alcohol. cause death if they bleed.
are more likely to be women. It often takes a family quite awhile
to realize that one of its members has an alcohol problem. Gastrointestinal Disturbances
The individual with an alcohol problem often learns Alcohol damages the lining of the stomach and esophagus
behavioral tolerance, a compensatory adjustment made by by irritating the mucosa and causing inflammation or ulcer
an individual under the influence of a particular substance. The formation. Aspirin with alcohol can result in greater irritation
person under the influence of alcohol learns how to compen- and bleeding in the gastrointestinal (GI) tract. Gastric pain,
sate for the deterioration of motor performance and speech. vomiting, and diarrhea are common in alcohol abuse and are
often what brings the individual to the health care system.
Signs and Symptoms
The ingestion of alcohol causes a feeling of euphoria, relax- Pancreatitis
ation of skeletal muscles, changes in mental activity such as An alcoholic has a higher risk of developing pancreatitis than
altered judgment, and reduced self-control. It has a diuretic an abstainer. Severe pancreatitis can result in death.
effect that, in heavy drinkers, may cause increased loss of
electrolytes, especially potassium, magnesium, and zinc. An Wernicke’s Encephalopathy
increased level of alcohol depresses the cardiovascular and
respiratory systems and produces a toxic effect on the intes- This inflammatory hemorrhagic and degenerative condition
tinal mucosa, resulting in decreased absorption of thiamine, of the brain is caused by a thiamine deficiency. It is charac-
folic acid, and vitamin B12. Excess long-term consumption of terized by delirium, memory loss, unsteady gait, a sense of
alcohol often results in a severe lack of nutrient intake. apprehension, and an altered level of consciousness. Thiamine
Psychosocial aspects include memory blackouts, secretive intake improves the situation.
drinking, rationalization of drinking behavior, trouble with
family and employer, loss of outside interests, neglect of food Korsakoff ’s Psychosis
intake, impaired thinking, and moral deterioration. Confabu- Disorientation, amnesia, insomnia, hallucinations, and periph-
lation, making up information to fill in memory gaps, is used eral neuropathologies characterize this psychosis. Both thia-
by individuals abusing or depending on alcohol. Alcohol may mine and B12 deficiencies contribute to the degeneration of
be detected in the blood for 6 to 10 hours after ingestion. the brain and peripheral nervous system. Frequently, there
Potential for Addiction is bilateral foot drop and pain. Thiamine and B12 intake may
improve the situation.
The potential for addiction is high. Alcohol is not a scheduled
or controlled drug. Cardiovascular Disturbances
Moderate amounts of alcohol cause cutaneous vasodilation
Table 18-3 Alcohol Content in Selected (flushed skin). This causes rapid heat loss, and the core
Beverages temperature may drop to a dangerous level. Blood pressure
decreases with intoxicating doses of alcohol. There may be
PERCENT EQUIVALENT irregularities in cardiac rhythm. Hematologic alterations such
COURTESY OF DELMAR CENGAGE LEARNING

BEVERAGE ALCOHOL AMOUNTS as bone marrow depression, anemia, leukopenia, or thrombo-

Beer 4 12 ounces
cytopenia may also occur.

Wine cooler 4 12 ounces Fetal Alcohol Syndrome

Wine 14 4 ounces Fetal alcohol syndrome (FAS) is caused by the teratogenic
Hard liquor 40 1½ ounces (causing abnormal development of the embryo) effects of
alcohol related to the amount of alcohol ingested and the

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 CHAPTER 18 Substance Abuse 623

stage of pregnancy when the alcohol is ingested. Even a small CRITICAL THINKING
amount of alcohol can be detrimental and have lifelong conse-
quences for the infant. For a diagnosis of FAS, the infant must Alcohol Withdrawal
meet these criteria:
• Prenatal and/or postnatal growth retardation (weight, A client, who is going through alcohol withdrawal
length, or head circumference below the 10th percentile) and is on the appropriate medication protocol, is
• CNS involvement (signs of neurologic abnormality, not clear mentally and is becoming very agitated.
developmental delay, or intellectual impairment) What would you investigate and how would you
• Craniofacial anomalies, at least two of the following communicate your findings to the physician?
(microcephaly or head circumference below 3rd percentile,
microophthalmia or short palpebral fissure, poorly developed
philtrum, thin upper lip, or flattening of maxillary area)
If only some of the FAS criteria are met, it is called fetal If alcohol abuse continues, symptoms of subsequent
alcohol effects (FAE). The only treatment for FAS or FAE withdrawals are generally more severe. It is recommended that
is prevention. Women who are pregnant or are trying to get withdrawal be medically monitored to decrease the chance of
pregnant should abstain from alcohol consumption. fatality.

Withdrawal Treatment/Rehabilitation
Withdrawal refers to the symptoms produced when a sub- Many treatment programs are based in hospital or residential
stance on which an individual has dependence is no longer treatment centers. These are generally called inpatient pro-
used by that individual. Alcohol withdrawal syndrome (AWS) grams and last 30 days. Many insurance companies are encour-
appears when the blood alcohol concentration of the alcoholic aging clients to participate in lower-cost outpatient programs.
decreases. The onset of symptoms usually occurs 6 to 12 Currently, there is no evidence that inpatient programs are
hours after drinking stops and may last up to 8 days. Chrono- more effective than outpatient programs.
logically, how long the drinking has occurred and the amount Many outpatient programs have both day and evening
of alcohol consistently consumed are factors in the severity of sessions so clients can maintain their usual occupations. The
the withdrawal symptoms. Figure 18-2 shows alcohol with- programs usually consist of a 4-week intensive session with
drawal patterns. follow-up sessions for 6 to 24 months. The first part of either
Alcohol withdrawal has three stages: type of treatment program is detoxification.
• Stage 1 (minor withdrawal) includes restlessness, anxiety,
sleeping problems, agitation, and tremors; other signs Detoxification
include low-grade fever, tachycardia, diaphoresis, and The goal of detoxification (DETOX) is to halt or control the
hypertension. neuronal overactivity that occurs when the alcohol level is
• Stage 2 (major withdrawal) includes stage 1 signs and reduced or alcohol is no longer present in the client’s body.
symptoms plus visual and auditory hallucinations, whole- This is done by substituting a pharmacologically similar drug
body tremors, pulse >100 beats/min, diastolic BP >100 and gradually reducing the dose given. The benzodiazepine
mm Hg, pronounced diaphoresis, and possibly vomiting. drugs, chlordiazepoxide (Librium), diazepam (Valium), lora-
• Stage 3 (delirium tremens) includes a temperature >37.8°C zepam (Ativan), and clorazepate dipotassium (Tranxene), are
(100°F); disorientation to time, place, and person; global the most commonly used.
confusion; and inability to recognize familiar objects or During DETOX, other problems such as malnutrition,
persons. This is a medical emergency with a mortality rate vitamin deficiencies (B vitamins, especially thiamine), dehy-
of 1% to 5% (Kasser, Geller, Howell, & Wartenberg, 2004). dration, and potassium and magnesium deficiencies must
also be treated. A client with hypoglycemia should be given
thiamine before administering dextrose to prevent Wernicke’s
encephalopathy. Ignoring these problems complicates the
Intensity of symptoms

management of detoxification.

Psychological Intervention
The classic psychological intervention technique was origi-
nally described by Johnson in 1973 ( Johnson, 1990 & 2001).
Although several modifications have been published and used
1 2 3 4 5 6 7 8 since then, the technique is still used and is known as John-
COURTESY OF DELMAR CENGAGE LEARNING

Days sonian intervention, which is a confrontational approach to

Legend a client with a substance problem that lessens the chance of
Seizures denial and encourages treatment before the client “hits bot-
Severe withdrawal tom.” The client’s significant others (spouse, teenage or older
(Delirium tremens) children, one or two close friends, possibly employer) meet
Mild to moderate severity with a professional addiction counselor. This group rehearses
so that they may present a united front when confronting the
client. They present specific examples of painful or embar-
Figure 18-2 Alcohol Withdrawal Patterns rassing behaviors by the client while intoxicated that caused

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624 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

problems and concerns. It is difficult for the client to maintain Self-Help Groups
denial in this situation. Then the group encourages the client
to accept professional help. If the client refuses help, each Alcoholics Anonymous (AA), begun in 1935, is the model
individual of the group must plan to minimize codependent for other self-help groups such as AL-ANON for adults, AL-
behavior in the future. This technique can also be used for ATEEN for teenage children, and AL-ATOT for younger
substances other than alcohol. Examples of confrontations children in the family of an alcoholic. The holistic approach of
may be found in Johnson’s books (1989, 1990, 2001). Code- AA to the individual with alcohol problems is described in the
pendency is discussed later in the chapter. Twelve Steps (Table 18-5).

Education Disulfiram
The abuse of or dependence on alcohol is a maladaptive way Disulfiram (Antabuse) may be given to some alcohol abusers as
to cope with life stressors. Learning basic life skills to improve a deterrent to drinking. It inhibits the enzyme needed to metab-
personal competence and provide adaptive coping mecha- olize alcohol (NIAAA, 2008b). Drinking alcohol with disul-
nisms helps the individual resist the use of alcohol. firam in the body causes flushing of the neck and face, blurred
One adaptive coping mechanism is exercise. Assist clients vision, nausea, vertigo, anxiety, palpitations, tachycardia, and
to become active in an exercise program and encourage them hypotension. Clients must be instructed not to use cologne,
to participate. Exercise helps relieve feelings of stress and pro- mouthwash, aftershave, over-the-counter cold preparations,
motes feelings of well-being. cough syrups, vitamin-mineral tonics, as well as candies, sauces,
Teach clients about the Food Guide Pyramid for an and foods made with alcohol. These items will cause the same
adequate, balanced diet. Most alcoholics have, in the past, reaction as if the person took a drink of alcohol.
received most of their calories from alcohol. They must now Therapy should not be started until at least 12 hours
learn how to maintain health by eating nutritious foods. after the last drink of alcohol. The effects of disulfiram with
The interaction of alcohol with other drugs should also alcohol can occur for 6 to 12 days after taking the disulfiram.
be taught. Some effects can be life-threatening. Table 18-4 As with any drug, there are side effects such as drowsiness,
shows the interaction of alcohol with some classifications of fatigue, and impotence. Garlic-like breath occurs frequently
drugs. and is sometimes used as an indicator of compliance in taking

Table 18-4 Alcohol Interaction with Other Drugs

DRUG CLASSIFICATIONS WITH EXAMPLES INTERACTION
Narcotic analgesics • Loss of effective breathing (respiratory arrest)
• meperidine hydrochloride (Demerol) • Can be fatal
• morphine sulfate (Morphine)
• proproxyphene HCl (Darvon)
• hydromorphone HCl (Dilaudid)

Nonnarcotic analgesics • Stomach and intestinal bleeding

• aspirin • Liver damage
• acetaminophen (Tylenol)

Anticoagulants • Increases drugs’ ability to stop blood clotting

• warfarin sodium (Coumadin, Panwarfin) • May cause life-threatening or fatal hemorrhage
• dicumarol

Antihypertensives • Orthostatic hypotension

• reserpine (Serpasil)
• methyldopa (Aldomet)

Antimicrobials • Possible disulfiram-like reaction, nausea, cramps,

• metronidazole (Flagyl) vomiting, headache, flushing or hepatotoxicity
• cefotetan disodium (Cefotan)
• rifampin (Rifadin)

CNS stimulants • May reverse depressant effect of alcohol and give

• most diet pills a false sense of security
• dextroamphetamine sulfate (Dexedrine)
• caffeine (No Doz)
• methylphenidate HCl (Ritalin)

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 CHAPTER 18 Substance Abuse 625

Table 18-4 Alcohol Interaction with Other Drugs (Continued)

DRUG CLASSIFICATIONS WITH EXAMPLES INTERACTION
Diuretics • May reduce blood pressure and cause dizziness
• chlorothiazide (Diuril)
• furosemide (Lasix)

Antidepressants • Reduces CNS functioning

• imipramine HCl (Tofranil) • Chianti wine may cause hypertensive crisis
• desipramine HCl (Pertofrane)
• perphenazine and amitriptyline HCl (Triavil)

Antihistamines • Increased calming effect

• Most cold remedies • Person becomes very drowsy
• pseudoephedrine • Driving is hazardous
HCl and triprolidine
HCl (Actifed)
• chlorpheniramine maleate and acetaminophen (Couricidin)

Antipsychotics • Added CNS depression and impairs voluntary

• thioridazine HCl (Mellaril) movements
• chlorpromazine HCl (Thorazine) • Causes respiratory depression
• Can be fatal

Sedative-hypnotics • Reduces CNS functioning

COURTESY OF DELMAR CENGAGE LEARNING

• glutethimine (Doriden) • Sometimes causes coma and respiratory arrest
• pentobarbital (Nembutal) • Can be fatal

Antianxiety agents • Reduces CNS functioning

• diazepam (Valium) • Decreased alertness and judgment
• chlordiazepoxide (Librium) • Can lead to household and driving accidents

Table 18-5 Alcoholics Anonymous

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying
only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to
practice these principles in all our affairs.
The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.) Permission to reprint
the Twelve Steps does not mean that A.A. has reviewed or approved the contents of this publication, nor that A.A. agrees
with the views expressed herein. A.A. is a program of recovery from alcoholism only. Use of the Twelve Steps in connection
with programs and activities that are patterned after A.A., but address other problems, or in any other non-A.A. context,
does not imply otherwise.

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626 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

the disulfiram. Disulfiram is contraindicated in clients with

cardiovascular disease, hypothyroidism, suicide ideation, and
Potential for Addiction
in clients receiving antihypertensives or monoamine oxidase The potential for addiction is high for all of these substances.
inhibitors (MAOI). Benzodiazepines are schedule IV drugs; barbiturates may be
either schedule II, III, or IV drugs; and methaqualone is a
schedule I drug.
■ BENZODIAZEPINES AND
OTHER SEDATIVE-HYPNOTICS Withdrawal
W ith the introduction in 1961 of chlordiazepoxide
(Librium), the benzodiazepines have replaced most
of the short-acting barbiturates and other nonbarbiturate
Symptoms of withdrawal for benzodiazepines, which may not
manifest for a week or more, include cramping, sweating, disori-
entation, confusion, tremors, depression, hallucinations, and
sedative-hypnotics that were in use before that time. Examples paranoia. Barbiturate withdrawal symptoms include anxiety,
of benzodiazepines include diazepam (Valium), secobarbital weakness, anorexia, insomnia, tremors, delirium, and seizures
(Seconal), paraldehyde (Paral), and flunitrazepam (Rohyp- that occur within 72 hours of the last use. Withdrawal reactions
nol). Rohypnol when mixed with alcohol can incapacitate and related to other sedative-hypnotics include nausea, headache,
prevent the person from resisting sexual assault or remember- cramping, toxic psychosis, insomnia, and convulsions.
ing what she experiences under the effects of the drug. It is The withdrawal pattern is the same as for alcohol.
known as the “date rape drug” (NIDA, 2008b). Street names
include roofies, tranks, ludes, and barbs. Treatment/Rehabilitation
Ideally, treatment for benzodiazepine abuse is a gradual reduc-
Incidence tion in the amount taken until the client is no longer taking
Benzodiazepines are not commonly used as recreational drugs any. A cross-tolerant drug such as phenobarbital is sometimes
but are widely prescribed and are thus available for abuse. given to control symptoms and then its dosage is reduced.
Statistics are not available because some clinicians still deny Hospital treatment is likely to be needed. Treatment for bar-
that addiction to these drugs occurs. Withdrawal symptoms biturate and other sedative-hypnotics overdose or withdrawal
are subtle and delayed, and the symptoms are not always con- is symptomatic.
nected to the benzodiazepines. Rehabilitation that focuses on teaching clients alternative
Barbiturates and other sedative-hypnotics are more abused methods of coping with the anxiety and stressors in their lives
but less prescribed. These are available on the illegal market. is necessary. Supportive individual psychotherapy or a self-
help recovery group is almost always advisable. The goal is to
assist the client to identify the consequences of the behavior
Signs and Symptoms and to understand the risks of relapse.
Benzodiazepines in low doses produce drowsiness or sedation.
Larger doses produce sleep, but surgical anesthesia cannot be ■ MARIJUANA (CANNABIS)

M
induced. Respirations are not depressed, and there is little
effect on the cardiovascular system unless extremely large arijuana is the most common type of cannabis used. It
doses are taken. Then a decrease in systolic blood pressure and is composed of dried leaves, stems, and flowers of the
an increase in heart rate may result. Side effects may include plant Cannabis sativa and can be smoked or added to food.
motor incoordination, ataxia, increased hostility or rage, Hash or hashish is a potent concentrate of the resin from the
confusion, metallic-like aftertaste, headache, and blurred vision. flowers. Hash oil is extremely concentrated, made by boiling
Tolerance (a decreased sensitivity to subsequent doses of the hashish in a solvent and filtering out the solid matter. Street
same substance; an increased dose of a substance is needed to names include grass, pot, reefer, smoke, weed, and Mary Jane.
produce the same desired effect) to other benzodiazepines and “Blunts” are cigars emptied of tobacco and refilled with mari-
cross-tolerance (a decreased sensitivity to other substances juana. It is the most commonly used illicit drug in the United
in the same category) to other CNS depressants occur with States (NIDA, 2009d). Often, it is the “gateway” drug leading
chronic use. In some clients, particularly pediatric, geriatric, or to the abuse of other drugs.
autistic, a paradoxical reaction can occur. They show excessive
movement, increased talkativeness, agitation, violent behavior,
and physical assault instead of the expected calming effect Incidence
(Bramness, J., Skurtveit, S., & Morland, J., 2006, Mancuso, Use in the United States began in the early 1900s, peaked in the
C.E., Tanzi, M.G., & Gabay, M., 2004). period 1978 to 1980, and has steadily decreased since. Accord-
Barbiturates depress all areas of the CNS, some selectively ing to Johnston, O’Malley, and Buchman (1991, 1998, 2008a,
according to the dosage. They do not reduce pain. Respira- and 2008b), the prevalence of marijuana use by high school
tions are depressed but not significantly when therapeutic seniors increased from 20% in the class of 1969 to 60.4% in
doses are taken. When a barbiturate is given to a client in pain, the class of 1979 and decreased to 50.2% in the class of 1987
excitement rather than sedation may occur. Side effects may and decreased again to 40.7 percent in the class of 1990. Use
include drowsiness, residual effects on motor skills, and espe- increased between 1990 and 1997 but declined in 1998 to
cially in the elderly, excitement, irritability, or delirium. An 49%. A National Institute on Drug Abuse study (NIDA, 2007)
overdose of barbiturates causes decreased respirations, rapid showed that 10.3% of 8th, 24.6% of 10th, and 31.7% of 12th
and weak pulse, cyanosis, coma, and sometimes respiratory graders had abused marijuana at least once in 2006. The 2007
paralysis. Tolerance results from chronic use or abuse. Benzo- National Survey of Drug Use and Health (Substance Abuse
diazepines may be detected for 1 to 6 weeks. and Mental Health Services Administration (SAMHSA, 2008)

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 18 Substance Abuse 627

showed that of the 2.7 million Americans aged 12 or older who

used illicit drugs for the first time within the past 12 months,
Treatment/Rehabilitation
56.2 % reported that their first drug was marijuana (Figure 18-3). Treatment focuses on relapse prevention and the develop-
ment of new coping mechanisms, ways of living, and means
Signs and Symptoms of having fun without drugs. Weekly group therapy sessions to
maintain a commitment to abstinence and enhance interper-
Short-term effects of marijuana use include memory and sonal skills are often used. Participation in a self-help group is
learning problems; distorted perception; difficulty in think- encouraged.
ing and problem solving; loss of coordination; and increased
heart rate, anxiety, and panic attacks. Long-term use produces
changes in the brain that make a person more at risk of
becoming addicted to alcohol and cocaine. Long-term effects
CNS STIMULANTS
of marijuana use may lead to lung cancer, impairment of the
immune system, and a greater risk of getting lung infections
(NIDA, 2009d). A reverse tolerance can develop whereby
D rugs that stimulate the CNS include cocaine, amphet-
amines, caffeine, nicotine, and methylphenidate hydro-
chloride (Ritalin). They increase cortical alertness and
a smaller amount of marijuana will elicit the desired psychic electrical activity in the brain and spinal cord. There is tachy-
effects. Marijuana may be detected in urine for up to 3 to 30 cardia and an increase in blood pressure.
days depending on how much and how long it has been used.

Potential for Addiction ■ COCAINE

C
The potential for psychological addiction is moderate. More
than 290,000 persons seek treatment each year for their pri- ocaine is extracted from the leaves of the coca plant,
mary marijuana addiction (NIDA, 2009d). Marijuana is a Erythroxylum coca. It may be heated and the fumes
schedule I drug. inhaled. This is termed free-basing. As a white powder, cocaine
is snorted by inhaling it through the nose or heated to a
Associated Problems/ liquid state and injected intravenously. Crack is a crystallized
form of cocaine that is melted in a water pipe and smoked.
Disorders Street names include coke, crack, flake, rocks, snow, “C,” and
Critical skills related to attention, learning, and memory are blow.
impaired in heavy marijuana users even 24 hours after the last
use. Also, persons who use marijuana tend to be more accept-
ing of deviant behavior, have more aggression and delinquent
Incidence
behavior, act more rebellious, and have poorer relationships Cocaine abuse and dependence was the major illicit drug
with parents. problem for the United States in the 1980s. The introduction
of crack dramatically increased cocaine abuse among the poor.
Withdrawal
Crack is low cost and gives an intense “high.” It is estimated
that 1.6 million Americans are dependent on or abuse cocaine
Nausea, myalgia, restlessness, irritability, nervousness, insom- (SAMHSA, 2008).
nia, and depression may appear after ceasing marijuana use.
Symptoms may not appear for up to 1 week after the last use. Signs and Symptoms
The immediate reaction, less than 10 seconds, is an intense
19.0% euphoria that lasts 10 to 15 minutes. This short response time
Pain Relievers leads people to repeatedly use cocaine trying to maintain the
euphoria.
The heart rate increases, blood pressure goes up, pupils
10.7% dilate, peripheral blood vessels constrict, and temperature
Inhalants
increases. Normal pleasures are magnified, anxiety decreases,
self-confidence increases, social inhibitions are reduced, com-
6.5% munication is facilitated, and sexual feelings are enhanced.
Tranquilizers Other psychological effects are inability to concentrate,
4.1%
insomnia, reduced sense of humor, antisocial behavior, hal-
56.2% Stimulants lucinations, and compulsive behavior.
Marijuana An overdose may occur with the first use because there is
2.0%
Hallucinogens little quality control of drug strength in the street drug culture.
1.1% A client with an overdose may have arrhythmias, tremors,
0.6% Sedatives convulsions, respiratory failure, cardiovascular collapse, and
Cocaine death. Cocaine may be detected for up to 2 to 3 days in urine
and for up to several months to years in hair.
Figure 18-3 Specific Drug Used When Initiating Illicit
Drug Use among Persons Aged 12 or Older (Results from the
2007 National Survey on Drug Use and Health: National Findings, Potential for Addiction
Department of Health and Human Services, Substance Abuse and The potential for addiction is high. Cocaine is a schedule II
Mental Health Services Administration [SAMHSA] [2008].) drug.

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628 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Associated Problems/ Incidence

Disorders Amphetamines have been abused since the early 1930s. World
Many types of heart disease are linked to cocaine use, espe- War II greatly increased use and abuse when military per-
cially ventricular fibrillation, heart attack, and hypertension. sonnel used amphetamines to decrease fatigue and increase
When cocaine is snorted regularly, respiratory problems alertness. Today, abuse ranges from truck drivers and college
occur, including loss of sense of smell, nosebleeds, hoarseness, students who want to ward off sleep and increase alertness to
and respiratory failure. the heavy abuser who injects or smokes homemade metham-
When cocaine is taken with alcohol, the two drugs are phetamine, known as meth, chalk, ice, crystal, crank, and glass.
converted in the body to cocaethylene, which is more toxic An estimated 10.4 million people in the United States have
than either drug alone (NIDA, 2008a). tried methamphetamine at some time (NIDA, 2005b).

Withdrawal Signs and Symptoms

Besides suppressing fatigue and increasing alertness, amphet-
The crash, a period of exhaustion, occurs with symptoms of amines enhance psychomotor performance, induce a tempo-
depression, anxiety, and a great need for sleep. The depres- rary state of well-being, and give an instantaneous euphoria.
sion may be to the point of suicidal behavior. The client has Like cocaine, after several days the person becomes exhausted
no energy, shows little interest in the surroundings, and seems and lapses into a long period of sleep and depression (crash).
to have little ability to experience pleasure. These symptoms The action of amphetamines lasts much longer than that of
are the most intense during the first 3 days but continue for 1 cocaine, and there is a greater potential for adverse reactions
to 4 months. An intense craving for cocaine is felt, including and severe toxicity (Figure 18-4).
dreaming about cocaine. Then there is a period of less intense High abuse doses may cause insomnia, tachycardia, head-
craving for cocaine called extinction, which may last months ache, arrhythmias, hypertension followed by hypotension,
or even years. Withdrawal does not result in a medical emer- nausea, vomiting, cramping, diarrhea, hyperreflexia, convul-
gency as seen with alcohol. sions, and death. The psychological effect is termed amphet-
amine psychosis and closely resembles paranoid schizophrenia.
Treatment/Rehabilitation Symptoms include paranoid ideation, confusion, compulsive
Treatment is aimed at reducing the craving and managing behaviors, and visual and auditory hallucinations. Tolerance
the severe depression. Careful monitoring of the client is does develop. Amphetamines may be detected for up to 2
necessary to identify and prevent actions aimed at carry- days.
ing out the idea of suicide. An individual with a history of
cocaine usage has an intense craving for cocaine and a strong Potential for Addiction
denial that cocaine is addicting. This creates a problem The potential for addiction is high. Amphetamines are sched-
in engaging an individual in treatment. Inpatient programs ule II drugs.
are necessary for some clients with cocaine dependence,
whereas other clients can be effectively treated in outpatient
programs. Associated Problems/
Disorders
Medications Cardiovascular problems occur, including irregular and rapid
Bromocriptine mesylate (Parlodel) in small doses seems to heartbeat; hypertension; and irreversible, stroke-producing
reduce the withdrawal symptoms. Amantadine hydrochloride
(Symmetrel) also has some success in treating cocaine with-
drawal. Desipramine hydrochloride (Pertofrane) seems to
reduce the craving for cocaine. PROFESSIONALTIP
Education Methamphetamine
Individual or group therapy should focus on helping the Methamphetamine, known as meth, is an illegal
client feel pleasure again, improve energy level, and reduce
highly addictive drug belonging to the class of
cocaine craving. Peer support groups and self-help groups,
such as Cocaine Anonymous, may be very effective. Random drugs known as stimulants. Relatively inexpensive
and regular urine testing is an external support to promote over the counter products such as drain cleaner,
abstinence. antifreeze, and battery acid are used to make
meth in homemade labs. The production of meth
has led to widespread drug problems in communi-
■ AMPHETAMINES ties throughout the United States. Nurses can iden-

A mphetamines (also called uppers, speed, bennies)

include dextroamphetamine sulfate (Dexedrine),
amphetamine sulfate (Amphetamine), and methamphet-
tify methamphetamine users by signs of excited
speech, agitation, decreased appetite, weight loss,
nausea, vomiting, diarrhea, increased physical
amine hydrochloride (Desoxyn). Medically they are used activity and energy level, dilated pupils, hyper-
to treat attention deficit hyperactivity disorder (ADHD), tension, angina, dyspnea, and hyperthermia.
narcolepsy, and obesity.

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 CHAPTER 18 Substance Abuse 629

Methamphetamine vs. Cocaine

Stimulant Stimulant and local anesthetic

Man-made Plant-derived
Smoking produces a long-lasting high Smoking produces a brief high
50% of the drug is removed from 50% of the drug is removed from
the body in 12 hours the body in 1 hour
Increases dopamine release and blocks Blocks dopamine re-uptake
dopamine re-uptake
Limited medical use Limited use as a local anesthetic in
some surgical procedures

Figure 18-4 Basic Differences between Methamphetamine and Cocaine (Adapted from Research Report Series—Methamphetamine
Abuse and Addiction, National Institute on Drug Abuse, 2008.)

damage to small blood vessels in the brain (NIDA, 2008j).

Injecting the drug may damage blood vessels and cause
Potential for Addiction
skin abscesses, and if injection equipment is shared, there is The potential for addiction is moderate. Caffeine is not a
an increased risk of HIV/AIDS and hepatitis B and C scheduled drug.
transmission.

Withdrawal Withdrawal
Withdrawal produces headache, irritability, and tremulousness.
Symptoms of withdrawal include apathy, fatigue, irritability,
depression, disorientation, anxiety, paranoia, aggression, and
an intense craving for the drug. Treatment/Rehabilitation
Treatment/
A gradual reduction of caffeine intake can reduce or eliminate
the withdrawal symptoms. The client can then drink decaf-
Rehabilitation feinated coffee and tea and caffeine-free soft drinks. The
intake of cocoa and chocolate should be greatly reduced or
Urinary acidifiers, such as ascorbic acid (vitamin C), increase eliminated. Caffeine can be avoided by reading labels and not
the excretion of amphetamines. Diazepam (Valium) is given using nonprescription products that contain caffeine.
for sedation to ease the withdrawal crash. Bromocriptine
mesylate (Parlodel) or levodopa (Dopar) may help decrease
the craving. A quiet environment is also helpful. ■ NICOTINE

N
Behavioral therapy is used to help the client recognize
and accept the need to stop using amphetamines. Supportive icotine is found in tobacco in a 1% to 2% concentration.
individual or group therapy, and especially self-help groups, There is no therapeutic use for nicotine. Smoking and
aids the client to stay abstinent and in treatment. other uses of tobacco have been in and out of favor several
times during the past five centuries. This century has seen the
greatest degree of abuse. Reasons for this increase are related
■ CAFFEINE to the mass production of tobacco products, mass advertis-

C
ing campaigns, and the psychological dependence produced
affeine is found in coffee, tea, cola beverages, energy by nicotine. Tobacco, even when used in moderation, will
drinks, cocoa, chocolate, and some nonprescription likely produce disease and death. Tobacco kills more than
drugs (Table 18-6). 430,000 U.S. citizens and 5 million persons worldwide each
year (World Health Organization (WHO, 2008), Centers for
Incidence Disease Control and Prevention (CDC, 2008c).
Caffeine is probably the best known and most frequently used
and abused CNS stimulant. Incidence
In the United States 19.8% of the population, (43.4 million
Signs and Symptoms people) are current cigarette smokers (CDC, 2008a). Among
high school students, 20% were current smokers in 2007
Caffeine causes relaxation of smooth muscles in blood vessels (CDC, 2008b).
and bronchi, diuresis, an increased gastric acid secretion, sup-
pression of appetite, increased feeling of energy, and constric-
tion of cerebral blood vessels. An increased level of caffeine Signs and Symptoms
intake causes jitteriness, restlessness, nervousness, excitement, Nicotine causes decreased skeletal muscle tone, decreased
flushed face, palpitations, and nausea. sensitivity of some receptor sites (pain, heat, taste buds),

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630 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Table 18-6 Caffeine Content of Common Drinks, Foods, and Products

SUBSTANCE SERVING SIZE CAFFEINE CONTENT (MILLIGRAMS)
Coffee
Brewed, drip method 8 oz. 65–150
Instant 8 oz. 60–130
Decaffeinated 8 oz. 2–9
Espresso 1 oz. 30–64
Starbucks Cafe Latte 16 oz. 150
Starbucks Coffee Grande 16 oz. 330

Tea
Brewed 8 oz. 20–110
Instant 8 oz. 10–35
Green tea, brewed 8 oz. 30–50
Canned or bottled 8–12 oz. 10–75
Lipton Brisk Iced Tea, lemon flavored 12 oz. 10
Nestea, sweetened or unsweetened 12 oz. 17
Snapple Iced Tea 16 oz. 18

Soft Drinks
Mountain Dew (Regular & Diet) 12 oz. 54
Mello Yellow 12 oz. 53
Diet Coke 12 oz. 47
Sunkist Orange 12 oz. 41
Pepsi 12 oz. 38
Coca-Cola 12 oz. 35
Diet Pepsi 12 oz. 35
Sprite 12 oz. 0

Sports/Energy Drinks
Spike Shooter 8.4 oz. 300
No Name (formerly known as Cocaine) 8.4 oz. 280
Monster Energy 16 oz. 160
Rockstar 16 oz. 160
Full Throttle 16 oz. 144
Red Bull 8.3 oz. 76
Vault 8 oz. 47

Foods & Products

Milk chocolate candy bar 1–1.5 oz 2–10
Dark chocolate candy bar 1–1.5 oz. 5–35
Hot cocoa 8 oz. 2–10
Jolt Caffeinated Gum 1 stick 33
Foosh Energy Mints 1 mint 100
Coffee ice cream 8 oz. 8–85
NoDoz Maximum Strength 1 tablet 200
Vivarin 1 tablet 200
Excedrin Extra Strength 2 tablets 130

Data from Johns Hopkins University School of Medicine, Johns Hopkins Bayview Campus, Behavioral Biology Research Center, 2009, www.caffeinedependence
.org/caffeine_dependence.html#sources; Mayo Clinic, 2007, How much caffeine is in your daily habit? Retrieved from http://www.mayoclinic.com/health/
caffeine/AN01211/METHOD=print; Center for Science in the Public Interest, 2007, Caffeine content of food and drugs. Retrieved from http://www.cspinet.org/
new/cafchart.htm

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 CHAPTER 18 Substance Abuse 631

client not smoke while using the patch. Serious adverse effects
LIFE SPAN CONSIDERATIONS may be experienced with a high serum nicotine level. It can
be toxic. Later, a gradual withdrawal of the nicotine patch can
Smoking be accomplished. The first non-nicotine prescription drug to
treat nicotine addiction, bupropion (Zyban), was approved by
• Menopause generally occurs earlier in women the Food and Drug Administration in 1996.
who smoke. An exercise program will help with stress management
• The older smoker is often less motivated to quit and minimize possible weight gain. Relaxation techniques will
because of the feeling that “I’ve survived this also reduce stress. Support by family and significant others for
long.” the person quitting tobacco use may help the process. A lack of
support may greatly increase the difficulty of quitting for the
individual. The rate of relapse is highest in the first few weeks
and diminishes considerably after 3 months.
reduced appetite, vasoconstriction, decreased body tempera-
ture, and increased blood pressure. Tolerance develops so the
daily intake must increase to continue the desired effect. ■ METHYLPHENIDATE
HYDROCHLORIDE (RITALIN)
Potential for Addiction
The potential for addiction is high. Even first-time users can
become dependent within weeks of their initial use. Nicotine
C urrently, there is an increase in the use (misuse and
overuse) of Ritalin that is becoming a growing problem.
Ritalin is an accepted treatment for children with attention
is not a scheduled drug. deficit hyperactivity disorder (ADHD). Although Ritalin
is a CNS stimulant, there is a paradoxical calming effect on
Associated Problems/ children with ADHD. Many children are being given Ritalin
Disorders without thorough testing to eliminate other causes of atten-
tion deficit. These children have the potential for dependence.
Other ingredients in the smoke (tar, carbon monoxide, and Ritalin is also used for narcolepsy. It can be detected for 1 to
incompletely burned waste products) are largely responsible 2 days and is a schedule II drug.
for the negative health consequences.

Respiratory HALLUCINOGENS

H
Chronic obstructive pulmonary disease is caused by the many
changes tobacco use makes in the respiratory system. Smok- allucinogens refers to a group of naturally occurring
ers are more prone to developing pneumonia, and asthma is and synthetic agents that produce essentially the same
exacerbated by smoking. Chronic exposure to smoke inhala- mind-altering effects.
tion gives children higher rates of otitis media and respiratory Psilocybin and psilocin are naturally occurring organic
illnesses. compounds found in some mushrooms that grow in the
United States and Mexico. These mushrooms have been used
Cardiovascular for centuries in southern Mexico, primarily in religious cer-
emonies. Fresh or dried mushrooms, sometimes mixed with
Ischemic heart disease is twice as likely to develop in a smoker food, are ingested orally.
than in a nonsmoker. Cerebrovascular accidents and periph- Dimethyltryptamine (DMT) and diethyltryptamine
eral vascular disease are strongly associated with smoking. (DET) are found in tropical plant leaves and seeds. For cen-
Cessation of smoking, about 10 years, reduces the risks for turies they have been dried and powdered and used as snuff.
these three vascular diseases to the nonsmoker’s level. They are not orally active. Sometimes the powder is added to
tobacco or marijuana.
Cancer There are several amphetamine-like hallucinogens. Prob-
Many cancers—oral, pharyngeal, laryngeal, esophageal, ably the two best known are 2,5 dimethyl-4-ethylamphet-
lung, pancreatic, kidney, and bladder—are strongly associ- amine (DOM) and methylene-dioxyamphetamine (MDMA,
ated with tobacco. Secondhand smoke causes lung cancer in ecstasy), which are chemically manufactured compounds.
nonsmoking adults. Tobacco use is by far the most important These are usually taken orally but may be injected intrave-
risk factor in lung cancer development (American Cancer nously or inhaled.
Society, 2007).
■ LYSERGIC ACID
Withdrawal DIETHYLAMIDE

L
Short-term effects of nicotine withdrawal include nausea, diar-
rhea, headache, drowsiness, insomnia, irritability, and poor ysergic acid diethylamide (LSD), a manufactured chemi-
concentration. Increased appetite along with an intense crav- cal compound, is perhaps the most widely known and
ing for tobacco may persist for 6 months or longer. used hallucinogen. In the past, LSD has been used as a legiti-
mate medication and in research. In the 1960s, when its abuse
Treatment/Rehabilitation became so widespread, the manufacturer refused to supply
it for research. It had already been discontinued as a useful
Nicotine replacement therapy by patch, nasal spray, inhaler, or medication. It is generally taken orally but can be injected
gum helps individuals break the habit. It is important that the intravenously.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
632 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Incidence should be done in a quiet, pleasant manner. The person

should be encouraged to sit up or walk. Closing the eyes inten-
The use of hallucinogens declined throughout the 1980s. In sifies the “bad trip.” The person should be reminded that the
the early 1990s, LSD made a comeback. The 1990 and 1991 drug is causing the effects, which will soon go away.
annual survey of high school seniors found that for the first After cessation of chronic LSD use, long-term psycho-
time since 1976, more seniors had used LSD than cocaine therapy is usually required to determine what needs were
in the previous 12 months. The 1998 survey showed a slight fulfilled by the use of this drug. A 12-step program and family
downward movement in LSD use. The 2007 survey showed assistance are usually necessary to reinforce the decision to
that in 2006 more than 23 million Americans aged 12 or older remain abstinent. If the client is upset by flashbacks or the fear
had used LSD in their lifetime (SAMHSA, 2008). Other of flashbacks, an anxiolytic drug such as diazepam (Valium)
names for LSD are acid, blotter, and microdot. may be ordered.

Signs and Symptoms ■ PHENCYCLIDINE

The functioning of both the peripheral nervous system and
the central nervous system is altered by LSD. Physical effects
include hypertension, increased temperature, sweating, loss
of appetite, dilated pupils, and dry mouth. Time and dis-
P hencyclidine (PCP) was made for use as an anesthetic
agent, but it produced such adverse reactions that it
was withdrawn from clinical trials; however, it can easily be
tance are distorted, rational judgment is impaired, and visual manufactured in an unsophisticated laboratory from simple
hallucinations (perceiving things that are not really there) materials. The degree of purity varies widely. It is often found
and delusions along with synesthesia (hearing colors and as a contaminant in other street drugs. The anesthetic is used
seeing sounds) occur. A state of either euphoria or depression in veterinary medicine.
is experienced. The depression with feelings of anxiety, panic,
or suicidal tendencies is termed a “bad trip.” Flashbacks occur
suddenly days or years after LSD use. Their occurrence and Incidence
frequency are unpredictable but seem to happen in times of PCP is primarily used by adolescents and young adults, with
high stress. LSD may be detected up to 8 hours after use. the first use between the ages of 13 and 15 years. Approximately
12.8% of those between the ages of 12 and 17 years had used
Potential for Addiction PCP in 1979. The use decreased to 2.4% in 1992 and increased
to 3.9% in 1997. In 2006, The National Survey on Drug Use and
LSD is not considered an addictive drug, but it does produce Health reported that 6.6 million persons aged 12 or older had
tolerance. It is a schedule I drug. used PCP in their lifetime (SAMHSA, 2008). The Monitoring
the Future Survey showed that in 2007, 2.1% of high school
Associated Problems/ seniors had tried PCP (NIDA, 2007). Other names for PCP
Disorders are angel dust, ozone, wack, and rocket fuel. Marijuana com-
bined with PCP is called killer joints or crystal super grass.
Personality changes occur with LSD use and may happen after
a single LSD experience. Acceptable social behaviors seem to
diminish with use. Signs and Symptoms
There are usually four phases, with the symptoms dose related.
Withdrawal Acute toxicity is characterized by visual disturbances, auditory
hallucinations, combativeness, catatonia, convulsions, and
There is no withdrawal seen. coma, and lasts about 3 days. The toxic psychosis phase has
visual and auditory hallucinations, agitation, paranoid delu-
Treatment/Rehabilitation sions, and disturbed judgment, and lasts about 7 days. The
third phase has psychotic episodes, including thought disor-
A person on a “bad trip” should be carefully watched to pre- ders, paranoid ideation, and affect disorders much like schizo-
vent self-injury. Reassurance, support, and “talking down” phrenia and lasts a month or more. Depression is the fourth
phase that may end in suicide. The use of other street drugs
may alleviate the depression. Behavior is highly unpredictable.
Death can occur from respiratory depression. For 2 to 8 days,
PCP can be detected.
CULTURAL CONSIDERATIONS
Mescaline
Potential for Addiction
Even chronic use does not produce physical dependence. Psy-
Mescaline is the active ingredient in peyote cactus chological dependence does develop as evidenced by a craving
found growing in the southwestern United States for PCP. It is a schedule I and II drug.
and Mexico. It is the only legally used hallucino-
gen. Members of the Native American Church of Associated Problems/
the United States may use it for religious purposes.
It is ingested orally. A cross-tolerance to LSD and Disorders
psilocybin occurs. Seizures are a common occurrence with PCP. Hyperten-
sion and hyperthermia must be treated before they become

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 CHAPTER 18 Substance Abuse 633

a crisis situation. Opisthotonos, a complete arching of

the body with only the head and feet on the bed, usually is Table 18-7 Opioids
relieved as the blood level of PCP decreases. Cardiac arrhyth-
mias may need interventions by a cardiologist. Acute renal TYPE EXAMPLE
failure may result from the use of PCP. Strokes also have been Natural morphine sulfate
reported. Opiates codeine sulfate
Withdrawal Semisynthetic heroin
PCP is fat soluble and its effects are felt weeks after the last Opiates hydromorphone hydrochloride (Dilaudid)
use as it is gradually released from the fatty tissue into the
circulation. oxymorphone hydrochloride
(Numorphan)
Treatment/Rehabilitation oxycodone (in Percodan)
Treatment should begin in an inpatient setting because of the hydrocodone (in Hycodan)
high risk of suicide. The goal is to keep the client from resum-
ing drug use. Sedatives may be used, and urinary acidifiers Synthetic meperidine hydrochloride (Demerol)
such as ascorbic acid may be given to increase excretion of Opiates

COURTESY OF DELMAR CENGAGE LEARNING

methadone hydrochloride (Dolophine)
PCP. Minimal confrontation should be used in a nonthreat-
ening, nonstimulating, supportive environment. No effort propoxyphene (Darvon)
should be made to “talk down” or calm the individual. Diaz-
epam (Valium) may be ordered. Agonist- pentazocine (Talwin)
Vocational counseling and training may enhance self- Antagonists nalbuphine hydrochloride (Nubain)
esteem. Body awareness, yoga, and progressive relaxation butorphanol tartrate (Stadol)
help the client focus and improve attention span and concen-
tration. Participation in a self-help group such as Narcotics
Anonymous (NA) should be encouraged, although initial Tolerance may develop to one or more of the effects of
involvement is usually minimal. opioids but not to others. For example, morphine addicts will
always have pinpoint pupils even when the euphoric effects
are not experienced. Tolerance to one opioid usually means
tolerance to other opioids as well. Withdrawal symptoms from
■ OPIOIDS one opioid can be suppressed by using another opioid.

O pioids is a term used to refer to naturally occurring

opiates, semisynthetic opiates, synthetic opiates, and
agonist-antagonists. Table 18-7 provides examples of these
Potential for Addiction
The potential for addiction is high. Heroin is a schedule I
drug; methadone, schedule II; morphine, schedule II or III;
opioids. Heroin is the most abused and the most rapid acting and codeine and opium are schedule II, III, or IV.
of the opioids (NIDA, 2008i).
The Short-Term Effects of Opiates
Incidence
Kleber (1999) described the 1990s as the decade of heroin.
Cocaine addicts switched to heroin. Heroin was easily avail-
able, the purity was higher than in decades, and it could now
be sniffed or smoked instead of injected (NIDA, 2008i). In
2006, 560,000 Americans age 12 and older had abused heroin
at least once in the year before being surveyed (SAMHSA,
2008). Other names for heroin are horse, smack, “H,” skag,
and junk.

Signs and Symptoms

All of these drugs affect the CNS, causing mental changes, Opiates can depress breathing by changing
euphoria, drowsiness, analgesia, constricted pupils, and neurochemical activity in the brain stem, where
depressed respirations (Figure 18-5). These changes become automatic body functions are controlled.
more pronounced as the dose is increased. Opiates can change the limbic system, which
Opioids increase stomach tone, decrease intestinal peri- controls emotions, to increase feelings of pleasure.
stalsis, and increase the tone of the anal sphincter. This all
adds up to constipation. Prolonged drug use may result in a Opiates can block pain messages transmitted
through the spinal cord from the body.
fecal impaction.
Peripheral blood vessels are dilated by opioids, and ortho-
static hypotension frequently occurs. The work of the heart is Figure 18-5 Opiates act on many places in the brain and
not changed by opioids, so they are frequently used to treat the spinal cord. (From Research Report Series—Heroin Abuse and
severe pain of a myocardial infarction. Addiction, National Institute on Drug Abuse, 2008.)

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634 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

CRITICAL THINKING 4–5 days

Runny nose*
Extreme yawning*
Nausea, vomiting,
diarrhea
Narcotic Addiction Sweating*
Cold/hot flashes
Ejaculation/orgasm 7–10 days
Aching joints,
muscles, and bones
Twitchings
Tremor
A client who has had a series of abdominal surger- Muscle spasms
Elevated temperature
Gooseflesh*
ies with recurrent infections told his wife that he 12—20 hours

is afraid that he is becoming addicted to narcotics, "Yen" sleep

COURTESY OF DELMAR CENGAGE LEARNING

but he does not want anyone to know. The wife Dilated pupils*
Blurred vision
4—10 weeks

High blood pressure

confides in you and asks for advice. How would Restlessness, anxi-
ety, and irritability

you respond to the wife? Increased respirations

14 days
Insomnia

Days 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Associated Problems/
One Two Five Ten
week weeks weeks weeks
* Earliest signs of withdrawal

Disorders Figure 18-6 Duration of Morphine Withdrawal Signs and

Chronic heroin injection may cause scarred and collapsed Symptoms (Basic Pattern for All Opioids)
veins, bacterial infections of heart valves and blood vessels,
abscesses, and liver or kidney disease. Pneumonia may result
from the respiratory-depressing effect of heroin. Additives to Methadone Methadone is given and the dose adjusted to
street heroin may clog blood vessels or cause immune reac- keep withdrawal symptoms under control. The daily dose is
tions, leading to arthritis or other rheumatologic conditions. gradually reduced over a period of 3 to 6 months. Routine
Sharing injection equipment can lead to infections of hepatitis and random urine testing is usually done to ensure no other
B and C, HIV, and other blood-borne viruses, which can be drug use.
passed on to sexual partners and children.
Levo-alpha-acetyl-methadol Levo-alpha-acetyl-methadol
Withdrawal (LAAM) is a synthetic opiate, like methadone, used to treat
heroin addiction. It blocks the effects of heroin for up to
Withdrawal symptoms depend on drug purity, dose, and route 72 hours, so it need be taken only 3 times a week.
of administration. Withdrawal is characterized by a rebound
excitability of those functions that had been depressed. Symp- Naltrexone Naltrexone (ReVia) blocks the effects of mor-
toms include stomach cramps, nausea, vomiting, diarrhea, phine, heroin, and other opiates. Its effects last for 1 to 3 days,
diaphoresis, hypertension, aching of bones and muscles, lacri- depending on the dose. The pleasurable effects of heroin are
mation, rhinorrhea, cold flashes with goose bumps, yawning, blocked, making it useful to treat highly motivated individuals.
mydriasis, anxiety, irritability, restlessness, and sometimes It is also used to prevent relapse in former opiate addicts.
paranoia, violence, fear, or depersonalization.
Morphine withdrawal symptoms begin within 8 to Counseling/Self-Help Groups
12 hours after the last dose, and the acute phase is over in
Individual and/or group counseling must go hand in hand
about 10 to 14 days. Figure 18-6 illustrates the signs and
with the detoxification to help the client learn new methods
symptoms of morphine withdrawal. This is the basic pattern
of coping with life’s stresses. Participation in Narcotics Anony-
of withdrawal for all opioids.
mous (NA) helps the client maintain abstinence from drugs.
Codeine withdrawal symptoms may be a little less severe
than those of morphine withdrawal. Dilaudid and heroin with-
drawal may begin slightly earlier than morphine withdrawal. Behavioral Therapy
Meperidine (Demerol) withdrawal begins within 3 hours and Contingency management therapy employs a voucher system.
peaks in 8 to 12 hours. Propoxyphene (Darvon) withdrawal is Clients earn “points” for having negative drug tests. These can
considerably milder. be exchanged for items encouraging healthy living.
Methadone withdrawal is slower to develop and lasts
longer. Symptoms may not occur for 1 to 2 days, with acute
symptoms lasting 2 to 3 weeks but not disappearing until 6 ■ INHALANTS

I
weeks after abstinence begins. Symptoms of fatigue, sluggish-
ness, and irritability may last up to 6 months. nhalants are inexpensive and easy to obtain. Examples are
Withdrawal from the agonist-antagonists begins in 6 to toluene (glues), gasoline, kerosene, isopropyl alcohol, lac-
8 hours and is usually over in 8 days. The symptoms are the quer thinner, acetone, benzene, naptha, carbon tetrachloride,
same as for morphine only in a milder form. fluorocarbons (aerosol propellants), correction fluid, and
nitrous oxide. They are rapidly absorbed into the brain and
Treatment/Rehabilitation stored in body fat. Common names for inhalants are whippets,
poppers, and snappers.
Initial treatment is symptomatic and supportive of vital func-
tions until the acute phase is over.
Incidence
Detoxification In 1997, 21% of 8th graders, 18.3% of 10th graders, and
Several methods currently used for opioid detoxification are 16.1% of 12th graders reported using inhalants at least
methadone, LAAM, and naltrexone. once. By 2002, 15.2% of 8th graders, 13.5% of 10th graders,

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 18 Substance Abuse 635

and 11.7% of 13th graders reported using inhalants at least

once. The Monitoring the Future Study (NIDA, 2005a)
Signs and Symptoms
revealed that 17.3% of 8th graders have abused inhalants. Ecstasy provides an enhanced sense of pleasure and self-
Several National Surveys have reported that more than 22.9 confidence; feelings of peacefulness, acceptance, and close-
million Americans have abused inhalants at least once in their ness with others; and increased energy. Research has shown
lives (NIDA, 2005a). Inhalants are not scheduled drugs. that ecstasy can lead to disruptions in body temperature and
cardiovascular regulation. It also damages the nerves in the
Signs and Symptoms brain’s serotonin system and appears to produce long-term
deficits in memory and cognition (NIDA, 2001b). It appears
The desired effect of euphoria is followed by nausea, head- that the more ecstasy taken, the greater the deficit (NIDA,
ache, and amnesia. Other effects of using inhalants include 2001a).
dizziness, unsteady gait, slurred speech, auditory and visual
hallucinations, drowsiness, hypotension, heightened sexual
response caused by profound vasodilation, stupor, uncon-
Potential for Addiction
sciousness, and coma. Heavy use can lead to hypoxia, multiple The potential for addiction is currently being researched by
organ damage, and death. Airway freezing and/or laryngos- clinical studies. For some people, studies have found that
pasm can be caused by nitrous oxide. ecstasy can be addictive (NIDA, 2008f).
Behaviors that may indicate inhalant abuse include
decreased school performance; loss of interest in extracurricu- Associated Problems/
lar, family, and social activities; and the onset of legal problems. Disorders
Potential for Addiction MDMA interferes with the metabolism of other drugs, includ-
ing some that may be in the tablet with the ecstasy.
The potential for addiction is high for psychological depen-
dence only.

Associated Problems/ ■ ANABOLIC STEROIDS

Disorders
Chronic pulmonary irritation and/or chemical pneumonitis
may be caused by the use of inhalants. Toluene may cause
A nabolic steroids are synthetic derivatives of testoster-
one. They cause both androgenic (masculinizing) and
anabolic (tissue-building) effects. Most people use anabolic
renal tubular acidosis, hearing loss, and brain damage. Fluoro- steroids for their anabolic effects. Medically, they are used in
carbons sensitize the myocardium to catacholemines and may the treatment of some anemias and in some cancer therapies.
cause arrhythmias. The use of anabolic steroids is banned by the International
Olympic Committee and the National Collegiate Athletic
Withdrawal Association.
There are no withdrawal symptoms.
Incidence
Treatment/Rehabilitation Primary users are athletes seeking to improve their perfor-
Initial treatment is to provide oxygen and respiratory mance. Other people use anabolic steroids to improve their
support. Participation in a traditional chemical depen- physical appearance. In 2000, 3% of 8th graders, 3.5% of
dency program is often needed. An adolescent 12-step 10th graders, and 2.5% of 12th graders had used anabolic ste-
group is very helpful. Individual and family counseling are roids. The 2007 Monitoring the Future Study (NIDA, 2009e)
essential. reported that 0.8% of 8th, 1.1% of 10th, and 1.4% of 12th
graders had abused anabolic steroids at least once in the year
prior to being surveyed.

■ ECSTASY

E cstasy, also called MDMA (3,4-methylenedioxymetham-

phetamine), is a complex drug having similarities to
methamphetamine, a stimulant, and mescaline, a hallucinogen
PROFESSIONALTIP
(NIDA, 2008f). It produces stimulant effects and distorted
time and perception rather than true hallucinations. Street Club Drugs
names include “X”, “E”, “XTC”, Adam, hug, beans, clarity, Club drugs are being used by young adults at
lover’s speed, and love drug. Ecstasy tablets also often contain all-night parties such as “raves” or “trances,”
one or more of the following: caffeine, methamphetamine, dance clubs, and bars. MDMA (Ecstasy), GHB,
dextromethorphan, ephedrine, or cocaine. Rohypnol, ketamine, methamphetamine, and LSD
are some of the club or party drugs. These drugs
Incidence can cause serious health problems. Used in combi-
Americans using ecstasy for the first time increased from nation with alcohol, the drugs are even more
615,000 in 2005 to 860,000 in 2006. Most of these new users dangerous (NIDA, 2009b).
were 18 or older (SAMHSA, 2008).

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636 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Signs and Symptoms continued use). Problems in various areas of life are common,
such as frequent job changes; marital conflict, separation and/
The commonly perceived effects of anabolic steroids are an or divorce; work-related accidents, lateness, absenteeism; and
increase in skeletal muscle mass, enhanced physical perfor- legal problems, including arrest for driving while intoxicated.
mance of the skeletal muscles, and improved athletic ability; The client may describe having falls or fights and financial
however, there is no conclusive evidence that these perceived problems. Normal diet pattern and the presence of any disease
effects are medically accurate. conditions should be noted.
The client should be asked health history questions
Potential for Addiction regarding substance abuse (Table 18-8). The information
received from the client may not always be accurate. Validation
The potential for addiction is moderate. Anabolic steroids are with the family or significant other is helpful.
schedule III drugs.
Objective Data
Associated Problems/ Neglect of health and personal care is often evident. The
Disorders client may have dental caries, bad breath, gingivitis, unkempt
appearance, and be undernourished or malnourished. If sub-
Other effects found when anabolic steroids are used include stances have been inhaled, there may be irritation and bleed-
hepatocellular damage, cholestasis, hepatoadenoma, hepato- ing of the nasal mucosa, destruction of the nasal mucosa and
carcinoma, acne, hirsutism, male-pattern baldness, a deepen- cartilaginous structures, or depression of respirations. If sub-
ing of the voice, increased cholesterol level, increased blood stances have been injected intravenously, there will be scarring
pressure, decreased glucose tolerance, mood swings, aggres- of veins (needle marks, track marks), possibly skin infections,
siveness, depression, psychosis, and hepatitis or HIV infection enlarged lymph nodes, and hematomas.
if needles are shared. In males, there is also testicular atrophy,
oligospermia, impotence, prostatic hypertrophy, prostatic car-
cinoma, and gynecomastia. In females, there is also amenor-
rhea, clitoromegaly, uterine atrophy, breast atrophy, facial hair Table 18-8 Obtaining a Client History of
growth, and teratogenicity. Substance Abuse Problems
These effects seem to be reversible when the anabolic ste-
How often do you use drugs/alcohol?
roids are no longer taken, except for the male-pattern baldness,
liver tumors, and gynecomastia in males and clitoral enlarge- How much do you usually use?
ment, virilization, and male-pattern baldness in females. The Have you ever used drugs/alcohol more than you use
increased aggressiveness and euphoria are probably beneficial
them now? When?
during athletic competitions but otherwise may cause severe
social problems. Under what circumstances?
What substance did you last use?
Withdrawal

COURTESY OF DELMAR CENGAGE LEARNING

Has anyone ever told you to cut back or quit using
Symptoms of withdrawal include lethargy, abdominal muscle drugs/alcohol?
cramps, constipation, headache, and depression.
Have you tried?

Treatment/Rehabilitation Have you or are you having interpersonal, occupational,

physical, psychological or legal problems due to drugs/
Treatment of withdrawal focuses on providing symptom alcohol?
relief for the client and counseling to build self-esteem
and self-confidence in abilities without the use of anabolic
steroids.

MEMORYTRICK
NURSING PROCESS Substance Abuse Client
Nursing care is an essential component of the multidisci- Assessment
plinary approach to substance abuse treatment.
An easy memory trick for general assessment find-
Assessment ings for a client participating in substance abuse is
The subjective and objective data given are related to sub- DRUGS:
stance abuse and dependence in general. D = Depression
R = Reduced self-control
Subjective Data
The client will often describe being very relaxed; feeling U = Unkept appearance
wonderful; or having a headache, fatigue, depression, sleep G = Gives excuses (for absenteeism, memory loss, etc.)
disturbance, suppression of appetite, dizziness, hallucinations,
S = Sleep disturbance
paranoia, anxiety, emotional lability, memory loss, heightened
sexual desire (with early use), or loss of sexual desire (with

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 18 Substance Abuse 637

The client may appear older than the stated age and have 2. Assist with personal hygiene. Encourage self-care.
a chronic cough producing brown to black sputum, dilated or 3. Administer medications as ordered to decrease or pre-
pinpoint pupils, tremors, slurred speech, lack of coordination, vent symptoms of withdrawal. Keep call light in client’s
frequent episodes of sexually transmitted diseases, jaundice, reach. Keep siderails up.
or vomiting. There may be tachycardia, hypertension, ascites, 4. Provide warm milk at bedtime. Plan with client a time
or petechiae. for bed. Encourage use of relaxation techniques. Reas-
sure client that insomnia will improve.
Nursing Diagnoses 5. Encourage client to do active ROM exercises.
NANDA-International (2009) nursing diagnoses for a client 6. Assist client to turn in bed. Assist client to ambulate as
with substance abuse or dependence may include the following: able. Answer call light promptly.
7. Do not argue with a client having hallucinations. Remind
• Imbalanced Nutrition: Less than Body Requirements
client of day, time, and place.
• Self-Care Deficits 8. Monitor the client’s nonverbal communication.
• Risk for Injury 9. Encourage good personal hygiene. Inspect skin for
• Disturbed Sleep Pattern integrity.
• Activity Intolerance 10. Administer antibiotics as ordered. Monitor vital signs,
• Impaired Physical Mobility I&O, and results of diagnostic testing.
• Disturbed Sensory Perception 11. Administer vitamins as ordered. Provide cues as needed.
• Impaired Verbal Communication Encourage adequate diet intake.
12. Assess coping patterns to identify strengths and weak-
• Risk for Infection
nesses. Actively listen to client. Refer to appropriate
• Excess or Deficient Fluid Volume community agencies.
• Disturbed Thought Processes 13. Assist client to identify areas of low self-esteem. Encour-
• Ineffective Coping age client participation in group therapy. Refer to indi-
• Situational Low Self-Esteem vidual counseling as needed.
• Risk for Violence (Other-Directed or Self-Directed) 14. Monitor client closely. Use restraints as ordered. Keep
• Anxiety bed in low position and side rails up.
15. Introduce client to other recovering persons. Encourage
• Impaired Social Interaction
client to participate in self-help group.
• Hopelessness 16. Provide spiritual support if asked.
• Powerlessness 17. Involve client in decision making when possible. Give
• Compromised Family Coping positive reinforcement for abstinence.
• Defensive Coping 18. Encourage family to participate in treatment program.
• Self-Neglect

Planning/Outcome
Identification LIFE SPAN CONSIDERATIONS
There are several overall goals for the care of a client with a
substance abuse problem. The client will do the following: Substance Misuse or Abuse
1. Abstain from using psychoactive substances
In the older adult:
2. Adhere to the treatment plan
• Misuse (using a legal drug for something other
3. Make lifestyle changes to maintain abstinence than intended or exceeding the recommended
4. Engage in behaviors that foster good health dose of a drug) is more common than abuse or
Possible outcomes from Nursing Outcomes Classifica- dependence.
tion (NOC) include:
• Substances that decrease respirations can
• Distorted Thought Control increase the frequency of mental confusion.
• Risk Control: Alcohol Use • Decreased coordination from alcohol or other
• Risk Control: Drug Use substances is associated with falling more often
and fracturing the wrist, back, and hips.
Nursing Interventions • Chronic medical conditions can be made worse
Nursing interventions include active listening, providing care from even minimal use of alcohol or other drugs
in a nonjudgmental manner, teaching health promotion, and because these substances can change the effect
referral to self-help groups or individual counseling. Other of prescribed medications.
nursing interventions must be specific for the goals and nurs- • Unrealistic expectations of retirement may lead
ing diagnoses identified for the individual client. Examples to use of mood-altering substances to relieve
might include the following:
depression and boredom.
1. Provide a well-balanced diet. Monitor intake and results
of lab tests. Assess for GI bleeding.

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638 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Possible interventions from Nursing Interventions Clas-

sification (NIC) include: Table 18-9 Characteristics of the
• Delusion Management Codependent Person
• Hallucination Management
Caretaking “I always give to others. No one
• Anxiety Reduction
gives to me.”
• Delirium Management
• Mood Management Obsession “I can’t stop worrying about
problems.”
Evaluation Denial “I pretend I don’t have prob-
Each goal must be evaluated to determine how it has been met
lems.”
by the client and modified as necessary.
Poor communication “No one understands me.”

CODEPENDENCY Lack of trust “I don’t trust myself.”

Codependency was first recognized by those working with Anger “I resent feeling controlled and
families of alcoholics. It is a learned pattern of feeling and manipulated.”
behaving, a problem with relationships. In healthy relation-
ships, people share love, concern, and respect for each other. From Mental Health Concepts (5th ed.), by C. Waughfield, 2002, Clifton
There is equal give-and-take. This is termed interdependence. Park, NY: Delmar Cengage Learning. Copyright 2002 by Delmar
Cengage Learning. Adapted with permission.
In unhealthy relationships, people are often out of touch
with their own needs and feelings. They may be unwilling
or unable to take care of themselves and have little self-
esteem. Only by fulfilling the expectations of others do they
others means they are okay. They think they can fix others. The
feel good about themselves. This is termed codependence.
feeling of powerlessness occurs because they give power to oth-
Codependent persons live based on what others think of
ers by looking to them for approval. They go to extremes. For a
them. They always try to meet the needs of others, demand
while they will try very hard for approval, and then they will not
love from others, and manipulate and control the lives of
try at all or they will keep negative feelings inside with a smile
others.
on their face and then blow up over some little thing. Table 18-9
Serious family problems like addictions, abuse, family
lists some characteristics of the codependent person.
secrets, or other major stresses cause confusion and put a
family at risk. Codependent behavior thrives when fear, guilt,
blame, and low self-esteem become evident. When family
members do not relate to each other in positive ways or when
Treatment
their interactions do not provide a healthy environment, the Professional help is usually necessary to change codependent
family is called dysfunctional. Many children grow up in dys- behavior. The goal of treatment is to help the codependent
functional families and learn to be codependent. person feel happy and good about himself or herself. Therapy
Codependency tends to run in families. Parents cannot sessions focus on identifying and reconnecting with the true
teach their children how to cope in healthy ways if they do not self, dealing with feelings, learning how to communicate feel-
know how themselves. Without intervention or a conscious ings, learning to trust, setting boundaries for relationships, and
change by the individual, a pattern of codependent behavior taking charge of their own life.
will continue in other relationships.

Characteristics THE IMPAIRED NURSE

Persons who are codependent have specific characteristics Most states now have peer assistance programs to help nurses
or traits. They have low self-esteem, never feel they are good who are impaired by either alcohol or other substances. Sub-
enough, and often feel shame. Emotions are denied. They stance abuse and dependence are greater problems among
are out of touch with their own feelings and deny their own nurses than among the general public because nurses have
needs. Their smile is phony much of the time. Problems access to many controlled substances. The impaired nurse
with communication become evident as they have trouble often requests to give medications, makes medication errors,
expressing their needs and feelings. Often they say the and “wastes” drugs frequently. This nurse may wear long
opposite to hide their true feelings. They expect others sleeves and spend an extraordinary amount of time in the
to read their minds. Relationship problems occur because bathroom.
they are afraid of being hurt or that others might learn Peer assistance programs first appeared in 1980. They
of their secret feelings and reject them. They cannot risk have been formed through the state nursing association or
loving and losing. Relationships are desired, but walls are the state board of nursing, or through joint effort of both.
always put up. The goals of the peer assistance programs are to assist the
Codependent persons live through others. They are peo- impaired nurse to receive treatment; protect the public from
ple pleasers who would rather give than take. The approval of impaired nurses; help the recovering nurse reenter the nursing

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 CHAPTER 18 Substance Abuse 639

CRITICAL THINKING
PROFESSIONALTIP
Drug Testing
The Impaired Nurse
Should drug testing of all health-care workers
One of the reasons that nurses either lose their be required? How would you feel if you were
license or have it suspended is due to either alco- requested to comply?
hol use or drug diversion. As nurses, giving medica-
tions is a large part of our responsibility. Unless we
have developed positive self care skills, it may be
tempting to use drugs to cope. Most nursing pro- Before the peer assistance programs, impaired nurses
grams have a professional development course in were generally just dismissed from employment. Then they
which this issue is addressed. If it is not addressed would find employment at another health care agency where
in your program, review your Board of Nursing substance abuse or dependence would continue. This pattern
Nurse Practice Act. Many states have treatment often went on for years.
programs specifically for nurses.
As the name implies, peer assistance programs are staffed
with nurses to help nurses. Many of the staff are volunteers
who work in psychiatric nursing or substance abuse centers
or who are themselves recovering from substance abuse. It
is best not to cover up for a colleague with a substance abuse
workforce in a planned, safe manner; and monitor the nurse’s problem; rather, the nurse should report the situation to a
recovery for a time. The state board of nursing may restrict supervisor, who can arrange for the nurse to receive help.
access to controlled substances for the recovering nurse for Some boards of nursing will discipline a nurse for failing to
some period. report a fellow nurse who is abusing drugs.

CASE STUDY
Z.G., age 19, quit school 3 years ago. He has a part-time job at a fast-food place but has been tardy or absent quite
often lately. Sometimes he is easy to get along with, and sometimes he is aggressive and difficult. His mother, with whom
he lives, says he is a good boy and does not give her any trouble. Z.G. was brought to the emergency room by a friend
after he passed out. His temperature is 99°F, respirations 10, and pupils are pinpoint. There are track marks on both
arms.

The following activities will guide your development of a nursing care plan for the case study.
1. List signs and symptoms, other than Z.G.’s, that a client may experience as a heroin addict.
2. List diagnostic tests that may be ordered.
3. List subjective and objective data the nurse should obtain.
4. Write three individualized nursing diagnoses and goals for Z.G.
5. List resources within the medical center and local area that could assist Z.G.
6. Describe the use of methadone in heroin addiction.
7. List teaching that Z.G. will need as a part of his rehabilitation.

Nursing diagnoses for a client with substance abuse or dependency

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Imbalanced Nutrition: The client will maintain Teach client required nutritional needs and provide written
Less than Body body mass and weight information. Measure body mass and weigh client daily.
Requirements related to within range determined by Monitor intake for nutritional content and calories. Monitor
chemical dependency health care provider. lab values.

(Continues)

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640 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Nursing diagnoses for a client with substance abuse or dependency

include the following: (Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Injury related The client will avoid Provide a safe environment. Identify factors that affect the
to physical and mental physical injury. client’s safety needs, degree of intoxication, and/or changes
alterations resulting from in mental status. Encourage and assist client to develop risk
alcohol and/or drug control strategies.
abuse

Self-Neglect related to The client will demonstrate Provide a supportive nonjudgmental environment. Teach
substance abuse. adequate personal hygiene. the client the importance of daily personal hygiene. Provide
hygiene supplies if needed (shampoo, soap, toothbrush,
toothpaste, comb, deodorant, etc.).

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SUMMARY
• Substance abuse and dependence have been problems for • Street drugs vary in strength and purity. Higher-priced
centuries. drugs are often mixed with drugs that are cheaper or easier
• Factors related to substance abuse include individual, to obtain.
family patterns, lifestyle, environmental, and • Neglect of health and personal care are often evident in
developmental factors. substance abuse and dependence.
• A false-positive result on a drug screening test may be • Nurses have a higher incidence of substance abuse and
caused by ingestion of poppy seeds, use of a Vicks® inhaler, dependence than the general public.
or use of over-the-counter diet aids. • Most states have peer assistance programs for impaired
• Detoxification is the first step in the treatment and nurses.
rehabilitation of a substance abuser.

REVIEW QUESTIONS
1. A client is brought to the emergency room with 3. Clammy skin, dilated pupils, slow pulse, and low
pin point pupils, shallow breathing, and cyanosis of blood pressure.
nail beds and oral mucosa. Based on these clinical 4. Dilated pupils, agitation, visual hallucinations,
findings what is the most important initial nursing and elevated blood pressure.
intervention? 3. The nursing care plan of a client in moderate
1. Administer medication to reverse the action of to severe stage of alcohol withdrawal is likely to
the stimulant medication. include:
2. Offer fluids to reduce dehydration. 1. providing environmental stimulation.
3. Maintain an open airway. 2. expecting the client to participate in self-care
4. Explain all procedures to the client. activities.
2. A client with a history of methamphetamine depen- 3. administering intravenous fluids and anti-anxiety
dence is brought to the primary care clinic with medications.
suspected overdose. Which of the following assess- 4. administering antipsychotic medications.
ments will the nurse be able to make? 4. A 30-year-old client is brought to the emergency
1. Pinpoint pupils, hypothermia, elevated blood room by a police officer after his family calls 911
pressure. and reports that the client uses methamphetamine.
2. Decreased respirations, low blood pressure, con- His vital signs are blood pressure 170/100 mm Hg,
stricted pupils. pulse 92 beats/min, and respirations 32 breaths/

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 18 Substance Abuse 641

min. He is uncooperative with dilated pupils, mild 5. increased interest in social activities.
diaphoresis, and paranoia. On the basis of his pre- 6. headache.
sentation, what is the most important nursing inter- 8. The nurse is caring for a client that has been admit-
vention? ted to the hospital for morphine addiction. Which
1. Ensure personal safety. of the following symptoms will the client experience
2. Administer an IM antipsychotic agent. during morphine withdrawal?
3. Establish rapport by taking him by the hand. 1. Runny nose, nausea, yawning.
4. Administer an IM benzodiazepine. 2. Constipation, diaphoresis, tremors.
5. A 16-year-old client informs the nurse that she has 3. Hypotension, irritability, lacrimation.
been drinking alcohol and smoking cigarettes several 4. Nausea, vomiting, hypotension.
times a week for the past year. The most appropriate 9. The health-care provider has prescribed methadone
response from the nurse would be: for a morphine addicted client as part of their treat-
1. “How many people know this?” ment plan. Which of the following statements made
2. “Why do you drink and smoke?” by the client regarding methadone indicates that fur-
3. “May I ask you a couple of questions about this?” ther teaching is needed by the nurse?
4. “You need to stop this behavior immediately!” 1. The daily dose is gradually reduced over a period
6. A 32-year-old client informs the nurse that she expe- of 1 to 2 weeks.
riences headaches and shakiness on the weekends, 2. Routine and random urine testing is usually done
but not during the work week. The nurse knows that to ensure no other drug use.
this can be a symptom of caffeine: 3. Methadone is given and the dose adjusted to keep
1. Tolerance withdrawal symptoms under control.
2. Withdrawal 4. Counseling with the detoxification helps the cli-
3. Reverse Tolerance ent learn new methods of coping with stress.
4. Relapse 10. A nurse suspects that one of her coworkers is steal-
7. Parents of a 14-year-old teenager suspect that their ing narcotics from the medication cart. Which of
son is using inhalants to “get high”. The parents the following is the most appropriate action for the
should observe their son for signs and symptoms nurse to take?
of inhalant abuse that include: (Select all that 1. Inform the supervisor immediately.
apply.) 2. Confront the coworker.
1. euphoria. 3. Search the coworker’s locker.
2. increased school performance. 4. Ask the other coworkers if they have witnessed
3. dizziness. anything.
4. amnesia.

REFERENCES/SUGGESTED READINGS
Alcoholics Anonymous. (1939). Alcoholics anonymous. New York: Centers for Disease Control and Prevention (CDC). (2008b).
Alcoholics Anonymous World Services. Cigarette use among high school students- United States,
American Cancer Society. (2007). Lung cancer. Retrieved April 5, 2009 1991-2007. Morbidity and Mortality Weekly Report, 57(25),
from www.cancer.org/downloads/PRO/LungCancer.pdf 689–691.
Antai-Otong, D. (2009). Manuscript submitted for publication. Centers for Disease Control and Prevention (CDC). (2008c). Smoking
Arlington, Texas. attribute mortality, years of potential life lost, and productivity
Bayard, M., McIntyre, J., Hill, K., & Woodside, J. (2004). Alcohol losses—United States, 2000–2004. Morbidity and Mortality Weekly
withdrawal syndrome. American Family Physician, 69(6), 1443– Report, 57(45), 1226–1228.
1450. Griffiths, R., Juliano, L., & Chausmer, A. (2003). Caffeine
Bramness, J., Skurtveit, S., & Morland, J. (2006). Flunitrazepam: pharmacology and clinical effects. In: Graham, A., Schultz, T.,
psychomotor impairment, agitation, and paradoxical reactions. Mayo-Smith, M., Ries, R., & Wilford, B. Principles of addiction
Forensic Science International, 159(2), 83–91. medicine (3rd ed.), 193–224.
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. (2008). Hitchens, E. (2009). Manuscript submitted for publication. Seattle
Nursing Interventions Classification (NIC) (5th ed.). St. Louis, MO: Pacific University, Seattle, Washington.
Mosby/Elsevier. Johnson, V. (1989). Intervention: How to help someone who doesn’t want
Centers for Disease Control and Prevention (CDC). (2008a). Cigarette help. New York: New American Library.
smoking among adults—United States, 2007. Morbidity and Johnson, V. (1990). I’ll quit tomorrow: A practical guide to alcoholism
Mortality Weekly Report, 57(45), 1221–1226. treatment. San Francisco: Harper San Francisco.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
642 UNIT 7 Nursing Care of the Client: Physical and Mental Integrity

Johnson, V., (2001). I’ll quit tomorrow: a practical guide to alcoholism National Institute on Drug Abuse (NIDA). (2008d). NIDA infofacts:
treatment: revised edition. New York: HarperCollins heroin Retrieved April 5, 2009 from www.nida.nih.gov/infofacts/
Johnston, L., O’Malley, P., & Bachman, J. (1991). Drug use among heroin.html
American high school seniors, college students and young adults National Institute on Drug Abuse (NIDA). (2008e). NIDA infofacts:
1975–1990. Rockville, MD: National Institute on Drug Abuse, U.S. inhalants. Retrieved April 5, 2009 from www.drugabuse.gov/
Department of Health and Human Services, Alcohol Drug Abuse, infofacts/inhalants.html
and Mental Health Administration. National Institute on Drug Abuse (NIDA). (2008f). NIDA infofacts:
Johnston, L., O’Malley, P., & Bachman, J. (1998). Drug use by MDMA (ecstasy). Retrieved April 5, 2009 from www.drugabuse
American young people begins to turn downward. Retrieved from .gov/infofacts/ecstasy.html
www.isr.umich.edu/src/mtf National Institute on Drug Abuse (NIDA). (2008g). NIDA infofacts:
Johnston, L., O’Malley, P., Bachman, J., & Schulenberg, J. (2008a). nationwide trends. Retrieved April 5, 2009 from www.drugabuse
Monitoring the future national survey results on drug use, 1975-2007: .gov/infofacts/nationtrends.html
Volume I, secondary school students. NIH Publication No. 08-6418A, National Institute on Drug Abuse (NIDA). (2008h). NIDA infofacts:
pp. 707, Bethesda, MD: National Institute on Drug Abuse. understanding drug abuse and addiction. Retrieved April 5, 2009
Johnston, L., O’Malley, P., Bachman, J., & Schulenberg, J. (2008b). from www.drugabuse.gov/infofacts/understand.html
Monitoring the future national survey results on drug use, 1975-2007: National Institute on Drug Abuse (NIDA). (2008i). Research report
Volume II, college students and adults ages 19-45. NIH Publication series—heroin abuse and addiction. Retrieved April 5, 2009 from
No. 08-6418A, pp. 707, Bethesda, MD: National Institute on Drug www.nida.nih.gov/ResearchReports/Heroin/heroin2.html#what
Abuse. National Institute on Drug Abuse (NIDA). (2008j). Research report
Kasser, C., Geller, A., Howell, E., & Wartenberg, A. (2004). series—methamphetamine abuse and addiction. Retrieved April 5,
Detoxification: principles and protocols. American Society of 2009 from www.nida.nih.gov/ResearchReports/methamph/
Addiction Medicine. Retrieved April 5, 2009 from http://www methamph3.html#long
.asam.org/publ/detoxification.htm National Institute on Drug Abuse (NIDA). (2009a). Heroin. Retrieved
Mancuso, C., Tanzi, M., & Gabay, M. (2007). Paradoxical reactions April 5, 2009 from www.nida.nih.gov/DrugPages/Heroin.html
to benzodiazepines: literature review and treatment options. National Institute on Drug Abuse (NIDA). (2009b). Important
Pharmacotherapy, 24(9), 1177–1185. information and resources on club drugs. Retrieved July 2, 2009
Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing from http://www.clubdrugs.gov/
Outcomes Classification (NOC) (3rd ed.). St. Louis, MO: Mosby. National Institute on Drug Abuse (NIDA). (2009c). Inhalants.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Retrieved April 6, 2009 from www.drugabuse.gov/DrugPages/
(2006). Trends in alcohol-related fatal traffic crashes, United States, Inhalants.html
1982–2004. Retrieved April 5, 2009 from http://pubs.niaaa.nih National Institute on Drug Abuse (NIDA). (2009d). Marijuana.
.gov/publications/surveillance76/fars04.htm Retrieved April 5, 2009 from www.nida.nih.gov/DrugPages/
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Marijuana.html
(2008a). Liver cirrhosis mortality in the United States, 1970– National Institute on Drug Abuse (NIDA). (2009e). Marijuana:
2005. Retrieved April 5, 2009 from http://pubs.niaaa.nih.gov/ facts for teens. Retrieved April 5, 2009 from www.nida.nih.gov/
publications/surveillance83/Cirr05.htm MarijBroch/teenpg9-10.html
National Institute on Alcohol Abuse and Alcoholism (NIAAA). National Institute on Drug Abuse (NIDA). (2009f). Steroids
(2008b). Alcohol alert. Retrieved April 5, 2009 from http://pubs (anabolic). Retrieved April 5, 2009 from www.drugabuse.gov/
.niaaa.nih.gov/publications/AA76/AA76.htm DrugPages/Steroids.html
National Institute on Drug Abuse (NIDA). (2005a). Research report North American Nursing Diagnosis Association International. (2010).
series—inhalant abuse. Retrieved April 5, 2009 from www NANDA-I nursing diagnoses: Definitions and classification 2009-2011.
.drugabuse.gov/ResearchReports/Inhalants/Inhalants.html Ames, IA: Wiley-Blackwell.
National Institute on Drug Abuse (NIDA). (2005b). Research Santomier, J., & Hogan, P. (1992). Health implications of alcohol and
report series—methamphetamine abuse and addiction. Retrieved other drug use. In M. Naegle (Ed.), Substance abuse education in
April 5, 2009 from www.nida.nih.gov/ResearchReports/ nursing (Vol. 1). New York: National League for Nursing.
methamph/methamph2.html#scope Spratto, G., & Woods, A. (2009). 2009 PDR Nurses’ drug handbook.
National Institute on Drug Abuse (NIDA). (2007). Monitoring the future Clifton Park, NY: Delmar Cengage Learning.
study. Retrieved April 5, 2009 from www.monitoringthefuture.org Substance Abuse and Mental Health Services Administration
National Institute on Drug Abuse (NIDA). (2008a). Frequently asked (SAMHSA). (2008). Results from the 2007 national survey on
questions of NIDA’s drug facts chat day. Retrieved April 5, 2009 drug use and health: national findings. Retrieved April 6, 2009 from
from www.drugabuse.gov/chat/chatfaqs308.html oas.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#Ch5
National Institute on Drug Abuse (NIDA). (2008b). NIDA infofacts: Waughfield, C. (2002). Mental health concepts (5th ed.). Clifton Park,
club drugs (GHB, ketamine, and rohypnol). Retrieved April 5, 2009 NY: Delmar Cengage Learning.
from www.nida.nih.gov/infofacts/clubdrugs.html World Health Organization (WHO). (2008). WHO report on the
National Institute on Drug Abuse (NIDA). (2008c). NIDA infofacts: global tobacco epidemic, 2008. Retrieved April 5, 2009 from www
crack and cocaine. Retrieved April 5, 2009 from www.nida.nih.gov/ .cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
infofacts/cocaine.html

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 18 Substance Abuse 643

RESOURCES
Al-Anon Family Group, http://www.al-anon.org Mothers Against Drunk Driving (MADD),
Alcoholics Anonymous (AA), http://www.aa.org http://www.madd.org
American Council for Drug Education, Narcotics Anonymous (NA), http://www.na.org
http:// www.acde.org National Clearinghouse for Alcohol and Drug
Codependents Anonymous (CODA), Information, http://www.health.org
http://www.codependents.org National Council on Alcoholism and Drug
Drug Abuse Resistance Education (DARE), Local Dependence, http://www.ncadd.org
Police Department, http://www.dare-america.com Students Against Destructive Decisions (Founded
Drug Enforcement Administration (DEA), as Students Against Driving Drunk),
http://www.usdoj.gov/dea http://www.saddonline.com
Families Anonymous, (Families of Substance
Abusers), http://www.familiesanonymous.org

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Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 8 Older Adult
Chapter 19 The Older Adult / 646

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 CHAPTER 19
The Older Adult

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of the older adult:
Adult Health Nursing • Neurological System
• Surgery • Sensory System
• Respiratory System • Endocrine System
• Cardiovascular System • Reproductive Systems
• Gastrointestinal System • Integumentary System
• Urinary System • Mental Illness
• Musculoskeletal System • Substance Abuse

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe stereotypes associated with older adults.
• Discuss the biological and psychosocial theories of aging.
• Cite the normal physiologic changes that occur with aging.
• List the normal functional changes that occur with aging.
• Describe key factors of optimal health maintenance in the aging adult.
• Identify funding and policy changes that have influenced older-adult care.
• Identify common disorders related to aging.
• Detail nursing interventions for each disorder.
• Discuss areas wherein the nurse can advocate for older adults on the
individual, community, state, and national levels.

KEY TERMS
activities of daily living dementia gerontology
ageism gerontological nursing polypharmacy
delirium gerontologist

646

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 CHAPTER 19 The Older Adult 647

that normally occur with aging; and some common disorders

INTRODUCTION of aging along with nursing interventions to assist clients to
Gerontology is the study of the effects of normal aging and achieve optimal outcomes related to those disorders.
age-related diseases on human beings. It is a general term As caregivers for older adults, nurses and other members
used by all health care and social services disciplines. Aging of the health care team must understand the budgetary and
(senescence) is a complex phenomenon that occurs on a policy decisions that can affect the care they will provide to
continuum, beginning with birth and continuing throughout their clients. Thus, this chapter concludes with a short discus-
the life span. sion on health care financing for older adult care in the 21st
The phrase older adult is very subjective and has histori- century.
cally meant persons who are 65 years of age and older. How-
ever, there is a great deal of debate among gerontologists
(gerontological specialists in advanced-practice nursing, geri- GERONTOLOGICAL NURSING
atric psychiatry, medicine, and social services) as to whether The acceptance of gerontological nursing as a separate nurs-
this specific age delineation should continue to be used. The ing specialty that addresses and advocates for the special care
practice of using 65 years of age as a dividing line for social needs of older adults has not been realized without a struggle. In
welfare benefits began in the 1880s when Otto von Bismark 1961, gerontological nursing attained national recognition with
randomly selected that age for benefits in Germany. It should the creation of its own division of nursing within the American
be noted that there was no standardized clinical basis for estab- Nurses Association (ANA). Nurses in the United States who
lishing this age as the dividing line between young and old. were aware of the trends toward an aging population realized
Longer average life-expectancy rates (84 years for both sexes, the importance of taking such a step. The charter members of
82.4 years for men, and 85.3 years for women) (AoA, 2009b) the Division of Gerontological Nursing deserve a great deal of
along with a decrease in the average number of children per credit for their vision and commitment to developing gerontol-
family since the late 1960s have changed U.S. demographics. ogy education and recognizing the special nursing care needs
As a result, there is a great need to support and strengthen of older adults. The major topics addressed in the expanding
independence among older adults, and to value and use their scope of practice for gerontological nursing included:
life experiences in the areas of career, family, and community.
Retirement age is now less consistently determined by a • The historical evolution of gerontological nursing practice
mandatory age limit. Rather, retirement frequently is offered based on population statistics
when the employee meets a formula of combined age and • The way that ageism in U.S. society has affected the profes-
years of service. Since the 1990s, benefit penalties have been sion of nursing, the health care delivery system, and the
imposed on Social Security beneficiaries up to 70 years of age care of older adults
and who continue to earn incomes over a minimum amount. • Nursing education and care of older adults with a perspec-
This was changed in April 2000 when the Senior Citizens’ tive derived from studies of the attitudes and interests of
Freedom to Work Act of 2000 was signed into law by the presi- nursing personnel and nursing students
dent. This eliminates the Social Security retirement earnings • The delineation of various aspects of nursing care of older
test in and after the month in which a person is 65 years of age adults, including clinical practice based on the ANA Stan-
(the current full retirement age) (Social Security Administra- dards of Nursing Practice; select theories of nursing applied
tion [SSA], 2000). to the care of older adults; and the expanding scope of geron-
Currently, the clinical delineation of an older adult is still tological nursing, in general, and the roles of clinical nurse
someone who is 65 years of age or older; older-old adults are specialists and geriatric nurse practitioners, in particular
defined as those individuals 85 years of age or older. In 1900, • Trends in gerontological nursing and long-term care
there were a total of 3.1 million individuals older than age 65
in the United States; by 1996, there were 33.2 million, 3.8 mil- Number of persons 65+: 1900 to 2030
lion of whom were older than age 85 years (AARP, 1998). In
2001, there were 4.2 million people aged 85 and older in the 80
72.1
United States (NCOA, 2002). It is projected that by the year
2030, the number of older individuals in the United States 70
will reach 72.1 million (Figure 19-1)(AoA, 2009a). The most 60 54.8
rapid increase is expected to occur in the years 2010–2030,
when the “baby boomers” reach age 65. 50
Millions

The future will also place demands on those who were 40.2
born from the late 1950s to the late 1960s. Many in this age 40 35.0
31.2
group chose to focus first on career, delaying marriage and 30 25.5
childrearing until in their thirties. They have thus been labeled
“the sandwich generation” to denote the challenges they will 20 16.6
face in meeting social and financial responsibilities later in 9.0
10 4.9
life as they work to provide for children entering college and 3.1
for aging parents and, sometimes, grandparents and, in a few 0
instances, great-grandparents. 1900 1920 1940 1960 1980 1990 2000 2010 2020 2030
This chapter presents an overview of influences on the Year (as of July 1)
older adult, including the social impacts of aging. Also exam-
ined are theories of aging; myths and realities of aging; health Figure 19-1 Number of Persons Older Than Age 65:
promotion and aging; physiologic and functional changes 1900–2030 (Data from Administration on Aging [AOA], 2009a.)

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648 UNIT 8 Nursing Care of the Client: Older Adult

The battle continues against stereotyping older adults, experiential aspects of living. Several biological theories of
both in the health professions and in the community at large. aging have been proposed to explain the physiologic and
Health professionals, in particular, must be diligent in avoiding functional changes that are observed in older adults. Psycho-
age prejudice. Stereotypes can influence interactions between social theories of aging strive to explain the behaviors and
older adults and caregivers. The caregiver may treat the older social interactions of older adults. These theories are sum-
adult as a child in an old body. This approach is demeaning to marized in Table 19-1. Also, as more knowledge is garnered
older adults and strips them of their self-esteem and dignity. from scientific studies (e.g., the study of the impact on cells
Clients with cognitive or expressive deficits cannot always of auto-oxidization by free radicals and the study of dietary
process questions or comments quickly or follow through chemical exposure) and gene sequencing efforts (e.g., the
with responses. Nurses and caregivers must never make the human genome project), it is likely that the biological theories
mistake of believing that clients do not understand verbal of aging will change as well.
and, especially, nonverbal messages. Older adults are a diverse
group; they deserve respect and, through their memories
and life examples, can teach a great deal to younger persons
about life and survival and coping skills. Learning from clients
MYTHS AND REALITIES OF AGING
and their families and assisting clients to find activities that Myths are fictitious ideas. Myths about the older adult are
enhance the quality of life (regardless of state of health) make abundant and do not reflect the reality of the aging population.
caring for older adults a rewarding and satisfying experience. Ageism is the stereotyping of older adults based upon myths.
Aging is universal, progressive, and irreversible, and even- Some common ageism myths based in part on data from the
tually leads to death. The aging process itself, however, is National Institute on Aging (2009), the U.S. Census Bureau,
very individualized and is independent of chronological age. and A Profile of Older Americans developed by the American
The way an individual ages is influenced by genetics, lifestyle, Association of Retired Persons (AARP) in 1998 are:
availability and quality of health services, cultural beliefs,
Myth: Senility is an expected result of aging.
and socioeconomic status. Certain physiologic changes are
Reality: Senility is an outdated term once used to refer
expected with aging (Figure 19-2), although there exists
to any form of dementia that occurred in older people.
considerable variation in the time of onset, rate, and degree
Dementia is a result of disease, can affect adults of all
of these changes. In order to render effective and compassion-
ages, and is not a natural consequence of aging. Although
ate care to older clients, nurses working in gerontology must
some slight declines are noted in short-term memory
be familiar with the normal processes as well as the common
from the age of 40 on, most people adjust through the
disorders of aging.
use of memory aids such as lists and calendars. Although
long-term memory can remain somewhat intact long
into a dementia disease process, there is slower retrieval
THEORIES OF AGING of information. Thus, nurses and caregivers find that
interventions such as reminiscence, memory photo books,
At this time, no single theory of aging has been universally and activities that draw on the client’s long-practiced skills
accepted by practitioners in gerontology. Aging is a complex provide positive client outcomes.
issue that takes into account the psychosocial, cultural, and
Myth: Incontinence is an expected result of aging.
Reality: Incontinence is not an expected outcome of
aging and, in most cases, can be reversed through assess-
ment and treatment. Incontinence may be caused by
infection, disease, injury, and certain types of medication.
The challenge is that many people are embarrassed to
discuss this problem with family or primary providers.
Also, in long-term care settings, both the belief in this
myth and the historically low staffing levels have served to
dissuade clinical efforts at providing the needed nursing
interventions (prompted voiding; consistent, nonhurried,

CULTURAL CONSIDERATIONS
COURTESY OF DELMAR CENGAGE LEARNING

Aging
It is important to assess the older client’s spiritual/
religious beliefs, traditions, and culture because
they can influence the client’s health beliefs and
health practices. When assessing a client of a
different culture, show respect by using the
Figure 19-2 The aging process is a normal and natural part client’s full name.
of growth and development.

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 CHAPTER 19 The Older Adult 649

Table 19-1 Theories of Aging

Biological Theories

Title Major Premise

Somatic mutation theory Radiation or miscoding of enzymes causes changes in the DNA. Changes associated
with aging are the result of decreased function and efficiency of the cells and organs.

Programmed aging theory The life span is programmed within the cells. This genetic clock determines the speed
at which the person ages and eventually dies.

Cross-linkage, or collagen Collagen is the principal component of connective tissue and is also found in the skin,
theory bones, muscles, lungs, and heart. Chemical reactions between collagen and cross-
linking molecules cause loss of flexibility, resulting in diminished functional mobility.

Immunity theory The thymus becomes smaller with age. The ability to produce T-cell differentiation
decreases. This impairs immunologic functions and results in increased incidence of
infections, neoplasms, and autoimmune disorders.

Stress theory Stress throughout the lifetime causes structural and chemical changes in the body.
These changes eventually cause irreversible tissue damage.

Psychosocial Theories

Title Major Premise

Activity theory Roles and responsibilities change throughout the lifetime. Life satisfaction depends on
maintaining an involvement with life by developing new interests, hobbies, roles, and
relationships.

Disengagement theory There is decreased interaction between the older person and others in his social system.

COURTESY OF DELMAR CENGAGE LEARNING

The disengagement is inevitable, mutual, and acceptable to both the individual and
society.

Continuity theory Successful methods used throughout life for adjusting and adapting to life events are
repeated. Characteristic traits, habits, values, associations, and goals remain stable
throughout the lifetime, regardless of life changes.

timed voiding) to reverse urinary incontinence. In settings A national survey by NCOA in 1998 revealed that half of
where care is provided to older adults, lack of funding, lack those age 60 and older were sexually active. Approximately 72%
of policy support and education, and inconsistent enforce- of those were as satisfied or more satisfied with their sex lives
ment of adequate staffing levels have often had a negative compared to when they were in their forties (NCOA, 2001).
impact on client health outcomes. By developing urinary
incontinence treatment programs, care facilities could
improve clinical outcomes for clients and also reduce
health-care costs.
Myth: Older adults are no longer interested in sexuality or
sexual activity.
Reality: Sexuality is a lifelong need. Older adults can be
and are sexually active, regardless of age. Although a slow-
ing response time is a normal part of aging, many older
COURTESY OF DELMAR CENGAGE LEARNING

adults want and lead a satisfying sex life, and persons of

both genders are capable of orgasm into old age. Despite
interest and desire, physiologic or psychological prob-
lems and medication side effects may present barriers to
intercourse. In such situations, sexuality without coitus
can provide older adults with love and intimacy. Just as
small babies can fail to thrive without human touch (hugs,
nurturing, companionship, valuing of the individual), so
can older adults fail to thrive without these same human Figure 19-3 Individuals of all ages benefit from intimacy
interactions and support (Figure 19-3). and companionship.

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650 UNIT 8 Nursing Care of the Client: Older Adult

The medication sildenafil citrate (Viagra) has proven older women, who often have lower retirement incomes) is
beneficial to many older couples as they work to meet their that most of their assets are tied up in the family home or
sexual health needs. The debate over the acceptance and in other nonliquid holdings. Thus, when an acute illness
funding of this medication for erectile dysfunction sheds strikes, there is little financial reserve to help cover costs.
light on just how far U.S. society still has to go in debunk-
ing this myth and replacing it with the truth that normal
human sexuality needs continue throughout the life span. HEALTH AND AGING
Myth: Most people spend the last years of their lives in Like all age groups, older adults can do much to adopt a
nursing homes. healthy lifestyle that will enhance their remaining years.
Reality: According to NCOA (2002), in 2000, only 4.5%
of those older than age 65 lived in nursing homes. The
percentage rises steeply with age, however (1.1% of those Activities of Daily Living
65 to 74 years of age, 4.7% of those 75 to 84 years of age, Being well groomed enhances the self-esteem of all older
and 18% of those older than 85 years of age). For many, adults. Adaptive devices and techniques are available for
that stay will involve rehabilitation after surgery, a fracture, those who need assistance with the activities of daily living
or stroke before returning home after a short hospital stay. (ADLs), basic care activities that include mobility, bathing,
The late 1990s saw a growing interest in the use of alterna- hygiene, grooming, dressing, eating, and toileting.
tive care options for older adults (retirement communities,
assisted-living centers, group homes, respite care, and par- Mobility
tial hospitalization/adult day programs); however, most
older adults continue to live in communities with varying Many assistive devices are available to help the older client
levels of assistive services or support as they age. The pro- maintain mobility and independence. Handrails can decrease
jected trends in long-term care needs are for continued use the risk of falls while the person is walking; they are also useful
of alternate settings that will support interventions to meet in the tub and, when used in conjunction with a plastic riser,
residents’ physical, psychosocial, cultural, spiritual, cogni- can help the older adult get on and off the toilet safely.
tive, and mental health needs.
Traditionally, older adults in long-term care facilities Bathing
have been taken from home environments where they have Skin dryness increases with aging; thus, it may be preferable
likely experienced the highest level of independence they for older adults to bathe or shower only two to three times
have had in their lifetimes (to choose when to get up, eat, go per week and to take sponge baths in between. A gentle
to bed, and the like), and have been placed in settings where soap should be used sparingly for the bath, after which a
very few, if any, choices, including care decisions, are made moisturizing lotion should be applied. The individual or
based on their preferences. Gerontological nurses have caregiver should be instructed to inspect the skin during
an ongoing responsibility to help re-create the way care is bathing for any indication of skin breakdown, lumps, or
provided and to advocate for older clients in long-term care changes in moles.
facilities. Nurse leaders must learn to think in new ways With aging, oil secretion decreases in the scalp, and hair
about how to work with older clients and their families. can thus become dry. Shampooing one or two times per week
is usually adequate for most older adults, and a simplified
Myth: All older adults are financially impoverished. hairstyle may be helpful to those with limited mobility in the
Reality: Income range varies among those older than 65 arms. The use of mild shampoos and conditioners can also
years of age, just as it does among those in younger groups; enhance hair texture.
however, the high costs of medications does disproportion-
ately affect those older than age 65, who are more likely to
have one or more chronic conditions that require manage-
ment with medication. In the past, lack of reimbursement PROFESSIONALTIP
for preventive assessment, treatments, and medications led
many older adults to go without medications or to delay Activities of Daily Living
care until they were too ill to wait any longer. This resulted
in increased use of acute care services in hospitals. Additional safety measures to consider during ADL
In 2001, families headed by persons older than 65 years include:
of age had a median income of $33,938 (AoA, 2002). The • Filing nails instead of cutting because brittle
challenge for most older adults below the median (especially nails may split
• Avoiding perfumed bathing products due to
CRITICAL THINKING their potential irritating effects
• Showering (preferred) instead of taking a tub
Myths/Stereotypes bath because it is easier to step into a shower
stall than into a tub, the easier availability of
A health team member makes an ageist remark to shower chairs and hand bars that make it more
one of your older adult friends. How would you accessable and safer than stepping into a tub,
respond using a therapeutic communication and clean water is constantly circulating over
technique? the client during the shower procedure

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 CHAPTER 19 The Older Adult 651

Hygiene
Fingernails may become more brittle with aging. Keeping
the client’s fingernails clean and short can prevent accidental
injury or scratches to fragile older skin. Impaired circulation is
common among older adults, so special attention should be
given to care of the feet and lower extremities. Because toe-
nails frequently become thick and tougher with aging, soaking
the feet before trimming the toenails may ease the task. For
clients with circulation or skin integrity problems of the feet
and toes or for clients with diabetes, a referral to a podiatrist
should be made for nail trimming. During bathing, monitor
the client’s feet for discomfort; inflammation; broken skin;
color changes such as redness, pallor, or cyanosis (blue or
purple discoloration resulting from lack of circulation); heat
or coldness; cracking between toes; and corns or calluses.
The need for adequate oral care does not diminish
with aging. Dental problems can result in poor eating habits
and inadequate nutrition. Inadequate brushing and dental Figure 19-5 Assistive devices such as these for pantyhose
checkups can lead to gingivitis (bleeding and edematous and getting dressed are available to help older adults dress
gums), which, if left untreated, can progress to periodontal independently. (Courtesy of Maddak, Inc.)
disease that can destroy connective tissue, alveolar bone, and
periodontal ligaments. Monitor clients for proper oral care. that that razor be marked with the client’s name. Women may
Yoneyama et al. (2002) reports that nursing home residents also require attention to facial hair, as estrogen levels decrease
who received oral hygiene after each meal and professional after menopause. It is not uncommon for older women to
cleaning once a week were two times less likely to get pneu- notice hairs on the chin or upper lip that were not there in
monia and two times less likely to die from it. For those clients younger days. Also, both men and women are likely to notice
with dentures, inspect the dentures for cleanliness and proper graying and diminished hair on legs, underarms, and pubic
fit. Clients with dentures must brush the dentures and the areas as they age.
gums regularly with a soft brush and a mild cleanser. It is help-
ful to label dentures with the client’s name to facilitate identi- Dressing
fication of the dentures in the event that the client is admitted Dressing may be difficult for clients who have restricted joint
to a hospital or an assistive care setting. movement, paralysis, or limited endurance because of health
problems. Many choices are available to ease dressing, such
Grooming as elastic waists, Velcro fasteners, and assistive reaching and
Good grooming is important in promoting the older client’s dressing devices (Figure 19-5).
self-esteem and confidence. Keeping the hair neat and tidy,
choosing attractive clothing and jewelry, and making deci- Eating
sions about makeup and other personal care practices will all Many older adults are able to maintain the ability to self-feed,
contribute to the older client’s sense of well-being and inde- thereby promoting independence and self-esteem. Neurologi-
pendence (Figure 19-4). cal and musculoskeletal alterations may, however, affect the
Male clients may feel much better with a clean-shaven ability to self-feed. Dysphagia, or difficulty swallowing, may
face. Infection-control principles demand that each razor place the older client at increased risk of choking. A mouth
(either electric or blade) be used for only one individual and check is advisable until it is known that the client is safely
swallowing. Diminished taste sensation affects the desire to
eat. Adding seasonings and herbs to food may improve the
taste. Encourage client to eat dessert after consuming nutrient
dense foods.

Toileting
Toileting habits also change with aging. Bowel elimination
problems can often be prevented as clients age by:
• Ensuring adequate fiber intake (whole grains, fresh fruit)
COURTESY OF DELMAR CENGAGE LEARNING

• Ensuring adequate fluid intake (minimum 1500 mL/day)

• Ensuring regular daily exercise (prescribed by physician)
• Developing regular elimination habits
For the client in the hospital or a long-term care facility,
it is helpful to:
• Maintain previously effective habits such as drinking warm
liquids upon arising
Figure 19-4 Good grooming for the older adult includes • Assist the client to the toilet approximately 30 minutes
choosing personal items such as jewelry and clothing. after eating, to take advantage of the gastrocolic reflex

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652 UNIT 8 Nursing Care of the Client: Older Adult

resistance training can improve muscle strength and muscle

PROFESSIONALTIP size in frail older adult clients. Walking and all other maneuvers
required for ADLs are also beneficial. Individually plan exer-
Bowel Patterns in Older Adults cise programs taking into consideration the older person’s:
• General health status (Figure 19-6)
It is extremely important that caregivers of older
• Physiologic disorders (if present)
adults monitor bowel patterns. Long periods of
• Preference for solidarity or group activity
constipation (>2 to 3 days) should alert caregivers
to the need for interventions to minimize the like-
• Physical environment
lihood of bowel impaction, which can ultimately • Financial status
be life threatening if left untreated. Evacuation
aids such as laxatives, lubricants, stool softeners,
and enemas all have side effects and should thus
Nutrition
For many older adults, cultural heritage, religious rites, ethnic
be avoided if at all possible. Dietary changes or an practices, and family traditions are linked to food. The physi-
exercise regimen should be introduced first. ologic, psychological, sociological, and economic changes of
aging may compromise nutritional status. Older adults must
follow a balanced diet, often with lowered intakes of sugar, caf-
As a result of the physical changes that occur with aging, feine, and sodium. There are no universally accepted dietary
increased frequency of urination may be noted in older adults guidelines specific to older adults. A dietitian can determine
of both genders. It is not uncommon for older adults to self- the needed food intake for a specific individual by taking into
limit fluid intake because of a fear of incontinence. This habit account the individual’s height, ideal weight, activity level, and
is unhealthy and should be discouraged. Assess cases of incon- disease processes.
tinence to determine the cause and type, so that appropriate Older adults need 1,000 mg to 1,500 mg of calcium per
interventions and treatment can be implemented. Timing day for both men and women. Calcium supplements should
the use of prescribed diuretics in the morning rather than the also contain vitamin D to provide for optimal metabolism by
evening can prevent the increased need for urination at night, the body. Calcium supplements should not be taken at the same
which is especially helpful to older clients who are being time as enteric coated medications because drugs containing
treated for congestive heart failure (CHF). calcium dissolve enteric coatings, thus leading to gastric irrita-
tion (Shepler, Grogan, & Pater, 2006). The need for additional
Exercise supplements depends on the older individual’s nutritional
status and ability to maintain an adequate diet. Growing discus-
What was once accepted as the normal deterioration of old sion supports the needs for adequate protein intake, to maintain
age is now considered the result of disuse through sitting and both skin integrity and bone density, and moderate carbohy-
bed rest. Research indicates that high-intensity, progressive drate intake because carbohydrates metabolize to sugars.
It is important to know about community services
designed to help older clients meet their nutritional needs.
Such services include grocery transportation and delivery
services, homebound meals (e.g., Meals On Wheels), group
meals at senior food sites, and the Food Stamp program.
Nurses and caregivers should also realize that socialization and
companionship are necessary components of adequate dietary
intake, and should ensure that these areas are addressed as part
of any food-assistance intervention.

Psychosocial Considerations
Older adults, like all individuals, have psychosocial and
cognitive needs for lifelong learning. Many colleges have

PROFESSIONALTIP
COURTESY OF DELMAR CENGAGE LEARNING

Iron
When iron is prescribed for an older adult, encour-
age taking with foods and fluids containing vitamin
C to assist with iron absorption. A common side
effect when taking iron is constipation. Clients may
stop taking iron because of this problem. Therefore,
it is important to ask clients about the constipating
Figure 19-6 Exercise is important to all clients and should factor when reviewing their medications.
be tailored to interests and ability levels.

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 CHAPTER 19 The Older Adult 653

developed education program options for older adult students may be delayed by the physician depending on the client’s risk
(often at no tuition), and employers are beginning to recruit factors. If a client’s Pap smears have been negative (normal)
older workers for part-time positions (recognizing their his- for 5 consecutive years, they can be done less often. Men and
torically good work ethic and experience). Many older adults women older than age 50 should have a yearly stool test for
continue to volunteer countless hours each year, offering to occult blood performed. A colonoscopy may be recommended
help meet the social service needs of their communities. These to monitor for colon cancer. Teach clients habits for healthy
efforts can result in feelings of productivity and self-worth for living and inform them of signs and symptoms that require
the older adult. Mental activity and emotional involvement medical investigation. Older clients who have been exposed
are as necessary to the overall well-being as is physical activity. to environmental chemicals, tobacco, or extensive alcohol use
Older clients can benefit from building on their long-practiced over many years often experience serious health consequences
skills to develop interesting and stimulating activities or hob- as they reach older age. Older clients of any age can benefit
bies. Such activities may be of an individual or group nature. from healthy lifestyles and from disease-prevention interven-
Socialization with people of all age groups can help not only tions, such as being inoculated yearly against influenza and
the older participants, but also the young and middle-aged every 5 years against pneumonia, assessment of tuberculosis
participants, by illustrating that aging is not a disease but (TB) status, and adequate safe food and clean water intake.
rather, a rich and natural part of the life process. In many cases, by the time a person reaches 65 to 70 years
of age, that person has been prescribed medication to address
Strengths at least one ongoing (chronic) medical problem (e.g., hyper-
tension, heart disease, diabetes, allergies, gastrointestinal dis-
Older adults generally have experienced many losses over the orders). The challenge many older adults face is that side
years. Some losses are slight and require only minor adap- effects from one medication are often treated with another
tation, whereas others may significantly affect the person. prescription medication. If the client then goes to different
Physiologic changes or disease processes may result in losses, doctors, these doctors may prescribe even more medications
causing impairments in: to address the same or other health concerns. This is called
• Communication polypharmacy, or the problem of clients taking numerous
prescription and over-the-counter medications for the same
• Vision and learning
or various disease processes, with unknown consequences
• Mobility from the resulting combinations of chemical compounds and
• Cognition cumulative side effects. In many settings, primary care provid-
• Psychosocial skills ers, nurses, clinical pharmacists, and social workers collaborate
If the impairment is severe, the individual could lose some to assist the older client and the family to oversee the client’s
degree of independence, and adaptations may be required. medication management and other health needs.
Furthermore, losses can cascade for the older client, as one loss Among the biggest challenges facing older clients are shorter
contributes to another. For example, if an older adult with dia- hospitalization stays and reduced time with physicians in the
betes were to lose her driver’s license because of impaired vision physician’s offices. There is less time to ensure that the follow-up
related to diabetic retinopathy, socialization might be restricted, services the client will need are understood and in place and less
which in turn might increase her feelings of loneliness and time to educate client and family about medication regimens,
diminished self-esteem. If, however, her spouse provides care- including timing and possible interactions with other prescrip-
giving and transportation, these adaptations might allow her tion and over-the-counter drugs or herbal remedies that the cli-
to remain active socially while still living in her home. If her ent may also be taking. The nurse, as part of the interdisciplinary
spouse later dies, and her health continues to decline, a move to team, plays a vital role as client advocate when ensuring that older
an assisted-living facility may become necessary, if other com- clients have the teaching, services, and follow-up care they need.
munity adaptations are unavailable. She would then be faced Figure 19-7 is a concept map that discusses safe nursing consider-
with adapting to the loss of both her home and her spouse. ations when administering a medication to an older adult.
Health-care professionals should remember that persons
who have lived for many years are survivors and can adapt to life
changes better if they are allowed to use their existing strengths. PHYSIOLOGIC CHANGES
They are often much stronger and more ingenious and enterpris-
ing than they are given credit for. Identify the strengths of each
ASSOCIATED WITH AGING
individual (including past coping skills) and use them when Although the aging process brings with it many physiologic
planning care and assisting the older client to find new ways to changes, it should be remembered that aging and disease are
adapt and maintain optimal independence in a new setting. not synonymous. Whereas the physiologic changes of aging

Health Promotion and CRITICAL THINKING

Disease Prevention Polypharmacy
Older adults must be alerted to ways of preventing disease
and reducing risks. Being knowledgeable about self-care and You are caring for a client who is suffering from
participating in screening tests are important for health main- the effects of polypharmacy. What interventions
tenance. For older men, an annual prostate examination and will you discuss with this client to prevent future
a prostate specific antigen (PSA) level lab test, which can polypharmacy problems?
detect prostate cancer in the early stages, are recommended
every 1 to 2 years. For older women, the annual mammogram

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654 UNIT 8 Nursing Care of the Client: Older Adult

PROFESSIONALTIP
Identifying Strengths of Older Adults as Part of Assessment
Assessment should include the identification of • History of relinquishing roles as phases of life
strengths as well as problems. Strengths are utilized require and replacing them with satisfying new
to achieve or maintain optimal physical, mental, and roles
emotional function. All of the following can be • A pattern of successful mourning for losses
considered strengths: • Participation in groups: religious, spiritual,
• Cognitive health community, hobbies
• Freedom from or successful adaptation to deficits • Membership in family whose members respect
or impairments each other and are willing to give and receive
• A history of healthy lifestyle with regard to diet, help when necessary
sleep, stress management, exercise, and chemical • Successful problem-solving skills
abuse (none)
• Willingness to seek information to improve
• Adequate functional ability to carry out ADL situation
• Freedom from incapacitating physical discomfort • Evidence of initiative and self-confidence in
and pain abilities and judgment
• A physically safe living environment • Participation in self-care by making decisions and
• Feelings of security in present environment accepting responsibility for decisions
• Realistic knowledge about capabilities • Acceptance of that which cannot be
• Pattern of avoiding dangerous situations and changed
unnecessary risks • Successful use of assertive skills
• Compliance with health care regimen • Ability to find comfort and strength in spiritual
• Capability with regard to managing own and religious practices
environment • Appreciation for aging, with demonstrative
• An intact support system embrace of the positive aspects and adaptation
• Satisfying relationships with others to the negative aspects
• Opportunities for sexual expression • Participation in healthy reminiscing; evidence of
• Access to transportation few regrets about life past
• Adequate functional mobility • Appreciation for nature, art, music, hobbies, and
activities
• Successful adaptation to life changes and
crises • A sense of humor

described in the following sections are normal for most people, curve of the spine) can decrease diaphragmatic expansion.
the medical disorders described are not considered normal. Kyphosis in older clients can lead to a need for small, more
Older adults age at different rates. The following aging changes frequent meals to balance nutritional requirements and
for each system may not occur until late in the aging process. respiratory function because of the restriction of adequate
space for expansion and contraction of the diaphragm. It
Respiratory System can also create skin integrity risks because the bony promi-
nences of the client’s back press against the backs of chairs.
The following respiratory changes result from the aging process: Common respiratory disorders related to aging include
• Calcification of the rib cage and less flexible respiratory the following:
muscles may lead to a barrel chest and decreased vital • Respiratory tract infection (RTI)
capacity of the lungs.
• Chronic obstructive pulmonary disease (COPD)
• Decrease in functional capacity results in dyspnea on exer-
tion or stress; usual activity does not affect breathing. • Pulmonary tuberculosis (TB)
• Decreased ciliary action and a less effective cough mecha- Nursing Management: Respiratory Tract
nism increase the risk for lung infection.
• The alveoli thicken and decrease in number and size, Infections
causing less effective gas exchange (decreased oxygen 1. Encourage discussing the pneumovaccine with the pri-
saturation) and, in individuals who also have chronic lung mary care provider.
disease, intensifying respiratory deficits. 2. Encourage obtaining annual influenza vaccine.
• Structural changes in the skeleton, such as kyphosis (seen in 3. Assist the client to assume a position of comfort and assist
clients with osteoporosis as an often asymmetrical convex with medications and respiratory treatments, as ordered.

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 CHAPTER 19 The Older Adult 655

Cognitive Changes Dry Mouth

High Fowler’s when possible for oral drugs. Offer fluid before and during oral medication
Check two client identifiers before giving drugs. Decreased Hand Dexterity administration.
Mouth check with flashlight and tongue blade Provide adequate time for client to be Use nutritious liquids from meal tray, when
for retained drug when appropriate. independent. administering oral drugs.
Upright 30 minutes after oral drugs. Use medication cup for handing oral Avoid grapefruit juice, because it may affect
Validate subjective information from client drugs to client. the absorption of many oral drugs (toxicity).
correlates with the objective documented Have water/fluid prepared in an easy-to- Unless told otherwise by client, administer
information before administering drugs handle container. one oral drug at a time.
which require client data. (Ex. # BM’s) Ask if oral drugs were swallowed completely.
Monitor client for side effects which may
not be reported.

Decreased Skin Elasticity/Muscle Mass Decreased Sensation to Pain/

Use largest well developed muscle for IM Pressure
injections. Assess intravenous site every hour.
Give IM by Z-track to prevent oozing.
Older Adult
Assess old injection sites for irritation.
Clean drug off of skin, if oozing Medication Administration Upright for 30 minutes after oral drugs.
occurred, to prevent irritation. Mouth check with flashlight and tongue
blade for retained drug, when appropriate.

Decreased Cardiac Output

Assess intravenous rate every hour.
Monitor for signs and symptoms of fluid
overload such as abnormal lung sounds,
shortness of breath, and weight gain.
Investigate a 2 lb. weight gain in one
Decreased Immune Function day. A weight gain of 2½ Ibs. =1 L of Cultural Considerations
When administering multiple drugs at the same fluid. If drug effect needed immediately, Assess for use of traditional and folk
time, go from drugs requiring sterile technique use intravenous route when ordered. practices.
to drugs only needing clean technique. Slowed absorption, distribution and With the physician’s permission,
Wash hands before drug administration, during elimination from decreased blood flow incorporate harmless non-conflicting
drug administration as needed, and after drug cultural practices into the client’s care.

COURTESY OF DELMAR CENGAGE LEARNING

may result in drug toxicity. Change in
administration. mental status, appetite, or coordination Metabolism of drugs may vary by
Atypical signs and symptoms of infection may be the first sign of drug culture, so monitor for side effects
happen in the older adult. Change in mental accumulation. Avoid injections in an carefully.
status frequently occurs first. immobile extremity because this further
reduces drug absorption rate. Use the
smallest possible dosage when given a
prescribed range for an injectable drug.

Figure 19-7 Concept Map: Safe Administration of Medication to an Older Adult

4. Avoid distention of bowel, bladder, or stomach, any of Nursing Management: Chronic

which can increase breathing discomfort.
5. Allow adequate time for nursing care.
Obstructive Pulmonary Disease
6. Administer humidified oxygen therapy, as prescribed. 1. Assist the client to a position of comfort.
7. Administer analgesics and antipyretics, as prescribed. 2. Teach the client to use pursed-lip breathing to avoid
hyperventilation when short of breath.
8. Assess for signs of dehydration and ensure that fluids are
accessible to the client, unless contraindicated. 3. Teach the client diaphragmatic breathing for use when
active.
9. Review diagnostic data and monitor lung sounds and
intake and output every 8 hours or as needed given 4. Teach proper use of inhalers. Steroid inhalers should be
changes in the client’s condition. Weigh the client daily, used first, with a full 60-second wait between puffs; after
assessing for fluid retention. waiting 5 minutes, any bronchodilator inhalers that are
prescribed should then be used, also with a 60-second
10. Monitor for any signs of respiratory distress (cyanosis of wait between puffs.
lips, mucous membranes, or nailbeds) and obtain pulse-
oximetry readings, as needed. 5. Teach the client to cough and clear the airway.

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656 UNIT 8 Nursing Care of the Client: Older Adult

6. Administer chest physiotherapy (e.g., percussion, pos-

tural drainage), if prescribed. PROFESSIONALTIP
7. Establish a schedule for ambulation, gradually increas-
ing the distance ambulated. Chronic Obstructive Pulmonary
8. Assist with active assistive range-of-motion exercises. Disease
9. Monitor for signs and symptoms of infections (e.g., fever,
Remember that in the client with COPD, breathing
blood-tinged or thick, greenish colored sputum, and
diminished lung sounds) and immediately report same may not be triggered by a higher level of carbon
to the registered nurse and the primary care provider. dioxide as it is in clients without COPD, because
10. Monitor breathing and pulse rate and administer oxy- the client with COPD always has a consistently high
gen, if necessary, during periods of increased activity. CO2 level. The breathing impulse is instead trig-
11. Suggest smoking cessation programs, if the client is a gered by a low level of oxygen. Increasing the oxy-
smoker. gen level by more than 1 to 2 L/h in the client with
COPD can shut down the trigger to breathe, and
can put the client in respiratory failure.
Nursing Management: Pulmonary
Tuberculosis
1. Monitor clients for TB status and for symptoms includ- CRITICAL THINKING
ing fever, night sweats, weight loss, and cough produc-
ing blood-tinged sputum. Chronic Obstructive Pulmonary
2. Inform the client, family, and caregivers of the need for Disease
adequate isolation techniques.
3. Evaluate the client’s risk for infection with the human A 69-year-old client with COPD was given some
immunodeficiency virus (HIV) and related pneumo- stressful news by a relative 1 hour ago. Now, the
cystic pneumonia.
client reports that he can’t breathe. He wants his
4. Monitor that the client’s psychosocial needs are being ade- nasal oxygen turned up. What physical respiratory
quately met while the disease is being pharmacologically
assessment data will you collect? List the interven-
tions that you will perform to assist the client to
SAFETY breathe easier.

Oxygen and Smoking

Ensure that no smoking is allowed around clients addressed with medications like isoniazid (Laniazid). Tell
on oxygen therapy. the client and family that the entire course of medication
must be completed.
5. Monitor the client’s nutrition intake and provide supple-
ments as necessary to maintain adequate body weight.
6. Provide for rest periods throughout the day. Encourage
the older client with TB to monitor activity level and
PROFESSIONALTIP length of visits by family so as not to become overtired.

TB in the Older Adult

Cardiovascular System
Older adults can be vulnerable to TB because of: The following cardiovascular changes result from the aging
• An ineffective cough reflex and the resulting process:
inability to clear the lungs.
• Left ventricle and heart valves become fibrotic leading
• An altered immune system and a reduced to decreased cardiac output and slowed recovery time.
response to extrinsic antigens. Not only are older
adults at increased risk of infection via a new
contagion, but older clients who contracted INFECTION CONTROL
TB years ago and have been in remission since
can experience reexacerbation. The risk of TB
reexacerbation increases in cases where the initial Remember that TB is spread through droplets
infection was remote and healed (encapsulated) when a client sneezes or coughs (direct and indi-
such that the immune system’s memory of the rect contact). Consult the infection-control nurse
T cells has been lost. Facilities where health on the client’s interdisciplinary team and work to
care is provided to older clients and to immune- protect the client and others from transmission of
compromised clients thus must regularly assess the Mycobacterium tuberculosis and other infections.
TB status of both their clients and their employees.

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 CHAPTER 19 The Older Adult 657

The heart requires more time to return to a normal rate

after a rate increase in response to activity.
CLIENTTEACHING
• The heart rate slows. Dysrhythmias are more common.
• Blood flow to all organs decreases. The brain and coronary Digoxin Toxicity
arteries continue to receive a larger volume than do other Possible signs and symptoms of digoxin toxicity
organs.
include the following:
• Arterial elasticity decreases (arteriosclerosis), causing • Disturbances in cardiac rhythms
increased peripheral resistance and, in turn, a rise in systolic
blood pressure and a slight rise in diastolic blood pressure. • Fatigue
• Veins dilate, and superficial vessels become more prominent. • Listlessness
Common cardiovascular disorders related to aging • Anorexia
include the following: • Nausea
• Peripheral vascular disease (PVD) • Visual disturbances (halos around lights)
• Hypertension • Shaking
• Chronic CHF • Unsteady gait
• Confusion
Nursing Management: Peripheral Vascular
Disease
1. Assess the lower extremities, including the peripheral immediately contact the registered nurse and the physi-
pulses, for signs of arterial or venous insufficiency, such cian if abnormal serum level or signs and symptoms of
as cool pale skin and decreased sensation. toxicity are present.
2. Evaluate lifestyle factors that may aggravate or advance 2. Take the apical pulse for a full 1 minute before admin-
atherosclerosis, such as a high-carbohydrate, high-fat istering digoxin. Withhold the medication if the apical
diet and little exercise. pulse is below 60, and consult the registered nurse and
3. Teach the client about the disease, including treat- the physician if this or any other significant changes in
ment, medication actions and side effects, and signs of vital signs are noted.
thrombosis. 3. Monitor the client’s blood pressure and lung sounds.
4. Educate the client and caregivers about the care and 4. Monitor electrolyte levels, blood urea nitrogen (BUN),
inspection of the lower extremities. and creatinine level to observe system changes includ-
5. Provide instructions on interventions specific to the cli- ing decreased kidney efficiency.
ent’s type of PVD (arterial or venous). 5. Monitor for signs of fluid retention such as intake and
output (output too small), weight gain, shortness of
Nursing Management: Hypertension breath, coughing, and edema.
1. Evaluate food intake patterns, especially of cholesterol, 6. Encourage alternating periods of activity with periods
fats, sodium, and carbohydrates. Make recommenda- of rest.
tions based on findings. 7. Encourage the client to maintain a level of exercise/
2. Evaluate for fluid retention. Weigh the client daily. physical activity appropriate to physical condition.
Investigate a weight gain of 2 lbs. in one day. 8. Teach the client and family about the safe use of the
3. Recommend a smoking-cessation program, if necessary. prescribed medications.
4. Teach the client the importance of avoiding alcohol use. 9. For clients on diuretics, which deplete potassium,
5. Recommend and facilitate a consistent and appropriate monitor fluid intake and level of potassium, ensuring
exercise program. adequacy of each. Encourage administration of diuret-
ics early in the day, unless contraindicated, to prevent
6. Discuss the relationship of stress to hypertension and increased urination at night.
provide resources from which the client can learn relax-
ation techniques.
7. Provide information on medications and the impor- Gastrointestinal System
tance of taking daily blood pressure medications as The following gastrointestinal changes result from the aging
prescribed, regardless of health status on any given day. process:
8. Arrange for and encourage regular blood pressure • Tooth enamel thins.
checks and teach the client or significant others proper • Periodontal disease rate increases.
use of blood pressure equipment, if applicable.
• Taste buds decrease in number and sense of smell
decreases. Saliva production diminishes leading to a dry
Nursing Management: Chronic mouth.
Congestive Heart Failure • Effectiveness of the gag reflex lessens, resulting in an
1. Frequently monitor serum digitalis level and monitor increased risk of choking.
for any signs of digoxin toxicity, for which older clients • Esophageal peristalsis slows, and the effectiveness of the
are at increased risk because of the decreased rate of esophageal sphincter lessens, causing delayed entry of food
renal clearance of the drug. Withhold the digoxin and into the stomach and increasing the risk of aspiration.

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658 UNIT 8 Nursing Care of the Client: Older Adult

• Hiatal hernia may occur. intake to bladder infections and arrange for assis-
• Gastric emptying slows. Food remains in the stomach tance, as needed, for toileting.
longer, decreasing the capacity of the stomach. 3. Identify the reasons for any excessive fluid output and
• Peristalsis and nerve sensation of the large intestine treat accordingly.
decreases, contributing to constipation.
• The incidence of diverticulosis increases with age. Nursing Management: Dental Disorders
• Liver size decreases after age 70. 1. Teach the oral hygiene procedures of brushing and
• Liver enzymes decrease, slowing drug metabolism and the flossing, and facilitate and encourage brushing of the
detoxification process. teeth and gums and flossing of the teeth, as tolerated.
• Emptying of the gallbladder lessens in efficiency, result- 2. Inspect the mouth regularly for signs of dental disorders.
ing in thickened bile, increased cholesterol content, and 3. Encourage fluids to assist with salivary secretions and
increased incidence of gallstones. reduction of bacterial growth.
Common gastrointestinal disorders related to aging 4. Advise regular dental checkups.
include the following:
• Over-/undernutrition
• Constipation
• Dehydration PROFESSIONALTIP
• Dental disorders
Determining Alterations in Nutrition
Nursing Management: Over-/ • Height and weight: Record actual body weight,
Undernutrition usual body weight, and ideal body weight. If
1. Assess nutritional status. usual weight has varied significantly from the
2. Provide nutritional instruction based on assessment ideal for several years, the use of height/weight
findings. tables may be meaningless. Compare actual
3. Recommend and discuss community nutrition pro- body weight to usual body weight to determine
grams (e.g., Meals On Wheels, senior center food sites, present status.
food pantries, and Food Stamp program). • Review laboratory values: hematocrit, hemoglobin,
4. Small, frequent meals may be more tolerable. total iron-binding capacity, total protein, BUN.
5. Maintain client in upright position for several hours • Determine whether client is on a weight-loss
after each meal to reduce the risk of aspiration. diet.
• Determine whether client was edematous when
Nursing Management: Constipation initially weighed and has lost weight with
1. Assess food and fluid intake. treatment.
2. Make recommendations based on assessment findings • Evaluate cognitive status. Cognitively impaired
(e.g., increase fiber intake, increase fluid intake).
clients may be unaware of hunger or be unable
3. Discuss the relationship of exercise to bowel activity. to attend to the task of eating.
4. Discuss the importance of routine for regular bowel
• In clients with central nervous system damage,
elimination.
evaluate the presence of sensory–perceptual
5. Teach the importance of avoiding the overuse of laxa-
deficits that interfere with eating.
tives. Frequent use leads to dependency.
6. Monitor adequate bowel elimination and provide inter- • Evaluate ability to pick up utensils and glasses
ventions (e.g., prune juice, senna bars, milk of magnesia, and to get items from table to mouth.
as ordered) to assist the client in returning to a normal • Evaluate dental/oral status: status of teeth/
bowel elimination routine. dentures, gums, presence of oral dryness
(xerostomia).
Nursing Management: Dehydration • Determine presence of impaired swallowing.
1. Identify the reason for dehydration (e.g., inadequate • Determine whether client has distaste for
fluid intake or excessive fluid output). certain food groups.
2. Identify the reason and corresponding interventions for • Assess knowledge in regard to nutrition and
inadequate fluid intake:
food purchase and preparation.
• Fluids are inaccessible because of the client’s • Determine whether client is taking medications
physical limitations: offer fluids on a regular basis that interfere with taste or food absorption.
throughout the day.
• Determine whether financial status interferes
• The client dislikes water or other available fluids:
identify fluid choices. with food purchasing.
• The client restricts fluids because of a fear of incon- • Evaluate for history of compulsive eating.
tinence: explain the relationship of decreased fluid

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 CHAPTER 19 The Older Adult 659

• Bladder and perineal muscles weaken, resulting in the

inability to empty the bladder and predisposing the older
client to cystitis.
Nutritional Status • Incidence of stress incontinence increases in older
females.
Evaluate the following when assessing a client’s • The prostate may enlarge in older males, causing urinary
nutritional status in the home: frequency or dribbling.
• Ability to shop for and prepare meals Common urinary disorders related to aging include the
• Mealtime environment, for unpleasant odors, following:
noises, and visual stimuli • Incontinence
• Table setting, for appealing table cover, • Urinary tract infections (UTIs)
centerpiece, colorful dishes
• Appropriateness of food storage system Nursing Management: Incontinence
(cabinets, refrigerator, freezer) 1. Complete an assessment for bladder management
(Figure 19-8).
2. Identify the type of incontinence present (Table 19-2).
Urinary System 3. Implement an appropriate bladder management pro-
gram (Table 19-3).
The following urinary changes result from the aging process: 4. Frequently monitor for skin impairment.
• Nephrons in the kidneys decrease in number and function, 5. Offer absorbent incontinent pads or briefs that draw the
resulting in decreased filtration and gradual decrease in moisture away from the skin.
excretory and reabsorption functions of the renal tubules.
6. Teach all caregivers, the client, and the family the
• Glomerular filtration rate decreases, resulting in decreased importance both of adequate cleansing of the genital
renal clearance of drugs. By age 75, renal blood flow area (proper retraction, cleansing, and replacement
typically diminishes by 40% (Shepler, Grogan, & Pater, of the foreskin in the uncircumcised male and proper
2006). cleansing of the skin folds of the female), legs, and back
• Blood urea nitrogen increases. The creatinine clearance and of the use of clean linens, to ensure that the client’s
test is a better indicator than is BUN of renal function in skin is kept clean and dry. Apply a moisture barrier
older adults. cream as needed to prevent skin maceration from exces-
• Sodium-conserving ability diminishes. sive exposure to moisture.
• Bladder capacity decreases, causing increased frequency of 7. Teach and employ effective infection-control techniques
urination, including nocturia. (e.g., wipe and clean [from front to back only] after toi-
• Renal function increases when the older client lies down, leting and when bathing).
sometimes causing a need to void shortly after going 8. Instruct client to avoid bladder irritants such as caffeine,
to bed. spicy foods, and alcohol.

To be completed and reviewed every 90 days or as frequently as needed based on outcome and response.
CLIENT__________________ Adm No. _________ Date____________ Diagnoses_______________ Birthdate_______
Bladder function: History of infection or other urinary problem.____________________________ Urinalysis: Date_________
Protein___ Glucose__ Ketones__ RBC__ WBC__ Bacteria__ Crystals__ Sp.Gr.__ Culture: Date_____ Result_______
Treatment________
BUN___ Ser.Creatinine___ Tot.Pro.___ FBS___ To be completed after 2-week assessment period.
Frequency of voiding______ Average amount______ Is client aware of need to void?____ Urgency?____ Dribbling?____
Incontinence preceded by laughing, sneezing_____
Medications affecting bladder function/continence_____________________________________________
Mental status: Short-term memory__________ Orientation__________ Able to express self__________
Able to follow directions__________ Reaction to incontinence__________
COURTESY OF DELMAR CENGAGE LEARNING

Hydration baseline: Daily average fluid intake: Days______ Eve.______ Night______

Mobility/self-care skills: Ambulatory/self______ Cane______ Walker______ Requires assist of one or two______
Weight-bearing______ Propels self by w/c______ Transfers self______ Requires assistance______
Can manage clothing______ Cleanses self after toileting______ Washes hands______

Figure 19-8 Assessment for Bladder Management

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660 UNIT 8 Nursing Care of the Client: Older Adult

Table 19-2 Types of Urinary Incontinence

TYPE CHARACTERISTICS
Functional Bladder emptying is unpredictable but complete. Incontinence is related to impairment of cognitive,
physical, or psychological functioning or to environmental barriers.
Urge Incontinence occurs immediately after the sensation to void is perceived.

COURTESY OF DELMAR CENGAGE LEARNING

Reflex Incontinence is related to neurogenic bladder and central nervous system or spinal cord injury. Bladder fills,
and uninhibited bladder contractions cause loss of urine.
Stress Increased abdominal pressure is higher than urethral resistance. Stress associated with coughing or
laughing causes incontinence.

Total Unpredictable, unvoluntary, continuous loss of urine.

9. Encourage referral to discuss medical options (in of indwelling catheter), to prevent unnecessary intro-
addition to nursing interventions) for treatment of duction of bacteria into the bladder.
incontinence. 5. Teach female clients to wipe from front to back only;
10. Allow the client to voice concerns over incontinence cleanse thoroughly after bowel movements; avoid bub-
and assist to overcome any adverse effects on psychoso- ble baths, colored toilet paper, douches, and vaginal
cial functioning. sprays; and wear underwear made from cotton rather
than synthetic fibers.
6. Teach the client and caregivers that hematuria (blood
Nursing Management: Urinary Tract in the urine) and fever indicate the need for immediate
Infections assessment and intervention, as these signs and symp-
NOTE: Older persons frequently do not present with the toms can signify a potentially serious infection or condi-
usual signs and symptoms of urinary tract infections. Falling tion. Any signs and symptoms of bladder infection should
or signs of acute confusion (more than usual) often are the be immediately reported to the registered nurse and the
major clinical manifestations. physician.
1. Monitor fluid intake and output. Increase intake unless
contraindicated. Offer cranberry juice frequently, per
ordered diet. Musculoskeletal System
2. Teach and encourage client to empty the bladder every The following musculoskeletal changes result from the aging
3 to 4 hours. process:
3. Encourage the client to take all medication as pre- • Muscle mass and elasticity diminish, resulting in decreased
scribed. strength, endurance, coordination, and increased reaction
4. Use proper infection-control techniques to minimize time.
the risk of infection, including maintaining sterile tech- • Bone demineralization (osteoporosis) occurs, causing
nique for any urinary catheterization procedure (for skeletal instability and shrinkage of intervertebral discs.
urinalysis, assessment for bladder retention, or insertion The flexibility of the spine lessens, and spinal curvature

Table 19-3 Bladder Management Techniques

PROGRAM DESCRIPTION
Kegel exercises Used for stress incontinence in cognitively alert persons. Exercises strengthen pelvic floor
musculature.
Scheduled toileting Client is on a fixed schedule of toileting—usually every 2 hours. Technique can be used to facilitate
voiding and emptying of the bladder.
Habit training Client is toileted according to individual pattern of voiding. Several days must be spent assessing
pattern.
COURTESY OF DELMAR CENGAGE LEARNING

Bladder retraining Restores normal pattern of voiding/continence. Requires accurate assessment before establishing
schedule with progressive shortening or lengthening of toileting intervals. Client must be cognitively
alert.

Prompted voiding Client is prompted to toilet at regular intervals and is given social reinforcement for appropriate
toileting behavior.

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 CHAPTER 19 The Older Adult 661

(kyphosis) often occurs. Height may decrease 1 to 4 inches 5. Encourage the client to seek ongoing evaluation by the
throughout the aging process. physician, as new arthritis medications such as celecoxib
• Joints undergo degenerative changes, resulting in pain, (Celebrex) are continually being developed and trialed.
stiffness, and loss of range of motion.
Common musculoskeletal system disorders related to Nursing Management: Fractured Hip
aging include the following: NOTE: Nursing interventions may vary depending on
• Osteoporosis whether the older client has an open reduction/internal fixa-
tion fracture (ORIF) or total hip arthroplasty (THA).
• Osteoarthritis 1. Maintain postoperative positioning as appropriate to
• Fractured hip the client’s form of treatment.
2. Provide adequate pain control before physical therapy and
Nursing Management: Osteoporosis on an ongoing basis throughout the recovery process.
1. Make dietary recommendations to ensure adequate 3. Prevent complications, including skin breakdown, RTIs,
intake of calcium, protein, and vitamin D. infections at the surgical site, and dislocation of the
2. Recommend a smoking cessation program, if necessary. prosthesis or internal fixation device.
3. Teach the client the importance of avoiding alcohol. 4. Facilitate and monitor with the registered nurse the
4. Encourage the client to take a calcium supplement in client’s consistent use of antiembolism stockings as
conjunction with vitamin D, as ordered by the client’s ordered and the administration of anticoagulant medi-
primary care provider. cations and the related monitoring of lab values, to
decrease the risk of pulmonary embolism (which can be
5. Recommend consultation with the primary care pro- a significant risk to older clients after hip fracture and/
vider regarding bone-density testing and to discuss or hip replacement).
estrogen replacement therapy (ERT) options for females
or the use of medications like alendronate sodium 5. Teach the client about fall prevention. Evaluate the cli-
(Fosamax) and ibandronate (Boniva) to address bone ent’s environment (home, room, bathroom) for safety
density loss associated with osteoporosis. with regard to mobility and make recommendations for
rectifying any threats to safety.
6. Teach the client, family, and caregivers about measures
to reduce the risk of falling and sustaining fractures.
7. Recommend evaluation (x-ray) for the presence of Neurological System
stress, or compression, fractures of the spine in cases of The following neurological changes result from the aging
severe back pain that occurs with or without a fall. In cli- process:
ents with osteoporosis, these fractures can occur more • Neurons in the brain decrease in number, resulting in
easily because the vertebrae are compacted by shrinkage decreased production of neurotransmitters and, thus,
of the intervertebral spaces as a consequence of aging. reduced synaptic transmission.
8. Provide adequate pain control for back pain or other
musculoskeletal discomfort.
9. Monitor for adequate dietary intake of calories and CRITICAL THINKING
fluids and for effective elimination patterns.
10. Teach, encourage, and assist clients to establish exercise
Home Safety
programs appropriate to their capabilities. Especially
promote exercise programs that include walking or Your 65-year-old grandmother tells you that she
other weight-bearing activities, as tolerated. is planning to build a new home. She has been
researching and gathering information about
Nursing Management: safety measures to include in her new home for
people over age 60. She wants reassurance that
Osteoarthritis her money is going to be well spent and asks you
1. Suggest a schedule for alternating periods of activity what are important safety measures to consider.
and rest.
Share pertinent information about the following
2. Recommend a weight-reduction plan, if necessary, to along with rationale.
eliminate extra strain on affected joints.
1. Location of home (country versus town)
3. Teach, assist, and encourage the client to establish an
exercise program that emphasizes gentle stretching and 2. One- versus two-story home
movement of all joints. For those clients who are more 3. Paint colors to use
independent, exercise programs in warm water can have 4. Gas versus electric appliances and heat
positive outcomes. 5. Type of door knobs for opening doors
4. Provide adequate pain control. Teach clients and
6. Type and location of alarms
caregivers to monitor for gastrointestinal distress
related to arthritis medications such as nonsteroidal 7. Location of lighting
anti-inflammatory drugs (NSAIDs) and to be aware that 8. Location for grab bars/railing
enteric-coated medications cannot be crushed because 9. Type of flooring
they are designed to protect the stomach by dissolving
in the duodenum.

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662 UNIT 8 Nursing Care of the Client: Older Adult

dently or as an exacerbation of a current dementia-related

PROFESSIONALTIP disorder in the client. Acute confusion can result from
many stresses such as infections, medication side effects,
Neurological System in the drug interactions, metabolic imbalances, dehydration, or
Older Adult injuries from falls (e.g., subdural hematomas). Elimination
of the causative factor can often turn the acute confusion
In the absence of pathology, intellect and capacity around in a relatively short period to the preexacerbation
for learning remain unchanged with aging. level of functioning, unless further pathology to the brain
has occurred.

• Cerebral blood flow and oxygen utilization Nursing Management: Alzheimer’s

decrease.
• Time required to carry out motor and sensory tasks Disease
requiring speed, coordination, balance, and fine-motor 1. Before diagnosis, encourage a medical and psycho-
hand movements increases. Incidence of slight tremors logical diagnostic workup including a mental status
is common. examination.
• Short-term memory may somewhat diminish without 2. Facilitate orientation in the early stages of the disease
much change in long-term memory. with calendars, lists, and consistent schedules.
• Night sleep disturbances occur because of more frequent 3. Arrange an environment that is therapeutic, consistent,
and longer wakeful periods. calm, and safe and that alternates rest with activities that
• Deep-tendon reflexes decrease, although reflexes at the require the use of long-practiced skills.
knees remain fairly intact. 4. Encourage and facilitate access for the client and fam-
Many disorders that affect the neurological system are not ily to support groups where they can independently
unique to older adults; however, the risk of acquiring one of share their feelings and concerns and have questions
these disorders increases with age. One of the most common addressed.
diagnoses among older adults in long-term care facilities is 5. When assistance is needed with ADLs, implement
dementia, particularly one form of dementia called Alzheim- consistent routines with consistent caregivers but
er’s disease (AD). Dementia is an organic brain pathology allow for delay of care if needed because of client
characterized by losses in intellectual functioning. The clinical stress or irritability. Encourage independence of the
manifestations associated with dementia are never considered client while assisting with ADLs (e.g., offer a warm
normal aging changes. washcloth for client to wash the face and assist with
It is important for care providers to assess the length of those ADLs that the client cannot complete without
onset of confusion or cognitive changes in the client. Gen- assistance).
erally, dementia describes declines that have a slow onset of 6. Monitor general health status. Treat any underlying
greater than 6 months, whereas delirium (or acute confu- medical problems. Provide adequate pain control, as
sion) describes cognitive changes that have a shorter onset needed, and monitor for lack of sleep to minimize the
of 6 months or less. Acute confusion can occur indepen- risk of violent behavior. Observe for the client’s better
times of the day, and plan activities or interventions
accordingly.
7. Build a trusting relationship with the client. Use clear,
PROFESSIONALTIP simple directions and treat clients with respect and as
individuals, building on their strengths and their unique
Mental Health in the Older Adult interests and histories. Doing so demonstrates appre-
ciation for the individual and can help build the client’s
Mood disorders including depression, bipolar self-esteem.
disorder, anxiety disorders, late-onset psychosis, 8. Be aware that as much is communicated to the AD cli-
sleep disorders, substance abuse, schizophrenia ent through the caregiver’s nonverbal behavior and tone
(chronic and late-onset), and other psychiatric and volume of voice as is communicated through actual
diseases certainly occur among older clients and words. A calm attitude allows the client time to process
often go unaddressed or are ineffectively treated. and retrieve information when spoken to or asked a
Appropriate assessment, treatment, and clinical question.
management of these clients require effective 9. Support the client’s mobility within a safe environ-
interdisciplinary teams comprising a geriatric ment, recognizing that as the disease progresses,
psychiatrist; a neurologist; a clinical nurse specialist
baseline wandering often increases as a coping skill,
whereas verbal communication often decreases. Bean-
specializing in gerontology and mental health; a
bag chairs, low mattresses, bed and chair alarms, posi-
licensed social worker; a clinical pharmacist; other tional (antisliding) wedges for chairs, merry walkers
multidisciplinary team members (including direct that support independent mobility, and assisted-ambu-
care nurses and staff and activity therapists); and lation programs to build leg strength are all therapeutic
the client’s family and, whenever possible, the interventions for AD clients as the disease progresses
client. and represent preferable alternatives to the use of
restraints.

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 CHAPTER 19 The Older Adult 663

10. Monitor for changes in baseline behaviors and for intensity

of wandering, pacing, and lethargy, as these often indicate
underlying infections, metabolic imbalances, or stress.
Encourage clients to alternate periods of activity and rest.

Nursing Management: Depression

1. Assess for signs of a physical basis for any fatigue (e.g.,
infection, pain, altered nutritional status, or shortness of
breath upon exertion).
2. Administer treatment for underlying physiologic prob-
lems, if applicable.
3. If symptoms persist, encourage the client to have a
medical diagnostic workup with a geriatric psychiatrist, Figure 19-9 Cataract (Courtesy of Salim L. Butrus, MD,
if such a workup has not yet been done. Senior Attending, Department of Opthalmology, Washington
4. Monitor for verbal or nonverbal signs of suicidal Hospital Center, Washington, D.C., and Associate Clinical Professor,
thoughts/intent. Determine whether the client has a Georgetown University Medical Center, Washington, D.C.)
plan.
5. Provide one-on-one supervision of the client as needed causing presbyopia (trouble seeing objects up close) and
and assure the client that the caregiver will keep him decreased accommodation. The lens also yellows, causing
safe. If appropriate for the client, seek an agreement that distorted color perceptions, with greens and blues washing
he will not try to harm himself. out and warm colors such as reds and oranges becoming
more distinct. The incidence of cataracts also increases
6. Administer antidepressant medication as ordered. Pro- (Figure 19-9).
vide client and family education regarding medication,
including length of time before therapeutic results should • Accommodation of pupil size decreases, resulting in both
occur, and potential side effects. Report immediately to decreased adjustment to changes in lighting and decreased
the registered nurse and primary care provider any ability to tolerate glare. For instance, high-gloss tile floors
extrapyramidal side effects (e.g., tremors, drooling, pin in hallways can appear like hills and valleys to older clients,
rolling of the fingers, shuffling gait) that are observed. especially those with perceptual deficits; this may increase
anxiety and safety risks.
7. If the client is not assessed as being at risk for suicide but
is isolating in his room, establish small goals with the • Vitreous humor changes in consistency, causing
client (e.g., coming out of the room and sitting safely in blurred vision. Changes in the anterior chamber may
the hallway with the nurse for 5 minutes two times per increase the pressure of the aqueous humor, resulting in
day and for meals). Advance to more challenging goals glaucoma.
as the client demonstrates increased tolerance for social • Lacrimal glands secrete less fluids, causing dryness and
interaction. itching. Entropion or ectropion (turning of the eye
8. Facilitate the client’s reintegration into a healthy sup- inward) or ectropion (turning of the eye outward)
port system and provide small community group time occasionally occurs in older clients. These conditions can
for the client to share his views. not only impact vision, but can also increase the risk of
infection caused by dryness and ineffective blinking. In
these conditions, obtaining an order for artificial tears,
Nursing Management: Transient Ischemic lacrilube, and eye drop treatments for dryness or infection
Attack may be necessary.
1. Assess for risk factors for stroke and for the existence of • Arcus senilus, a hazy grayish yellow ring around the cornea
any previous carotid vascular tests for potential narrow- may develop, but it does not affect vision.
ing, stenosis, or blockage.
2. Provide client and family education explaining the rela-
tionship between risk factors and TIA and stroke.
INFECTION CONTROL
3. Provide teaching to assist in reducing risk factors.
Eye Care
4. Monitor orthostatic blood pressure and encourage
clients to change positions slowly to decrease the risk To decrease infection risks, all caregivers should
of falling. wash from the nose outward when washing
clients’ eyes.

Sensory Changes Common vision disorders related to aging

include the following:
The following sensory changes in vision and hearing result
from the aging process. • Presbyopia
• Cataract
• Glaucoma
Vision • Age-related macular degeneration
• With aging, the lens becomes less pliable and less able to
increase its curvature in order to focus on near objects,

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664 UNIT 8 Nursing Care of the Client: Older Adult

Nursing Management: Visual Impairment

1. Teach visually impaired clients adaptive techniques for
ADL, such as extra lighting.
2. Recommend regular examination by an ophthalmolo-
gist.
3. Provide preoperative and postoperative care and teach-
ing to clients undergoing cataract surgery, including
lifting and bending restrictions as well as measures to
prevent infection.
4. Teach proper eye drop administration techniques to all
clients who are prescribed eye drops, including holding
the drop in the eye with the lid closed for 30 seconds

COURTESY OF DELMAR CENGAGE LEARNING

after administration and lacrimal pressure for 1 minute
when appropriate.
5. Ensure that older clients have their glasses on when
needed to decrease perceptual and spatial deficits.
Teach clients that to have a better chance of keeping their
vision they should not smoke, maintain a healthy weight, con-
trol blood pressure, and eat a healthy diet rich in fish and green
leafy vegetables (Covell, Graziano, Rich, & Tobin, 2007).
Figure 19-10 The use of hearing aids helps to compensate
Hearing for hearing loss experienced by some clients.

• As aging occurs, the pinna becomes less flexible, the hair verbal questions or communication with written text
cells in the inner ear stiffen and atrophy, and cerumen represents a therapeutic intervention for hearing impair-
(earwax) increases. ment. If writing dexterity or ability is also impaired, a
• The number of neurons in the cochlea decrease, and the story board that has pictures indicating the client’s needs
blood supply lessens, causing the cochlea and the ossicles (e.g., bathroom, food, rest) can assist the client to inde-
to degenerate. pendently communicate needs to caregivers.
• Presbycusis, the impairment of hearing in older adults, is 6. The consonants f, g, s, and t may become difficult to
often accompanied by a loss of tone discrimination. High- understand as the client ages. Rephrase sentences and
frequency tones are lost first; thus, keeping the voice low questions when the client has difficulty with interpret-
and calm and decreasing any background noise can improve ing communication.
the client’s comprehension of the caregiver’s message.

Nursing Management: Hearing Impairment PROFESSIONALTIP

1. Assess for ear pain, drainage, inflammation, abnormali- New Technology for the Older Adult
ties, surgeries, perforations, or impacted cerumen.
2. Evaluate medication regimen and assess for ototoxicity, Massachusetts Institute of Technology’s (MIT)
if medication history reveals such a risk. AgeLab designs new ideas to improve the qual-
3. Recommend hearing testing by an audiologist, if the ity of life for older adults and those who care for
previous assessments are negative. them. Health innovations that AgeLab is research-
4. Monitor the care and use of a hearing aid by the older ing or has developed include: the Home Health
client with unilateral or bilateral aids (Figure 19-10). Station, an intelligent cardiopulmonary decisions
Provide teaching and assistance as needed for cleaning system that uses telemedicine at home to provide
the hearing aid(s) and replacing batteries. a “checkup a day” for managing chronic illnesses
5. Instruct caregivers and family about the communication such as CHF and diabetes; the Smart Personal Advi-
and socialization needs of the client. For some older cli- sor that uses the older adult’s diet information to
ents, either the use of a small erasable board to augment provide guidance when grocery shopping; Pill Pets,
an electronic pill pet that uses emotions and play
CRITICAL THINKING to remind the older adult to take their medication;
Digital Danskins for older adults that integrate bio-
Driving Safety sensors to monitor health conditions and chronic
diseases; and the “Aware Car,” a Volvo XC90
An 80-year-old client is contemplating giving up
designed with cameras and sensors that provide
automobile driving. What physical changes have
the older adult driver with information to pro-
occurred with aging that make it more difficult to
mote safe driving. To view additional technology
drive safely? If the client decides to continue driv-
being created by MIT for the aging population visit
ing, what safety measures would you recommend?
http://web.mit.edu/agelab/index.shtml (MIT, 2009).

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 CHAPTER 19 The Older Adult 665

SAMPLE NURSING CARE PLAN

The Client with Alzheimer’s Disease (AD)
J.R., 64 years old, was admitted to the Alzheimer’s unit of a long-term care facility. Last month, J.R. was
visiting her daughter in another state and wandered away from the daughter’s home. J.R. was found
60 miles away, unharmed but completely disoriented and agitated. J.R. had worked as a nursing assis-
tant before she retired. She is a widow and has two children in the same community where the nursing
home is located, in addition to the daughter who she was visiting in another state. Unless reminded,
J.R. does not shower or change clothes. She awakens at least once each night and asks for breakfast.

NURSING DIAGNOSIS 1 Disturbed Thought Processes related to progressive dementia as evidenced

by disorientation to time and place, loss of short-term memory, inability to concentrate, and periods of
agitation
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Memory Dementia Management
Cognitive Ability Environmental Management
Cognitive Orientation

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

J.R. will remain calm and will not Provide J.R. with clues for Helps J.R. cope with her
experience agitation and anxiety orientation: “Good morning, J.R. environment.
as a result of her disorientation My name is Jean, and I will help
and memory loss. you today.” Avoid putting her on
the spot.
Place a large sign on J.R.’s door with Helps her find her room.
her name printed in large letters.
Have family bring in snapshots Stimulates reminiscing and allows
and photos taken in past years. her to recall happy times.
Avoid changing J.R.’s room. Consistency reduces frustration.
Always put items back in the
same place.
Consult with activities staff in Prevents boredom, which can
planning self-expressive, non- lead to irritation.
fail activities that require little
concentration (e.g., painting
with nontoxic paints, modeling
with nontoxic clay).
If J.R. is resistant to care, provide Often, delaying care for even 10
clear, simple, nonthreatening to 15 minutes when resistance
instructions and delay care as is encountered improves client
needed until she is calmer. outcomes.

EVALUATION
J.R. remained calm and showed no signs of agitation or anxiety.

NURSING DIAGNOSIS 2 Risk for Injury related to risk factors of mode of transportation and cogni-
tive and affective factors as evidenced by wandering behavior, impaired judgment, and disorientation
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Safety Behavior: Personal Pain Management
Safety Behavior: Home Physical Environment Dementia Management
(Continues)
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666 UNIT 8 Nursing Care of the Client: Older Adult

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
J.R. will remain free of injury Keep only nonpoisonous plants Does not recognize unsafe acts or
while retaining as much on the unit. Arrange furniture conditions due to loss of impulse
independence and freedom as so that walkways are open. Pad control and loss of judgment.
possible. sharp corners of tables and chests. Does not comprehend cause and
Cover electrical outlets and hot effect.
radiators. Place electrical cords
and telephone wires out of reach.
Provide assurance during fire drills. Agitation increases especially
when noise level is increased.

EVALUATION
J.R. has experienced no injury.

NURSING DIAGNOSIS 3 Bathing/Hygiene and Dressing/Grooming Self-Care Deficit related to

perceptual or cognitive impairment (memory loss and sensory–perceptual deficits) as evidenced by
needing a reminder to shower and change clothes
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Self-Care: Bathing Self-Care Assistance: Dressing/Grooming
Self-Care: Hygiene Self-Care Assistance: Bathing/Hygiene
Self-Care: Dressing
Self-Care: Grooming

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

J.R. will complete ADLs with Use verbal cues and hand-over- Minimizes the need for
minimal assistance now and hand assistance with ADLs. Instruct assistance, thereby increasing
with increasing assistance as the staff to avoid doing tasks that J.R. feelings of self-esteem.
disease progresses. can do by herself. Watch for signs
of frustration and irritation and
intervene when appropriate.
Ask family to bring in clothing Allows J.R. to be more
that is easy to manipulate. Set independent.
clothing out in the order it is to
be put on.
Consider tub baths rather than Showers may be threatening
showers. Provide privacy, check the or confusing to persons with
temperature of the bathroom, and Alzheimer’s disease. Tub baths
do not leave the client alone. are more relaxing.

EVALUATION
J.R. participates in ADLs.

NURSING DIAGNOSIS 4 Disturbed Sleep Pattern related to disorientation as evidenced by

wakefulness at night
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Information Processing Sleep Enhancement
Mood Equilibrium Simple Massage

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 CHAPTER 19 The Older Adult 667

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
J.R. will experience fewer periods Avoid stimulating activities prior Overstimulation before bedtime
of wakefulness during the night. to bedtime. Establish a consistent may increase anxiety, preventing
If she awakens, she will remain bedtime routine. Take J.R. to the sleep. A consistent bedtime
calm and free of agitation. bathroom and allow sufficient routine is helpful.
time for complete bladder
emptying.
Help J.R. with a sponge bath and Provides relaxation.
with oral care; give her a back
rub using warm lotion and slow,
smooth strokes.
Provide a light snack of a warm, Hunger or overeating can
noncaffeinated beverage and interfere with sleep.
a plain, easily digested cracker,
cookie, or a piece of toast. Be
patient and do not rush her.
Question family concerning Allows same routine to be
previous bedtime routines and followed.
sleeping habits.
Repeat bedtime routine when Makes J.R. think it is time to go
J.R. awakens during night. to bed.
Encourage a short nap early in Sleep pattern disturbances may
the afternoon. result from overfatigue.
Avoid the use of sleeping Prevents confusion,
medications. disorientation, and restlessness.

EVALUATION
J.R. sleeps through the night several times a week.

Endocrine System 3. Develop a personal exercise program with the client

based on the client’s physical condition, mental status,
The following endocrine changes result from the aging process: resources, and interests.
• Alterations occur in both the reception and the production 4. Provide information on prescribed oral hypoglycemic
of hormones. medications.
• Release of insulin by the beta cells of the pancreas slows, 5. Teach the causes, signs, and treatment of hypoglycemia
causing an increase in blood sugar. and hyperglycemia.
• Thyroid changes may lead to decreased T4 and 6. Educate on self-care and on careful monitoring of the
hypothyroidism. extremities and of sores on the skin to minimize threats
The most common endocrine disorder related to aging is to skin integrity.
diabetes mellitus type 2. 7. Encourage the client to wear shoes and to have nails
trimmed by a podiatrist, if unable to safely perform self-
Nursing Management: Diabetes Mellitus care.
Type 2
1. Arrange for a consultation with a dietitian to assess Reproductive System:
nutritional status and to provide food-management
instruction.
Female
2. Teach the client, family members, or caregivers (as The following reproductive changes result from the aging process:
appropriate) the procedure for blood glucose monitor- • Estrogen production decreases with the onset of menopause.
ing specific to the equipment the client will be using. • Ovaries, uterus, and cervix decrease in size.

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668 UNIT 8 Nursing Care of the Client: Older Adult

• The vagina shortens, narrows, and becomes less elastic,

and the vaginal lining thins. Secretions decrease and
Reproductive System: Male
become more alkaline, resulting in increased incidence of The following reproductive changes result from the aging
atrophic vaginitis. These changes may result in dyspare- process:
unia (discomfort during coitus), which can often be recti- • Testosterone production decreases, resulting in decreased
fied with the use of a water-based lubricant. As at any age, size of the testicles.
protected intercourse (safe sex) through the use of a latex • Sperm count and viscosity of seminal fluid decrease.
condom should be advised with new partners. • Although more time is required to obtain erection, the older
• Supporting musculature of the reproductive organs weak- man often finds that he and his partner can enjoy longer
ens, increasing the risk of uterine prolapse. periods of lovemaking (greater control) before ejaculation.
• Breast tissue diminishes and nipple erection lessens As at any age, protected intercourse (safe sex) through the
during sexual arousal. use of a latex condom should be advised with new partners.
• Libido and the need for intimacy and companionship in • The prostate gland may enlarge.
older women remain unchanged (Figure 19-11). • Impotency may occur. Medications and other medical
Common female reproductive system disorders related to interventions have been successful in reversing impotency
aging include the following: problems in many older males. A thorough evaluation by
• Breast cancer (the risk of which increases with age) the primary care provider and a urologist can provide cli-
ents with available options given health status and current
• Altered sexuality patterns related to physiologic changes, medication regimen.
medications, changes in body image, or psychosocial
changes such as the loss of a significant other or a move to a • Libido and the need for intimacy and companionship
setting that provides some level of assistive care (i.e., group remain unchanged in older males.
home, assisted living center, or care facility) Common male reproductive disorders related to aging
include the following:
Nursing Management: Female • Altered sexuality patterns related to physiologic changes,
medications, changes in body image, or psychosocial
Reproductive System Disorders changes such as the loss of a significant other or a move to a
1. Teach and encourage monthly breast self-exams and setting that provides some level of assistive care (i.e., group
yearly mammograms for early detection and treatment home, assisted living center, or care facility)
of disorders. • Benign prostatic hypertrophy (BPH)
2. Establish rapport and encourage the client to verbalize
feelings and concerns related to sexuality, body image,
and self-esteem. Nursing Management: Male
3. Complete a sexual history and recommend interven- Reproductive System Disorders
tions based on findings. Support the client’s needs for 1. Establish rapport and encourage the client to verbalize
companionship and intimacy throughout the life span. feelings and concerns related to sexuality, body image,
4. Recommend that a bone density scan (Dexa-Scan) and self-esteem.
be discussed with the client’s primary care provider to 2. Complete a sexual history and recommend interven-
allow for early detection and treatment of osteoporosis. tions based on findings. Support the client’s needs for
5. Encourage annual gynecological examinations with the companionship and intimacy throughout the life span.
client’s primary care provider. 3. Provide client and family education regarding the signs
and symptoms of prostate disorders (e.g., difficulty in
starting the urine stream, a smaller urine stream, fre-
quent urination, frequent nighttime awakening for the
purpose of urinating, or, in severe cases, the failure or
inability to urinate).
4. Teach and encourage monthly testicular self-exam and
yearly digital rectal examinations of the prostate gland
by a primary care provider. The benefits of a PSA lab
test performed every 1 to 2 years to facilitate early
detection and treatment of prostate cancer are being
researched and debated.
COURTESY OF DELMAR CENGAGE LEARNING

Integumentary System
The following integumentary changes result from the normal
aging process:
• Subcutaneous tissue and elastin fibers diminish, causing
the skin to become thinner, less elastic, and wrinkled.
• Ability of melanocytes to produce even pigmentation
Figure 19-11 Sexuality and companionship remain diminishes, resulting in hyperpigmentation or liver spots,
important throughout the life span. typically on the hands and wrists (Figure 19-12).

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 CHAPTER 19 The Older Adult 669

• Melanin production decreases, causing gray-white hair.

• Scalp, pubic, and axillary hair thin, and women display
increased facial hair on the upper lip and chin.
• Nail growth slows, nails become more brittle, and longitu-
dinal nail ridges form.
Common integumentary disorders related to aging
include the following:

COURTESY OF DELMAR CENGAGE LEARNING

• Pressure ulcers (alteration in skin integrity)
• Herpes zoster (shingles)
• Skin cancer (included because the risk of skin cancer
increases with age)

Nursing Management: Alteration in Skin

Integrity
Figure 19-12 Hyperpigmentation is a normal result of the 1. Perform a pressure ulcer risk assessment upon the client’s
aging process.
admission to the health care setting (Figure 19-13).
2. Implement pressure ulcer prevention protocol for
clients at risk for pressure ulcer formation. It is impor-
• Eccrine, apocrine, and sebaceous glands decrease in size, tant to consider and document pressure-relieving inter-
number, and function, resulting in diminished secretions ventions for all surfaces that the client will sit or lay on
and moisturization and, thus, pruritis. during the course of the day (Table 19-4).
• Body temperature regulation diminishes because of 3. Encourage adequate intake of protein and fluids to help
decreased perspiration and, many times, decreased ensure good skin integrity.
circulation, placing the older adult at risk for hypo- and 4. Dress clients in long sleeves and slacks, when appropri-
hyperthermia. ate, to protect fragile skin and provide warmth.
• Capillary blood flow decreases, resulting in slower wound 5. Assess skin turgor on sternum or forehead due to loss of
healing. skin elasticity.
• Blood flow decreases, especially to lower extremities. 6. Monitor client for exaggerated drug effects due to
• Vascular fragility causes senile purpura. age related thinning of skin, potentially causing faster
• Cutaneous sensitivity to pressure, touch, pain, and absorption of topical medications (Shepler, Grogan, &
temperature decreases. Pater, 2006).

Date of assessment: _____ Nurse: ____________________

Pressure ulcer present on admission: No ____ Yes ____ Stage ____

A score of 11 or more places a client at risk for pressure ulcer formation. Preventive protocol should be established.

Activity Total Level of Consciousness Total

Ambulant without assistance 0 Alert 0
Ambulant with assistance 2 Slow verbal response 1
Chairfast 4 Responds to verbal or painful stimuli 2
Bedfast 6 _____ Absence of response to stimuli 3 _____

Mobility—Range of Motion Nutritional Status

Full range of motion 0 Good (eats 75% or more of required intake) 0
Moves with minimal assistance 2 Fair (eats less than 75% of required intake) 1
Moves with moderate assistance 4 Poor (minimal intake, consistent weight loss) 2
Immobile 6 _____ Unable/refuses to eat/drink, emaciated 3 _____

Skin Condition Incontinence—Bladder

Hydrated and intact 0 None 0
Rashes or abrasions 2 Occasional (fewer than 2/24 hours) 1
COURTESY OF DELMAR CENGAGE LEARNING

Decreased turgor, dry 4 Usually (more than 2/24 hours) 2

Edema, erythema, pressure ulcers 6 _____ Total (no control) 3 _____

Predisposing Disease Process Incontinence—Bowel

No involvement 0 None 0
Chronic, stable 1 Occasional (formed stool) 1
Acute or chronic, unstable 2 Usually (semi-formed stool) 2
Terminal 3 _____ Total (no control, loose stool) 3 _____

Figure 19-13 Pressure Ulcer Risk Assessment

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670 UNIT 8 Nursing Care of the Client: Older Adult

Table 19-4 Protocol for Clients at Risk for Pressure Ulcers

OBJECTIVE INTERVENTIONS
Relieve pressure • Establish positioning schedule.
• Place pressure relieving mattress on bed, cushions on chair.
• Teach client wheelchair exercises.
• Stand and/or ambulate client in chair frequently.
• Use wheelchair for transporting only.
• Allow client to sit on bedpan, commode, or toilet for only brief periods.
• Check areas of pressure under casts, braces, splints, slings, prostheses.
Relieve friction and shearing • Use turning sheet for positioning in bed and chair.
• Keep head of bed lower than 30 degrees unless contraindicated.
• Use supportive devices to prevent sliding in chairs.
• Use appropriate transfer techniques.
• Do not use powder on skin.
• Place bed cradle under top covers.
Prevent moisture/maceration • Implement scheduled toileting or bladder retraining program.
• Use absorbent incontinent briefs or pads.
• Check incontinent clients frequently. Wash and rinse thoroughly. Apply moisture barrier.
• Avoid use of plastic/rubber sheets, protectors.
Prevent spasticity and • Avoid quick, rough movements.
contractures • Do range-of-motion exercises at least twice daily.
• Assess for synergy patterns when positioning.
• Administer oral antispasmodics if ordered.
Maintain hydration/nutritional • Assess nutritional status.
status • Investigate causes of anorexia.

COURTESY OF DELMAR CENGAGE LEARNING

• Correct underlying nutritional deficits.
• Encourage additional fluids, unless contraindicated.
• Give high protein supplement, if necessary.
• Monitor weight weekly.
Continue with routine skin care.
Do skin checks with each position change.

INFECTION CONTROL Nursing Management: Herpes Zoster

1. Treat the pain.
Skin Integrity 2. Treat the ulcer with medications (e.g., acyclovir [Zovirax]
topical cream), as ordered, to reduce the length of time
It is a nursing responsibility to educate caregivers of the outbreak.
(including other staff members, as necessary) about
3. Develop a plan to ensure continuity in meeting the
the need to thoroughly wash and dry the client’s client’s psychosocial needs, and allow the client time to
perineal area and to keep linens and clothing share concerns.
clean and dry, especially when incontinence is
a problem. Such education may also include
instruction on maintaining client privacy; properly
retracting, cleansing, and repositioning the
foreskin of an uncircumcised older male client;
and proper cleansing of the skin folds of female
client’s perineal area. Clients and caregivers should
CULTURAL CONSIDERATIONS
also be instructed to cleanse front to back only
and to not rinse and reuse washcloths again or use Pain Assessment
them on other body areas. These simple hygiene Overt signs of pain may not be expressed by some
and infection-control guidelines can help maintain cultures or sexes. Older adults may not sense pain
the client’s skin integrity and can also prevent until the condition has become severe. Therefore,
unnecessary infections. a thorough pain assessment is crucial for effective
pain management.

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 CHAPTER 19 The Older Adult 671

INFECTION CONTROL •
•
Acupuncture
Chiropractic services (some exceptions)
Herpes Zoster • Cosmetic surgery
• Dental care and dentures (few exceptions)
Prevent cross-infection from drainage from the • Eye exams (routine) and eye glasses
vesicular eruptions by practicing proper hand
• Foot care (routine)
hygiene and implementing appropriate isola-
• Hearing aids
tion procedures, especially if the client is in the
hospital or another health care facility.
• Laboratory tests (screening)
• Long-term care
• Orthopedic shoes (few exceptions)
• Physical exams (routine)
Nursing Management: Skin Cancer • Prescription drugs (few exceptions)
1. Teach clients and caregivers both cancer prevention • Travel (healthcare while traveling outside the United
methods and skin self-examination to detect lesions States) (Medicare, 2009a)
early. Early detection and treatment of skin cancers are In the late 1990s, many insurance policies were available
essential to optimal client outcomes. to supplement at varying levels the benefits paid by Medicare.
2. Provide information in both verbal and written form This led many older clients to “stack” insurance policies or to
and in collaboration with the client’s multidisciplinary buy numerous overlapping policies for fear of being underin-
team regarding treatment (surgery, chemotherapy, radi- sured. The insurance industry and Congress worked together
ation, and other options). to outlaw stacking of Medicare supplement policies.
3. Monitor for signs of infection at the lesion site. Although there has been some improvement in insurance
coverage for preventive screening tests such as mammograms,
4. Ensure that the client’s psychological, psychosocial, the lack of reimbursement for prescription drugs continues
spiritual, and dietary needs are also addressed. to significantly burden older Americans, many of whom must
choose between costly medications and food.
On January 1, 2006, a new prescription drug coverage
FINANCING OLDER ADULT CARE program began for persons older than 65 with Medicare
regardless of income or health (CMS, 2009c). This program
Since the 1960s, the U.S. Congress has developed and imple- is referred to as Medicare Part D. This is insurance that should
mented a series of national entitlement programs to help cover half of the cost of needed medications for the older adult.
ensure adequate income, housing, and access to medical care Medicare reports that 33% of persons covered by Medicare
for older Americans. As the number of older clients (those will meet the qualifying factors for extra help so that almost all
older than age 65, particularly those older than age 85) con- of the medication costs for this group will be covered.
tinues to rise, caregivers and advocates for older-adult care According to Kurtzman and Buerhaus (2008), the CMS,
should strive to understand the budgetary policies that have in an effect to refine Medicare’s prospective payment system
influenced and continue to influence the U.S. health care and improve quality care, implemented a new payment rule
delivery system. known as CMS-1533-FC to eliminate additional Medicare
payments for eight preventable hospital-acquired conditions.
Medicare The eight conditions include pressure ulcers, preventable
Medicare (Title XVIII) is a nationwide health insurance injuries, catheter associated UTI’s, vascular catheter associ-
program for Americans who are 65 years of age or older, for ated infections, surgical site infections, air emboli, blood
persons who are eligible for Social Security disability pay- incompatibility reactions, and objects mistakenly left inside
ments for longer than 2 years, and for certain workers and surgical clients.
dependents who need kidney transplants or dialysis. The In 2009, Medicare estimates coverage for items and ser-
Health Care Financing Administration (HCFA) was the fed- vices for more than 43 million beneficiaries (CMS, 2009b).
eral agency in charge of administering the Medicare program.
Since July 2001, the HCFA is now the Centers for Medicare
and Medicaid Services (CMS). More than the name has Medicaid
changed. Now there is an increased emphasis on responsive- The Medicaid program was also enacted as part of the Social
ness to beneficiaries and providers, and quality improvement Security Act of 1966 and is often referred to as Title XIX. This
(CMS, 2001). program, which is federally funded but state operated and
The program was enacted as part of the Social Security administered, provides medical benefits to certain indigent,
Act of 1965 and became effective on June 1, 1966. It consists or low-income, Americans. Nursing home bills represent a
of two separate but coordinated programs: hospital insurance staggering burden for many older Americans who require
(called Part A) and medical insurance (called Part B), which nursing care. In 1995, nursing home bills averaged $22,000
covers physician’s services, outpatient services, some medical per person per year, and projections showed that two-thirds
supplies, and some skilled nursing and home health services. of older adults who lived alone would run out of savings after
Medicare provides basic protection for the cost of health care 13 weeks in a nursing home (Gallo, Paveza, Fulmer, 2003).
but does not cover all expenses. Among the expenses not Medicaid takes into account government-determined poverty
covered by Medicare for older Americans are those associated levels when providing benefits, with coverage being extended
with the following: to persons who are at certain percentages of the poverty level

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672 UNIT 8 Nursing Care of the Client: Older Adult

(e.g., 200% of poverty level, 150% of poverty level, and 100% CRITICAL THINKING
of poverty level). Long-term care facilities serve both private-
pay clients (those whose expenses are paid by themselves, Nurse Advocate
their families, or their long-term care insurance policies) and
Title XIX- (Medicaid-) funded clients. Medicaid coverage How can you, as a nurse, advocate for your older
for long-term care is not available until a person’s assets have clients?
been depleted to a certain set level. Older-adult care advocates
continue their efforts to protect the assets of the spouse who
is able to stay in the family home after the other spouse must
be placed in a nursing home. skilled nursing facilities (SNFs) with a prospective payment
To some in the United States, the debate over Social Secu- system (PPS) based on client assessment within a resource
rity, Medicare, and Medicaid financing is viewed as someone utilization group system (RUGS). Reimbursement for home
else’s priority; however, the moral responsibility for provid- health services also shifted to a PPS.
ing access to quality services and care for our country’s older The BBA also states that discharge from hospitals to
adults is shared by all Americans. Older-adult care services SNFs or home care for 10 common but as yet unpublished
should be developed to promote independence yet should diagnosis-related groups (DRGs) is to be considered as a
provide assistance when needed. transfer for payment purposes. Medicare’s goal was to make a
single blended payment that combined the traditional hospital
Omnibus Budget DRG payment and the payment for postacute care services to
be shared by the providers.
Reconciliation Act The intended implications for practice included reduced
The Omnibus Budget Reconciliation Act (OBRA), first reimbursement to some SNFs, fewer discharges from hospitals
enacted in 1987 and reenacted in 1990, sought to ensure qual- to independent facilities for subacute care or home care, and,
ity services for older Americans. The act included guidelines thus, encouraged the creation of integrated delivery systems
for services that were required to be made available to seniors and managed care. In reality, however, it has become more
and promoted the rights of seniors. As was the case with all difficult to find placement in SNFs for clients with complex
health care costs, however, older-adult care costs continued to needs because the new reimbursement system simply does
rise in the United States, and discussions and proposed legisla- not fund all of their health care needs.
tion for financial reforms intensified. These reimbursement and regulatory changes surely rep-
resent only the beginning of such efforts to balance resources
Balanced Budget Act of 1997 and need as the U.S. population continues to age. Certainly,
significant work lies ahead for advocates of quality older-adult
Among the most significant influences on the financing of old- care in the United States and the world. Nurses will play a vital
er-adult care is the Balanced Budget Act (BBA) of 1997. The role in the ensuing debates, for they will see firsthand the posi-
BBA replaced cost-based reimbursement for care provided in tive and negative outcomes of their clients.

CASE STUDY
N.O., a 72-year-old man, was admitted to a skilled care facility for rehabilitation after an open reduction/internal
fixation of the right hip. N.O. had fallen while going up the stairs of his home, suffering an intertrochanteric,
comminuted fracture of the right femur. He has no recollection of what caused him to fall. He is married and,
until his surgery, was working part time as a school-crossing guard. While in the hospital, N.O. exhibited mental
status changes, including disorientation and confusion. His wife reports that he never had this problem before
the surgery. He is continent of bowel and bladder. N.O. was in relatively good health until the fall. He and his
wife agree that he should return home after rehabilitation is complete.
The following questions will guide your development of a nursing care plan for the case study.
1. Identify specific admission assessments that would be required for N.O. because of his age and condition.
2. Identify complications for which N.O. is at risk.
3. List interventions to prevent each complication.
4. Cite possible reasons for N.O.’s fall.
5. Describe methods for assessing N.O.’s mental status.
6. Describe possible reasons for his altered mental status.
7. Write three individualized nursing diagnoses and goals for N.O.
8. List nursing actions related to altered mental status.
9. List four successful outcomes for N.O.
10. Develop a teaching plan for N.O.
11. List the community resources N.O. may need after discharge.

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 CHAPTER 19 The Older Adult 673

SUMMARY
• The older adult population is rapidly growing. • Nurses knowledgeable about aging can plan interventions
• Although many stereotypes and myths are associated that will prevent complications for which older adults are
with aging, older adults are in fact very diverse in their at risk.
characteristics. • Nurses have a responsibility to advocate for their older cli-
• Health maintenance is as important for older adults as it is ents. Nurses should be active legislatively and should work
for younger persons. A healthy lifestyle can enhance the collaboratively to develop older-adult care services that are
quality of life. affordable, provide equal access for all older Americans,
• Many changes are associated with aging. The disorders and promote optimal wellness and independence.
commonly seen among older adults are often the results of
pathology and are thus not considered a normal part of
aging; however, the risk of acquiring these disorders
increases with age.

REVIEW QUESTIONS
1. The senior citizens center has requested a nurse to 5. While assisting an older client during bathing, the
speak to its members on the effects of aging. Which client asks “What is causing all of my skin prob-
statement would be included in the presentation? lems?” How should the nurse respond?
1. All people eventually become senile if they live 1. “The increased glandular secretions cause
long enough. pruritus.”
2. People lose interest in sex as they age. 2. “The increased capillary blood flow reduces body
3. Most older adults are financially impoverished. temperature.”
4. Incontinence is not an expected or normal 3. “The melanin production results in loss of hair.”
change of aging. 4. “The increased vascular fragility leads to
2. A student nurse is reading a book on the theories of ecchymosis.”
aging. You know the student understands the pro- 6. The nurse assesses bilateral ectropion and presbycu-
grammed aging theory if the student states that: sis on an older client. As care is being planned, the
1. “Stress causes structural and chemical changes in nurse should:
the body, which, in turn, cause aging.” 1. refer the client to a dermatologist and otologist
2. “A genetic clock determines the speed at which for treatment.
people age.” 2. ask the nursing technician to obtain a walker for
3. “Changes in collagen are the cause of aging.” the client.
4. “The decreasing ability to produce T-cell differ- 3. provide additional fluids and extra protein in the
entiation causes aging.” client’s diet.
3. The nurse is reviewing preventive respiratory tract 4. use a low-pitched voice to give the client
infection care with an older adult client. A preven- directions while instilling artificial tears into
tive instruction would include: his eyes.
1. obtaining an influenza vaccine each year. 7. The nurse is preparing medications for a newly
2. staying inside throughout the winter. admitted client. The medication sheet states the
3. avoiding exercise. client is 95 years old. Which of the following
4. limiting fluid intake. age-related changes would the nurse expect to find
4. The family of an older adult client is requesting which will increase the risk for drug toxicity?
information about the appropriate amount of 1. Faint pedal pulses and low body temperature.
exercise needed to maintain musculoskeletal 2. Loss of bone density and decreased blood flow.
function in their family member. As a nurse you 3. Urinary incontinence and thoracic rigidity.
would explain that: 4. Dry skin and decreased heart conduction time.
1. weight-bearing exercise is not recommended for 8. An older adult nursing home client frequently
older adults. repeats his World War II stories. The nursing assis-
2. high-intensity resistance training can improve tant complains she is tired of hearing about his war
muscle strength in older adults. stories. How should the nurse respond?
3. muscle deterioration in older adults is to be ex- 1. “Yes, I’m tired of hearing about those war
pected. stories, too.”
4. walking is the only healthy exercise for older 2. “Reminiscing is good to help maintain long-term
adults. memory and self esteem.”

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674 UNIT 8 Nursing Care of the Client: Older Adult

3. “Whenever he starts to repeat another war story, 3. 600 mL

change the subject.” 4. 400 mL
4. “Just pretend you’re listening to the war stories, so 10. A family member of a client with dementia asks the
you won’t hurt his feelings.” nurse the difference between delirium and dementia.
9. Your older adult client complains he feels bloated. The best response would be:
Upon reading the chart, you note he has gained 1. dementia is a reversible confusion which is treatable.
2.5 pounds since yesterday. This 2.5 pounds would 2. delirium is a chronic confusion with remissions
be equivalent to approximately how many milliliters and exacerbations.
of body fluid? 3. dementia is a slow progressive confusion which is
1. 1000 mL irreversible.
2. 800 mL 4. delirium is an acute confusion which is irreversible.

REFERENCES/SUGGESTED READING
Administration on Aging (AoA). (2001). The Administration on Aging Dowling-Castronovo, A., & Specht, J. (2009). Assessment of transient
and the Older American’s Act. Retrieved from www.aoa.dhhs.gov/ urinary incontinence in older adults. American Journal of Nursing,
aoa/pages/aoafact.html 109(2), 62−71.
Administration on Aging (AoA). (2002). Income and poverty among Estes, M. (2010). Health assessment & physical examination (4th ed.).
the elderly. Retrieved from http://www.aoa.gov Clifton Park, NY: Delmar Cengage Learning.
Administration on Aging (AoA). (2009a). A profile of older Americans: Flaherty, E. (2008). Using pain-rating scales with older adults. American
2008: Future growth. Retrieved August 4, 2009 from http://www Journal of Nursing, 108(6), 40−47.
.aoa.gov/AoARoot/Aging_Statistics/Profile/2008/4.aspx Gallo, J., Paveza, G., & Fulmer, T. (2005). Handbook of geriatric
Administration on Aging (AoA). (2009b). A profile of older Americans: assessment. Gaithersburg, MD: Jones & Bartlett.
2008: The older population. Retrieved August 4, 2009 from http:// Hamilton, S. (2001). Detecting dehydration & malnutrition in the
www.aoa.gov/AoARoot/Aging_Statistics/Profile/2008/3.aspx elderly. Nursing2001, 31(12), 56–57.
American Association of Retired Persons (AARP). (1998). A profile Hogstel, M. (Ed.). (2001). Gerontology: Nursing care of the older adult.
of older Americans. Washington, DC: Department of Health and Clifton Park, NY: Delmar Cengage Learning.
Human Services. Kimbell, S. (2001). Before the fall: Keeping your patient on his feet.
Andersen, C. (1999). Antecedents, correlates, and impact of violent Nursing2001, 31(8), 44–45.
behaviors in the elderly VA client. Unpublished thesis, University of Kurtzman, E., & Buerhaus, P. (2008). New Medicare payment rules:
Iowa, Iowa City, IA. Danger or opportunity for nursing? American Journal of Nursing,
Andersen, C. (1998). Nursing student to nursing leader: The critical 108(6), 30−35.
path to leadership development. Clifton Park, NY: Delmar Cengage Logue, R. (2002). Self-medication and the elderly: How technology
Learning. can help. AJN, 102(7), 51–55.
Bendix, J. (2009). Exploiting the elderly. RN, 72(3), 42−46. Manno, M., & Hayes, D. (2006). How medication reconciliation saves
Bray, B., Van Sell, S., & Miller-Anderson, M. (2007). Stress lives. Nursing 2006, 36(3), 63−64.
incontinence: It’s no laughing matter. RN, 70(4), 25−29. Massachusetts Institute of Technology (MIT). (2009). Innovations.
Bulechek, G., Butcher, H., McCloskey, J., & Dochterman, J., eds. (2008). Retrieved August 4, 2009 from http://web.mit.edu/agelab/index
Nursing Interventions Classification (NIC) (5th ed.). St. Louis, MO: .shtml
Mosby/Elsevier. Mezey, M., & Mitty, E. (2006). The teaching nursing home: Models
Covell, C., Graziano, J., Rich, D., & Tobin, K. (2007). New outlook for for training clinicians in geriatrics. American Journal of Nursing,
age-related macular degeneration. Nursing2007, 37(3), 22−24. 106(10), 72.
Centers for Medicare & Medicaid Services (CMS). (2002). Medicare Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007).
aged and disabled enrollees by type of coverage. Retrieved from Nursing Outcomes Classification (NOC) (4th ed.). St. Louis, MO:
http://cms.hhs.gov/statistics/enrollment/natltrends/hi_smi.asp Mosby.
Centers for Medicare & Medicaid Services (CMS). (2003). Medicare Napoli, M. (2009). The marketing of osteoporosis. American Journal of
Part B physicians supplier data. Retrieved from http://cms.hhs.gov/ Nursing, 109(4), 58−61.
data/betos/cy2001.asp National Council on Aging (NCOA) (2002). Facts about older
Centers for Medicare and Medicaid Services (CMS). (2009a). Medicare Americans. Retrieved from http://www.ncoa.org/content
& you 2009. Retrieved August 7, 2009 from http://www.medicare .cfm5sectionID.106
.gov/Publications/Pubs/pdf/10050.pdf National Institute on Aging. (2009). What’s your aging IQ? Retrieved
Centers for Medicare and Medicaid Services (CMS). (2009b). Medicare August 4, 2009 from http://www.niapublications.org/quiz/index
coverage – general information overview. Retrieved August 7, 2009 .php
from http://www.cms.hhs.gov/CoverageGenInfo/ Peskin, B. (1999). Beyond the zone. Houston, TX: Noble.
Centers for Medicare and Medicaid Services (CMS). (2009c). Now Sharts-Hopko, N., & Glynn-Milley, C. (2009). Primary open-angle
Medicare covers more than ever. Retrieved August 7, 2009 from glaucoma. American Journal of Nursing, 109(2), 40−47.
http://www.cms.hhs.gov/AIAN/Downloads/CMS-11142-N.pdf Shepler, S., Grogan, T., & Pater, K. (2006). Keep your
Collins, J. (2002). Helping an older patient eat well to stay well. older patients out of medication trouble. Nursing2006, 36(9),
Nursing2002, 32(11), 32hn6–32hn8. 44−47.

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 CHAPTER 19 The Older Adult 675

Social Security Administration (SSA). (2000). The president signs the Victor, K. (2001). Properly assessing pain in the elderly. RN, 64(5),
“Senior Citizens’ Freedom to Work Act of 2000.” Retrieved from 45–49.
www.ssa.gov/legislation/legis_bulletin_040700.html Wallhagen, M., Pettengill, E., & Whiteside, M. (2006). Sensory
Steffen, K. (2003). When your trauma patient is over 65. Nursing2003, impairment in older adults: Part 1: Hearing loss. American Journal of
33(4), 53–56. Nursing, 106(10), 40−48.
Stein, A. (2003). Aging is more than skin deep. Nursing2003, 33(2), Wilkinson, J. (1999). A family caregiver’s guide to planning and decision
32hn7–32hn8. making for the elderly. Minneapolis, MN: Fairview Press.
Stockdell, R., & Amella, E. (2008). The Edinburgh feeding evaluation
in dementia scale. American Journal of Nursing, 108(8), 46−53.

RESOURCES
Administration on Aging (AoA), http://www.aoa.gov American Nurses Association (ANA), Council on
American Association for Geriatric Psychiatry, Gerontological Nursing Practice,
http://www.aagpgpa.org http://ww.nursingworld.org
American Association of Retired Persons (AARP), National Council on Aging (NCOA),
http://www.aarp.org http://www.ncoa.org
American Geriatrics Society,
http://www.americangeriatrics.org

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 Nursing Care of the Client:
UNIT 9
Health Care in the Community
Chapter 20 Ambulatory, Restorative, and
Palliative Care in Community
Settings / 678

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 CHAPTER 20
Ambulatory, Restorative, and
Palliative Care in Community
Settings

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of nursing care within
ambulatory/urgent, rehabilitative/restorative, home health, long-term, palliative, and
hospice care settings:
Adult Health Nursing
• The Older Adult

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• List reasons for a significant change in the growth of nonacute care
services.
• Describe the differences between Medicaid and Medicare.
• Explain the role of the licensed practical nurse/vocational nurse (LPN/VN)
as a member of the interdisciplinary health care team in various health care
settings.
• Discuss the types of clients that would benefit from participation in a
rehabilitation/restorative care program.
• Explain the responsibilities of the LPN/VN in ambulatory care, rehabilitation/
restorative care nursing, nursing in long-term care, in-home care, and
hospice.

KEY TERMS
adult day care disability impairment
age-appropriate care extended care facility (ECF) long-term care
ambulatory care handicap managed care
assisted living hospice minimum data set (MDS)
678

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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 679

Outcomes and Assessment rehabilitation restorative care

Information Set (OASIS) reportable conditions telehealth
palliative care respite care urgent care center

and wellness continuum. Specialty centers provide services

INTRODUCTION such as family planning, ambulatory surgery, and oncol-
There has been a strong emergence in the past decade of ogy care. Other facilities provide care to a specific group of
nonacute health care services. The growth of these services clients, for example primary care centers for Veterans and
is a reflection of changes occurring in health care within the Indian Health Service. There are also specialty clinics (ortho-
United States. These changes resulted in a vast increase in pedic, dermatologic, or urologic centers) defined by their
ambulatory/urgent care services, rehabilitation/restorative providers.
care, home health, long-term care, and hospice. There is an Some clinics categorize clients according to their disease
intermingling of services and settings under each of these processes. There are nurse-run clinics for anticoagulation
categories of care. Restorative care, for example, may be therapy, diabetes management, and hypertension. At these
provided in an acute care setting, in a rehabilitation hospi- clinics, specially trained registered nurses coordinate care,
tal, in a long-term care facility, in an extended care facility provide educational services, and make treatment recommen-
with rehabilitation units, or in the client’s home. Although dations as a delegated medical function.
many of the clients requiring these services are elderly, Another cost-saving effort is the development of man-
there is an increasing number of services specializing in aged care, a system where a case management individual or
pediatric care. team controls what specialists the client sees, as well as the
frequency or duration of that specialty care. Within these
systems, primary care clinics often serve as gatekeepers for cli-
AMBULATORY AND URGENT ents, who must receive an initial evaluation by their provider
before receiving a referral for specialty services. Although
CARE SETTINGS managed care reduces unnecessary health care expenditures,
it is a source of frustration for clients who perceive it as a loss
The tremendous changes in the delivery of health care of control and independence.
during the past several decades are expected to continue
(Cicatiello, 2000). These changes have a direct impact on
the environment where nurses practice. Decreasing reim-
bursement rates for health care are creating a competitive Care Provided in
climate for physicians and other health care providers. Ambulatory/Urgent Care
Direct marketing of pharmaceuticals and renewed inter-
est in alternative therapy is changing the expectations of Centers
people who seek health care solutions. U.S. populations Traditionally, medical clinics provided preventive, wellness,
are shifting, and the immigration of people to this country and illness family-centered care, where the client forms a
from other parts of the world requires increasingly complex relationship with the same provider or group of provid-
ability on the part of nurses to communicate and interact ers over time. Changing health care needs brought about
effectively. urgent care centers, facilities designed for the effective
Providing care outside of a hospital is less costly for and efficient treatment of acute illnesses and injuries. At an
clients, their employers, and their insurers. Changes in health- urgent care center, clients receive many of the same services
care policies and reimbursement rates during the past several they receive at a traditional medical clinic. Clients do not
decades have resulted in shorter hospital stays. That means require an appointment, they do not see the same provider
that clients are being discharged before their need for medi- consistently, and they are usually seen either in the order of
cal and nursing interventions are completely resolved, which arrival or the order of acuity. An urgent care center is fast
increases the need for outpatient follow-up. paced similar to a hospital emergency department and serves
the needs of an increasingly busy, mobile population. Clients
Ambulatory Care Settings with severe trauma or who have life-threatening condi-
tions, such as chest pain or respiratory distress, typically are
Ambulatory care settings are facilities where diagnosis, rerouted to a hospital emergency room, where appropriate
treatment, preventive care, and even restorative care are pro- interventions are provided.
vided for clients on an outpatient basis. The client is able to An innovation in health care delivery is the development
walk in, receive care, and return home. The average American of nonemergent clinics that are cropping up to provide rapid
visits an ambulatory care center 4 times per year (National care for minor illnesses. These clinics are located in shopping
Center for Health Statistics, 2008). This number is increas- malls and grocery stores and provide care to clients who are
ing because the aging population increasingly requires the in a hurry. They are often staffed by advanced practice nurses
treatment and monitoring of chronic diseases. Ambulatory who specialize in providing treatment for non-complicated
care settings are the primary site for health care delivery in cases while offering client convenience.
this country.
Many types of ambulatory care exist and include health
care provided at physician’s offices, urgent care centers, and Ambulatory Care Nurses
hospital emergency departments. Family practice clinic care Within the ambulatory care setting, one may find nurses at
is provided to clients of all ages and at all points on the health every educational level, including practical, associate degree,

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680 UNIT 9 Nursing Care of the Client: Health Care in the Community

baccalaureate degree, and advanced practice nurses. It is vital

for the ambulatory care nurse to have strong interpersonal
communication skills and a high level of maturity to function
CLIENTTEACHING
effectively as part of the health care team. Client Teaching in an Ambulatory
The focus of the visit may be as simple as routine blood Care Setting
work or a complex procedure or treatment. In most cases,
clients return home after receiving care within a relatively The nurse in an ambulatory care setting
short time. Within this timeframe, the nurse collects perti- relinquishes control over much of the treatment
nent data and assesses the client quickly and efficiently, as the client ultimately receives versus the care
shown in Figure 20-1. The nurse provides age-appropriate received in a hospital setting and understands
care, taking into consideration the client’s physical, mental, that thorough and appropriate client education
emotional, and spiritual developmental level. Health care is is vital to ensure adequate understanding of,
adapting to reflect the needs of society despite soaring costs, and compliance with, medical treatment. For
limited reimbursement, and an increasingly diverse and aging
example, the nurse cannot be sure that the client
population.
will fill his prescription and, if he does fill it, that
the medication will be taken as ordered or for
LEGAL ISSUES the length of time indicated. The nurse accepts
the responsibility of providing education to the
As our society changes and technology continues to take a client to ensure this result. The nurse customizes
more important position in the workplace, nurses are faced education to the client’s age, socioeconomic status,
with extraordinary ethical and legal challenges. All nurses educational and cognitive level, and health status.
receive education to help them understand the challenges and
make wise decisions in their practice. Whether nurses are prac-
ticing in a hospital, clinic, long-term care facility, or in the cli-
ent’s home, they must be prepared to act within safe and legal
parameters. In the ambulatory care setting, the legal issues that
most likely occur center on confidentiality, obtaining consent
Confidentiality
to treat, care of a minor, and reportable conditions. Protecting client’s medical confidentiality is part of a
nurse’s ethical responsibility. In 1996, the Health Insurance
Portability and Accountability Act, or HIPAA, became law.
This legislation was enacted with several purposes—to
simplify health care administration, to assure the portabil-
ity of insurance coverage for pre-existing conditions, and
to provide standardization of electronic billing and claims
settlement.
HIPAA requirements mandate that access to protected
health information is limited only to those who are autho-
rized to receive that information and who need the informa-
tion to provide care. The law also requires that adequate
security measures are in place to safeguard protected health
information where it is stored or used (Futch & Phillips,
2003). This legislation has provided uniformity from facility
to facility and from state to state in the management and pro-
tection of client health information. All individuals who are
involved in the procuring or storing of medical information,

PROFESSIONALTIP
Workload Stress
COURTESY OF DELMAR CENGAGE LEARNING

Work management is one of the biggest stressors

of nurses working in an ambulatory care setting.
According to Swan and Griffin (2005), nursing
workload measurement is influenced by the
number of clients who present for care, the
characteristics of the clients, and the characteristics
of the nursing role. Ambulatory care settings
require the nurse to work quickly and efficiently to
Figure 20-1 A nurse is collecting pertinent data from a provide care and teaching to clients.
client in an ambulatory care center.

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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 681

CRITICAL THINKING CRITICAL THINKING

HIPPA Teenage Ambulatory Care Client

L.W. is a nurse in a busy obstetrical/gynecological T.G., age 16, presents to the clinic unaccompanied
clinic. Another nurse has just completed care of a by a parent. T.G. wants the health care provider
client and cleaned the examination room. As L.W. to give her oral contraceptives. She tells the nurse,
enters the room with a new client, she sees that “My boyfriend and I are having sex. I cannot talk
the nurse left the previous client’s chart open on to my parents about it because they would be
the computer screen in clear view of the new client very upset with me. I am old enough to make
and herself. my own decisions and I do not want to have an
1. What should L.W. do to protect the privacy of unplanned pregnancy. Please let me talk to the
the previous client? doctor.” The nurse knows that the state where
2. What measures can be taken to prevent this they practice requires parental consent for a
potential HIPPA violation from occurring minor child to receive non-emergent medical
again? care.
1. What should the nurse tell T.G.?
2. If the nurse believes that T.G. has the right
to contraceptive care without parental con-
or those who may come across medical information in their
sent, how does the nurse resolve the conflict
work, are required to receive HIPPA training on an annual
basis. between ethical beliefs and legal requirements?

Consent to Treat
When selected invasive procedures are performed in an
office setting, it is necessary to obtain a consent form signed
by the client. The information the client receives before REHABILITATION/RESTORATIVE
signing is provided by the physician and includes possible CARE
procedure risks as well as the benefits. The nurse’s role is to
Rehabilitation and restorative care are used interchangeably.
witness the client’s signature and provide any necessary clari-
The goal of rehabilitation (rehab) is to assist individuals
fication or explanation after the physician provides the basic
in reaching their optimal physical, mental, and psychosocial
information.
functioning level. This goal is accomplished by prevent-
ing complications, modifying the effects of the disability,
Treatment of a Minor and increasing independence. Restorative care is an orga-
nized, methodical interdisciplinary program that thoroughly
Another legal issue that may arise in an ambulatory care set- evaluates the client’s feelings, thoughts, lifestyle, and physical
ting concerns the care of a minor. Two frequently asked ques- abilities with the goal of restoring and maintaining each indi-
tions are whether the minor receives treatment when a parent vidual’s performance potential. An emphasis is on improving
or legal guardian is not present and whether the minor’s medi- the client’s self esteem by having them manage as much self
cal information is released to parents. This comes into ques- care as possible by focusing on potential rather than limita-
tion particularly with an older child, most often in the areas of tions (Resnick & Fleishell, 2002) (See Figure 20-2). For the
mental health and reproductive health. Legislation regarding restorative staff to know the functional level of an individual,
these issues varies from state to state, and it is important for the team uses measurement instruments or tools to assess
nurses to know the statutes in the state where they practice to the functional status. The functional areas assessed are called
meet legal requirements. activities of daily living (ADL). These include bathing,
The nurse encounters ethical issues regarding the care of grooming, eating, toileting, and dressing. Also assessed are
a vulnerable adult, such as a person who is developmentally instrumental activities of daily living (IADL). These tasks
challenged. In most cases, there is a guardian appointed to include meal preparation, shopping, management of money,
provide support to the vulnerable adult and serve as their taking medication, and housekeeping. Restorative care is con-
advocate in a medical setting. cerned with increasing the client’s ability to complete basic
ADL and IADL (See Figure 20-3).
Reportable Conditions
The nurse notes reportable conditions, diseases or injuries
that the government requires to be reported to the appro- Minimum Data Set
priate authority or agency, and the protocol to follow in The minimum data set (MDS) is an assessment tool for
reporting these conditions. Reportable conditions include assessing resident’s physical, psychological, and psychosocial
suspected abuse and/or neglect, sexually transmitted infec- functioning in a Medicare and Medicaid-certified, long-term
tions (i.e., STIs), and certain other contagious illnesses that care facility. Refer to Box 20-1 for an example of an MDS
could threaten the health of the general public. These fall areas of assessment. Medicare and Medicaid use the MDS
under state regulation and vary from state to state. as a reimbursement tool. The MDS is completed upon the

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682 UNIT 9 Nursing Care of the Client: Health Care in the Community

BOX 20-1 MDS ASSESSMENT AREAS

Cognitive patterns
Communication/hearing patterns
Vision patterns
Mood and behavior patterns
Psychosocial well-being
Physical functioning and structural problems
Continence in last 14 days
Disease diagnoses
Health conditions
Oral/nutritional status
Oral/dental status
Skin condition
Activity patterns
Medications
Special treatments and procedures
Discharge potential and overall status
Therapy supplement

Interdisciplinary
Health Care Team
The interdisciplinary health care team, as shown in Table 20-1,
Figure 20-2 An occupational therapist teaches ADL to is an essential component to any restorative care process. The
a client. The kitchen is in a rehabilitation unit. (Courtesy of
client and family are the focus of the team and are encouraged
Kingston Residence of Fort Wayne, Fort Wayne, IN.)
to participate in the planning of care. The degree of family
participation is determined by the client. The professional
resident’s admission to the extended care facility and at members of the team are selected based on the needs of the
regular time intervals set by federal policy. After reviewing client (See Figure 20-4).
the MDS data, the interdisciplinary team (MDS coordinator,
director of nursing, dietitian, activities director, social worker, Roles of the Interdisciplinary
and director of therapy departments) completes a care plan to
assist the resident in reaching their full potential while living Health Care Team
in the facility. The interdisciplinary health care team assesses, maintains,
and evaluates the abilities of individuals in need of functional
therapy. The physical therapist develops a specific exercise pro-
gram to improve or maintain physical mobility, function, and
strength as shown in Figure 20-5. The occupational therapist

LIFE SPAN CONSIDERATIONS

Pneumonia and Urinary Tract
Infections in the Elderly
A study by Lim and Macfarlane (2001) showed
that those who are elderly and in long-term care
display more functional impairment when they
have pneumonia than the same populace in the
community. Clients with urinary tract infections
who are asymptomatic also have decreased
functional abilities. An MDS assessment effectively
reveals the declined function level in elderly clients
Figure 20-3 Pool therapy in a rehabilitation unit assists with pneumonia and urinary tract infections
individuals in reaching their optimal physical, mental, and (Goldrick, 2005).
psychosocial functioning level. (Courtesy of Kingston Residence
of Fort Wayne, Fort Wayne, IN.)

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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 683

A pharmacist reviews the resident’s medications monthly

Table 20-1 Interdisciplinary Health and oversees that the facility is meeting federal state regulations.
Care Team Roles If the resident’s physician does not serve the facility, a medical
director provides medical care to the resident and also to any
TEAM MEMBER ROLE residents in need of a physician while in the extended care facil-
Nurse See text for description of roles
ity. Depending on the facility, a dentist, podiatrist, and psycholo-
gist are available every month to every three months as needed.
Physician or Prescribe medical and Each discipline completes an assessment and pools this
physiatrist pharmacological treatment
information at the care planning conference so that a consensus
among members, including the client and family, are reached. The
Physical therapist Muscle and joint training team process avoids both duplication of services and fragmented
care. A holistic approach is used so that the client’s physical,
Occupational Fine muscle training, self-care mental, and psychosocial needs are identified (Wenckus, 1995).
therapist skills
Role of the LPN/VN
Nutritionist Assess for caloric intake Restorative nursing is a specialty practice and requires special-
ized knowledge, skills, and attitudes. A sound knowledge base
Speech therapist Swallow evaluations, speech in anatomy and physiology of the neurological, musculoskeletal,
retraining gastrointestinal, and urological systems is a prerequisite. The
nurse has excellent clinical skills in the areas of therapeutic posi-
Psychologist Test for cognitive, emotional, and tioning, range of joint motion exercises, transfers, ambulation,
psychological function; counseling and ADLs, as shown in Figure 20-6. The nurse is responsible for
for grief, loss, and depression planning measures to prevent complications such as impaired
skin integrity and contractures and to implement interventions
Social worker Evaluate need for financial for dysphagia, incontinence, and other identified problems.
resources, community resources; The nurse is a member of the interdisciplinary team and
counseling family issues
functions as caregiver, counselor, coordinator of care, and
client advocate (Mauk, 2007). The nurse seeks to understand the
Visiting nurse Evaluation of home setting; roles and responsibilities and to interrelate with each discipline.
assess, teach, and coordinate
There is a steady demand for restorative nurses in all settings.
Nurses are advocates for the older adults and their families in
home care
the health care system. The nurse is aware of the residents needs
and refers them to the appropriate health care service. The nurse
Vocational Vocational retraining, adaptation
continues to work alongside the health care services to reinforce
counselor of work setting
the older adult’s optimal health promotion and wellness.
Recreational Provides socialization Functional Assessment
therapist opportunities; teaches how to
adapt to community and Evaluation for
Rehabilitation/Restoration
Respiratory Treatment of respiratory or
Terms such as disability, impairment, and handicap describe
therapist ventilatory equipment problems functional levels. Disability is an individual’s lack of ability to
complete an activity in the normal manner. Impairment refers
Clergy Spiritual counseling to an abnormal psychological or physiologic behavior or an ana-
tomic loss, such as a loss of a limb (Eliopoulos, 2005). According
Clinical nurse Case management
to the Self-identification of Handicap form, handicap means
specialist the physical or mental inability to complete a role in one or more
From Nursing Fundamentals: Caring and Clinical Decision Making
major ADL (U.S. Office of Personnel Management, 1987).
(2nd ed.), by R. Daniels, R. Grendell, & F. Wilkins, 2010, Clifton Park, Clients who need restorative care are screened before
NY: Delmar Cengage Learning. admission to a program. Assessments are completed by health-
care professionals whose services may be required by the cli-
ent (Figure 20-7). The purpose of screening is to select the
assesses individuals to regain or maintain their ADLs. Occu- best setting for services. Criteria for admission to a program
pational therapy includes the use of assistive devices to reach usually require that the client be:
a needed item, or pull up socks, or move a leg after a stroke or • Medically stable
knee replacement. The speech therapist is the professional who
• Able to learn
assesses disabilities involving speech, communication whether
spoken or written, and swallowing ability. All of these individu- • Able to sit supported for at least one hour a day and to
als are professionally trained to complete these tasks. actively participate in the program
The social worker is a professionally trained individual Interdisciplinary programs may stipulate that the client
who assists in the admissions process. Resident and family has disabilities in 2 or more areas of function:
questions or concerns are usually addressed by a social worker • Mobility
in an extended care facility. • Performance of ADL

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684 UNIT 9 Nursing Care of the Client: Health Care in the Community

Admission to health care system

Interdisciplinary assessment Involves:

Requires knowledge of:
Client and family
Physical sciences Physician services
Developmental tasks Nursing
Maslow’s theory Problem indentification
Rehabilitation services
Aging process Physical therapy
Disease processes Occupational therapy
Learned helplessness Speech therapy
Self-care Care plan conference Nutritional services
Social services
Pastoral care
Activities

Interventions:
Goals:
Assist
Restorative Monitor
Preventative Counsel
Maintenance Teach
Comfort

Evaluation

Goal attainment:
Goals not attained:
Improvement
Deterioration
(physical, cognitive,
(physical, cognitive,
psychosocial)
psychosocial)
Freedom from
Complications

COURTESY OF DELMAR CENGAGE LEARNING

complications
Increasing functional
Maintenance of
deficits
status quo

Reassessment

Figure 20-4 The Interdisciplinary Health Care Team Process

• Bowel and bladder control

• Cognition
• Emotional function
• Pain management
• Swallowing
• Communication
There are a number of standardized assessment instru-
ments that are designed to evaluate motor function, cognition,
speech and language, mobility, and the client’s performance
of ADLs.

Assessment of Abilities
The Uniform Data System for Medical Rehabilitation (UDS)
was developed by a grant from the U.S. Department of Edu-
cation, National Institute on Disability and Rehabilitation Figure 20-5 The physical therapist assists a client with
Research. The UDS offers a uniform method to document a a specific exercise program to improve or maintain physical
client’s disability and medical rehabilitation, thereby provid- mobility, function, and strength. (Courtesy of Kingston Residence
ing a database of disability rehabilitation in more than 1,400 of Fort Wayne, Fort Wayne, IN.)

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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 685

Barthel Index
The Barthel Index is a functional measurement tool that mea-
sures a person’s level of independence in areas of self care and
mobility. It is used in restorative care areas to predict length
of stay and the amount of assisted care needed to complete
ADL. The Barthel Index is included in the FIM and PULSES
profile tools and only takes 5 minutes to complete.
These functional measurement tools assist in the objec-
tive documentation of changes that occur over time. With
these tools, professionals recognize changes as they occur and
promote optimal functional independence, which is the goal
of restorative care.

Rehabilitation/Restorative
Care Settings
Rehabilitation/restorative care settings are found in hospitals,
extended care facilities with rehabilitation units, and reha-
bilitation hospitals as stand-alone facilities. Private rooms in
hospitals and rehabilitation units are now the norm.

Special Beds
For residents with integumentary needs, whether they are the
result of poor nutrition or poor circulation, there are special
beds to aid in protecting the skin from breakdown. Pressure-
relieving support surfaces, including special beds, mattresses,
and mattress overlays, are available to support the body in
bed. Special air-fluidized beds flow pressurized air through
the oversized mattress to relieve pressure areas. A similar
bed is a low-air-loss bed that works on the same principle
of relieving pressure areas. Ring cushions (donuts) are not
recommended because they cause fluid congestion and
edema. None of these devices replace timely repositioning
Figure 20-6 A nurse applies a splint to the arm of a and assessing for skin breakdown on at risk residents. Repo-
rehabilitation client. (Courtesy of Association of Rehabilitation sitioning the body decreases pressure point areas, and using
Nurses.)
positioning devices to raise vulnerable areas prone to pres-
facilities with more than 13 million clients for standardized sure decreases skin breakdown. Pillows and foam wedges are
rehabilitation comparison. The UDS measures impairment placed between bony areas and under heels to relieve pressure
(function), disability (activity), and handicap (role). points from the mattress. Avoid shearing force when moving
There are several functional measurement tools to assess residents in bed.
functional status. Three functional measurement tools are
discussed in this chapter: Functional Independence Measure Urinary Devices
(FIM), Functional Assessment Measure (FAM), and the Bar- Incontinence causes skin tissue breakdown, and keeping the
thel Index. The FIM and the FAM are more commonly used skin dry prevents skin breakdown. In the past, indwelling
for the UDS. catheters were used. But years of research have proven that
indwelling catheters cause urinary tract infections and are not
Functional Independence Measure and used as frequently. For men, condom catheters are fit over the
penis and drained into a leg bag. Other devices for men are
Functional Assessment Measure urinary devices that act as an artificial sphincter for control of
The FIM is an assessment tool that assesses cognitive and urinary incontinence. The male incontinence clamp attaches
motor function status in relation to the amount of assistance to the penis to restrict incontinence.
needed to complete ADLs or IADL. Specific areas covered For women, there are medical devices to treat inconti-
include independence in cognition problem solving, memory, nence. One such device is a urethral insert, which is used in
communication, and social interaction. It also assesses physi- times of predictable incontinence, such as when taking part
cal independence in self care, control of bowel and bladder, in an activity like running. The disposable device is a small
transfers, and ambulation. The FIM is a widely used evaluation tampon-like plug that inserts into the urethra to prevent leak-
tool to review resident progress and rehabilitation/restorative ing urine. These devices require a prescription and are not
outcomes. meant for everyday use. Another female urinary device is a
The FAM assesses cognitive, behavioral, communication, pessary that is a stiff ring inserted into the vagina that holds up
and community functioning. The FAM is designed to use with a prolapsed bladder or uterus to prevent leakage of urine. The
the FIM (FIM+FAM) to provide a more comprehensive view device is worn all day and removed for cleaning on a regular
of the rehabilitation client. basis.

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686 UNIT 9 Nursing Care of the Client: Health Care in the Community

Client treated
Client dies
for acute stroke

Medical condition
stabilizes

Client screened Complete recovery

for rehabilitation no need for rehabilitation

Too incapacitated Needs recuperation Needs further Needs specific

for rehabilitation: before rehabilitation rehabilitation program: rehabilitation services:
Home decision: Inpatient Home
Nursing facility Home Nursing facility Outpatient
Chronic hospital Nursing facility Home

Reevaluate for rehablilitation Rehablilitation provided:

at a later date if condition Assess status
improves Individualized treatment
Monitor progress
Reassess needs

Discharged from rehablilitation or transferred

to another rehablilitation setting

COURTESY OF DELMAR CENGAGE LEARNING

Community follow up:
Assist with transition
Assess adaptation to community setting
Evaluate need for continued rehablilitation services
Evaluate need for other home care services
Monitor progress
Reassess rehabilitation needs

Figure 20-7 Assessing Potential Stroke Rehabilitation

complicated cases involving care required for wounds, intrave-

HOME HEALTH CARE nous therapy, diabetes, and cardiac or respiratory problems.
Home care encompasses a number of services delivered to per- Medicare-certified agencies provide intermittent care to
sons in their homes and is one of the fastest-growing segments persons meeting the criteria for care. A registered nurse calls
of health care delivery. Clients are receiving intravenous ther- on the client a specified number of times each week to assess
apy, ventilator care, parenteral nutrition, and chemotherapy the client’s condition, supervise the work of LPN/VNs and
at home. Many agencies have nurse specialists on staff for nonlicensed staff, and deliver skilled nursing care. Nursing
assistants are assigned to give personal care; check vital signs;
and do positioning, transfers, and passive range-of-motion
CRITICAL THINKING
exercises. In addition to nursing staff, the agency provides
therapists and social workers to serve their clients. These
Choosing Housing for a Family services are time-limited by Medicare and are not reimburs-
Member able if the client is not deemed to require skilled care.

How could a nurse assist an individual in evaluat-

ing an extended care facility for a family member?
Types of Home-Based Care
There are two types of home-based care. One type is profes-
sional and the other is technical.

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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 687

Professional that hold the assessment and plan of care for each home care
client. Most home health care facilities use an electronic
The professional division is based on scientific theory and clinical documentation system. The Centers for Medicare
principles bound by legal and professional standards and and Medicaid Services developed a computerized plan of
guidelines with licensed and certified employees. Employees care (Form 485) that is compatible with the home health
offering skilled services are nurses, therapists, social work- care electronic system. Nurses electronically document their
ers, and nursing assistants. Other additional services offered client assessments and delivery of nursing care on Form 485.
are homemaker assistance, meal preparation, cleaning, sitter The data are downloaded to the main frame computer in the
services, and transportation to physician offices. Respite main office for nurse managers to coordinate client care day or
care provides the caregiver with a short break from providing night. Through advanced technology, a nurse prioritizes the
care. This short break may be a period of hours, days, or even needs of the clients, implements a tighter control of nursing
weeks. case management, and decreases the cost of health care.

Technical Role of the Home Health

The technical division is driven by products sold for profit,
following guidelines for reimbursement of payment. Included Nurse
in the technical division would be the home medical equip- It is vital that the home health care nurse is experienced and
ment services or durable medical equipment that provides knowledgeable in various disease processes seen in clients
hospital beds, wheelchairs, scooters, walkers, oxygen, and within the home setting. The nurse works alone, draws on
related equipment. Also included in this division is the intra- previous experience, and knows when to call on or direct the
venous or home-infusion service that supplies the client with client to community resources to meet the health needs of the
intravenous equipment. Personnel from the home-infusion client. The nurse has fine tuned assessment skills along with
service either teach the caregiver how to run the equipment technological knowledge to use different equipment. The
or teach the client how to administer the infusion. Therapies nurse manages home cases by using the federal government
include tube feedings, hyperalimentation, antibiotics, blood assessment and plan of care forms necessary for reimburse-
or blood products, analgesics, or antineoplastics. Reimburse- ment. Communication techniques are crucial between all of
ment payment is determined by insurance companies, man- the health team members.
aged care companies, and Medicare.
Role of the LPN/VN
Home Visit Outcomes Although the role of the LPN is expanding, in 2006, 56,610
In 1999, that Medicare reimbursement requirements were LPNs were working in home health care. This means that 7.5%
mandated for home health agencies to validate client out- of all employed LPNs worked in home care (Bureau of Labor
comes, quality improvement, and client satisfaction of care. Statistics, 2007). The responsibilities of the LPN/VN vary
An outcomes measurable tool called Outcomes and Assess- among agencies. All nurses working in home care must have
ment Information Set (OASIS) was developed and imple- excellent assessment skills and a keen ability to identify actual
mented to determine the care given and reimbursement and potential problems. Teaching the client and family is a
required. OASIS data are reported to the Centers for Medicare major responsibility for the home health nurse. Communica-
and Medicaid Services. Each home health care agency uses tion skills are essential as the nurse provides care to the client
this system to review the agencies’ data results and compare and meets the needs of the client’s family (See Figure 20-8).
their outcomes and client satisfaction to other similar agen- The client with a chronic health problem will have ongoing
cies. Other home health care agencies, although not required needs after the home health care is discontinued. The home
by Medicare, use the Outcome Based Quality Improvement health nurse continually seeks out community resources to
System to improve client outcomes. use in caring for clients. Clients and their family caregivers are
taught the following:
Trends in Home Care The disease process
Home health care has evolved into a more technologic nurs- • Complications that may occur
ing care. Care within the home now includes apnea moni- • How to prevent the complications
tors, electrocardiographs, ventilators, parenteral nutrition, • Signs and symptoms of the complications
intravenous therapy, chemotherapy, chest tubes, and skeletal • How to reduce risk factors such as dietary changes and
traction. Client x-rays are taken by mobile x-ray machines. exercise programs
The advanced technology provides client care without clients
leaving their homes. Medications
• Actions of medications
Telehealth • Special administration guidelines such as timing related to
meals
Telehealth is electronic information services that offer
increased client and family participation. The nurse and • Side effects
client use interactive videos, telephone cardiac rate monitor- Special skills
ing with EKG readout, digital subscriber lines, and internet • Drawing up and administering insulin or other injectables
transmission of data. Photos of client’s wounds are viewed
with an in-home computerized, two-way viewing screen. • Using a blood glucose monitor
Home health care nurses use hand-held or laptop computers • Changing dressings

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688 UNIT 9 Nursing Care of the Client: Health Care in the Community

environment than a long-term care facility and maintains the

individual’s independence and freedom of choice. This level of
care may be offered in a freestanding facility or as a section of
a long-term care facility. A monthly fee is charged and covers
rent, utilities, housekeeping services, meals, transportation,
health promotion, exercise programs, and assistance with
ADL. There are an estimated 36,000 assisted living residences
in the United States, with more than 1 million residents
(Assisted Living Federation of America, 2009).

ADULT DAY CARE

Adult day care centers are located in a separate unit of a long-
term care facility, in a private home, or are freestanding. They
provide a variety of services in a protective setting for adults
who are unable to stay alone but who do not need 24-hour
care. The centers are generally open from 7:00 A.M. to
6:00 P.M., 5 days a week, and serve two or three meals in a day.
A daily or hourly fee is charged with an additional charge
for meals. Services are limited to socialization or may be
comprehensive, offering modest restorative care services and
nursing care. Adult day care is often used by working persons
who have a spouse or a parent living with them who cannot
be left alone.
COURTESY OF DELMAR CENGAGE LEARNING

RESPITE CARE
Respite care is offered by adult day care centers, long-term
care facilities, or in private homes. It is intended to provide a
break to caregivers and is used a few hours a week, for an occa-
sional weekend, or for longer vacations. Planned activities,
meals, and supervision are included in respite care services.
Figure 20-8 A home health nurse provides care to the
client and meets the needs of the client’s family.

• Monitoring vital signs LONG-TERM CARE

• Using special client care equipment, adaptive devices, and Long-term care refers to a spectrum of services provided to
assistive devices individuals who have an ongoing need for health care. Long-
Documentation and communication term care has traditionally meant a community-based nursing
home licensed for skilled or intermediate care. Although there
• How to keep records for nurse or physician visit; for is a great demand for this type of care, there is also a market for
example, blood glucose, blood pressure, and weight other levels of health care.
• Communication with health care providers
• How and when to contact the home health nurse
• How and when to contact the physician Long-Term Care Facilities
• How and when to contact emergency services Long-term care facilities provide services to individuals who
are not acutely ill, have continuing health care needs, and can-
not function independently at home. They are licensed for
Future of Home Health Care either intermediate care or skilled nursing care. Intermediate
Home health care has met the challenges of changes in the care facilities are not certified for reimbursement from Medi-
past with OASIS and reimbursement requirements of Medi- care but may be certified for Medicaid funding. Skilled nursing
care. It is imperative that home health care agencies and facilities are eligible for certification by both Medicare and
nurses continue to use evidence-based research to implement Medicaid, but not all facilities choose to become certified.
improvements to client care that is cost effective and ensures These facilities were formerly called nursing homes, rest
quality of healthcare. homes, or convalescent centers. The term extended care
facility (ECF) refers to any facility that provides care for a
long period of time. It has no concrete definition and could
ASSISTED LIVING refer to either an intermediate or skilled nursing facility. Facili-
ties in every state that receive any government funds from any
Assisted living combines housing and services for persons source are required by law to be in compliance with the Omni-
who require assistance with ADLs. Nursing care is usually pro- bus Budget Reconciliation Act of 1987 (OBRA) regulations.
vided for an additional fee. These are persons who cannot live The Act requires that residents be free from all unneeded
alone but who do not need 24-hour care. It is a less restrictive drugs and chemical restraints (psychotropic drugs).
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 689

A restorative philosophy of care provides direction for

the interdisciplinary team. Emphasis is placed on assisting
Holistic Nursing in Extended
the client (usually called resident) to attain and maintain the Care
highest level of physical, mental, and psychosocial function. Holistic nursing reaches beyond treating diseases and meets
A holistic approach is used, and families are important the needs of the total person by nourishing the biological, psy-
members of the care team. A large number of facilities have spe- chological, social, and spiritual parts of a person. The holistic
cial units devoted to the care of residents with specific problems. view promotes health and wellness.
These units care for persons with Alzheimer’s disease, diabetes, As the body changes through the aging process and has
respiratory disorders, wounds, and other conditions. acute and chronic health problems, the effect on the wellness
Long-term care or extended care facilities are available of the body, mind, and spirit is diminished. Wellness develops
for older adults in need of nursing care 24 hours a day. The from maintaining a positive purpose in life and an inner spiri-
older adult receives assistance with ADLs, nursing supervi- tual wholeness. Nurses change health outcomes as the result
sion, and activities to keep the mind stimulated. Physical, of their knowledge in the sciences and humanities. In caring
speech, and occupational therapy are offered to assist the older for the older adult, nursing plays a significant role in assisting
adult. Also offered are three nutritious meals planned by a the older adult to find their balance of health promotion and
dietitian to meet the physician’s orders, along with snacks for wellness (See Figure 20-9).
the older adult. The nursing staff includes registered nurses,
LPNs, and certified nursing assistants 24 hours a day. House-
keeping services are available to keep the older adult’s room Routines and Treatments
and linens clean. An activity coordinator and social service In an extended care facility, holistic gerontological nursing care
personnel are included in the extended care facility staff. goals are to: (1) enhance the older adult’s growth to wholeness;
This could be one or two people based on the number of beds (2) encourage improvement and learning from an acute or
in the extended care facility. Added client expenses include chronic disease; (3) optimize the quality of life during a terminal
medications, outside physician costs, various therapies, per- illness or disability; and (4) ensure comfort, peace, dignity and
sonal care items, and laundry services. integrity in death (Eliopoulos 2005).

Reimbursement
Federal and state reimbursement is determined by the resi-
Activities
The enjoyment of life does not have to end when an older adult
dent’s functional abilities and services used while in the enters an extended care facility. An older adult can continue
facility. The facility is reimbursed for a certain amount of to find purpose in life. This time in life provides the individual
money for expenses by Medicare and Medicaid. Each year, the with the freedom to reflect on life’s work experiences, family life,
Medicare/Medicaid facility is reviewed by state and/or federal
personnel to ensure that the facility is meeting expected stan-
dards of care. If not, and if the infractions are severe enough,
the facility is fined and/or loses Medicare/Medicaid funding.
Facilities have closed their doors based on poor results. Every
facility has to post these state/federal findings within the facil-
ity for the public.

Discharge
Client discharge planning begins at the time of admission and
is included in the care plan. By placing the information on the
care plan, all long-term care personnel know the same infor-
mation and goals for a satisfactory outcome.

EXTENDED CARE FACILITIES

Extended care facilities are designed to provide different
services to meet specific client needs. The basic extended care
facility offers 24-hour supervised nursing care with a certi-
fied nursing aide to assist with ADLs. The next level is skilled
nursing care. This level offers services of registered nurses
and licensed practical nurses 24 hours a day that includes treat-
ments, administration of medications, and procedures. Skilled
care services include professionals in physical, speech, occupa-
tional, and respiratory therapies. Subacute care offers the same
services as skilled care but is more focused on residents with
acute or chronic illness or injury. Some extended care facilities
are designed for special needs children and for older adults
with special needs, such as Alzheimer’s/dementia units. Senior
communities offer living options to meet the older adults’ Figure 20-9 A nurse provides quality care to a client in
needs such as totally independent apartments or condos, an extended care facility. (Courtesy of Kingston Residence of Fort
assisted-living areas, and skilled nursing care facilities. Wayne, Fort Wayne, IN.)
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690 UNIT 9 Nursing Care of the Client: Health Care in the Community

future goals, spiritual renewal, and social interactions. Taking part

in extended care facility activities can assist in these pursuits. BOX 20-2 SERVICES COVERED FOR THE
The activity department is staffed with professionally OLDER ADULT BY MEDICAID
trained personnel to create activities that meet the needs of each
older adult. Some of the outside activities include trips to malls, Outpatient/inpatient hospital
picnics that include the family, gardening, shopping, and attend- Laboratory
ing local concerts. Some of the indoor activities include musical
Radiology
activities; perhaps a local organ or piano talent, a choir, dances,
or parties that may include a juke box. Christmas dinner with the Medical expenses
resident’s family, woodworking projects, pet therapy, craft mak- Surgery expenses
ing, exercise groups, bingo, Bible study, and cooking are other Dental care exams
activities that are offered. Religious services of various beliefs are
arranged by the activity department. The activity department Home health care
can also assist in scheduling a visit to the beautician or barber. Extended care facility
Individual activities such as the use of audio taped books are Physician expenses
arranged when a resident is unable to leave the room. Monthly Family nurse practitioner services
activities are posted so residents anticipate the event and partici-
pate as desired. Activities provide a social gathering and stimula-
tion for the mind along with physical activity. Medicare is a federal health insurance program for persons
65 years of age and older or disabled individuals, regardless of
Dietary the income. There are two parts to Medicare: Part A and Part
There are several meals planned by a dietitian in an extended B. Part A is considered hospital insurance. Part A covers an
care facility. The dietitian consultant reviews each resident’s extended care facility if the resident requires skilled care after a
intake of meals by percentage, fluid intake, and laboratory test hospital stay of 3 days within a 30-day time limit for 100 days.
values to avoid nutrition deficiencies and dehydration. The Medicare covers home health and hospice care if the illness is
dietician then makes recommendations to the extended care terminal within 6 months. Medicare also covers hospital ser-
facility’s dietary manager and the director of nursing. Meal vices such as laboratory, pharmacy, radiology, surgical opera-
planning and dietary services are reviewed annually by the tions, critical care, rehabilitation/restorative care, extended
state government review board and, if necessary, the federal stays, and meals. Part B is a supplementary medical insurance
review board. It is the physician who determines and orders plan and covers physician services, and non-physician services
the diet for each resident. When a client is admitted, the such as flu vaccinations and some therapies.
dietary staff reviews personal food preferences. Long-term care insurance is paid monthly before the
need of service to offset the cost of long-term care. Policies
Financial Issues vary on what services are covered and type of facility.
Supplemental Security Income is not the same as social
Private funds, Medicare, Medicaid, long-term care insurance, security but is similar in that the government supplies a
and supplemental security income cover the cost of extended monthly check to a disabled person or one with a financial
care. Private funds are mostly used for independent and assis- need at age 65 and older. To receive Supplemental Security
tive living options. Assistive living facilities in some states Income, a person has to have little or no income.
accept Medicaid. Medicaid is a federal and state program that Veterans with a health condition can receive medical care
assists individuals and families who need financial assistance. or rehabilitation/restorative care in a veterans’ affairs hospital
Medicaid services vary from state to state; this is called a Med- or an extended care facility approved by the state to serve veter-
icaid waiver. The Medicaid rates are agreed on by the supplier ans. If the health condition is service related, the long-term care
of services and Medicaid and are accepted as full payment. is provided as needed in an approved extended care facility.
Refer to Box 20-2 for expenses covered by Medicaid.

CRITICAL THINKING
PALLIATIVE CARE AND HOSPICE
Clients with chronic diseases or diseases that are not respon-
Social Isolation sive to a cure are candidates for palliative care. Palliative
care addresses the complications of the illness rather than the
prognosis. Palliative care is separate from hospice care and is
Social isolation is a common psychological problem
effective if started early in the disease process rather than at the
for clients who are admitted to rehabilitative or
end stages of the disease. Palliative care relieves symptoms of
restorative facilities. the disease and assists the family in setting and reaching goals,
1. How can the nurse reduce the client’s social addressing and resolving conflict, and putting meaning to the
isolation while in the rehabilitation/restorative dynamics of the illness and dying experience (Ferrell & Coyle,
care hospital? 2002). The illness affects the entire life of the client and family.
2. What other disciplines within the rehabilita- The interdisciplinary team works through multiple
tion/restorative care hospital reduce the cli- obstacles, such as client symptoms, family miscommunica-
ent’s social isolation? tions, family members’ grief, and cultural barriers to provide
3. In what ways can the nurse involve the family quality care. Nurses play a vital role as the client and family
to resolve the client’s social isolation? rely on them to meet their needs. Clients have countless emo-
tions that nurses acknowledge and address such as anxiety,
depression, sadness, loneliness, hopelessness, and anger (See
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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 691

BOX 20-3 HOSPICE SERVICES COVERED

BY MEDICARE
Physician and nursing care
Home health aide care
House keeping services
Physical, occupational, and speech therapy
Counseling services
Pastoral services
Assistance with transportation, shopping, or other
chores
Bereavement support
Medical equipment and supplies
Pain medication (no prescription costs more than $5)
Five days of respite care for caregiver
(Scala-Foley M, Caruso J, Archer D, & Reinhard S, 2004;
Medicare.com, 2008)

the physician or hospice medical director states the client has 6

months or less to live, the client signs a paper choosing hospice
care rather than curative care, and the client signs a paper to enter
a Medicare-certified hospice program (Ferrell & Coyle, 2002).
Figure 20-10 A garden is a place of solace for a hospice
client and family. (Courtesy of Visiting Nurse and Hospice Home,
Fort Wayne, IN.)
Figure 20-10). The palliative and hospice nurses not only PROFESSIONALTIP
attend to physical conditions but must be perceptive in han-
dling psychological, psychosocial, and spiritual needs. The
nurse acknowledges the client and family members’ emotions Questions about Medicare Hospice
and guides the client and family in gaining a sense of control Benefits
and focusing on positive aspects of life. The State Health Insurance Assistance Program
Hospice provides care to the client and family through
(SHIP) answers question regarding Medicare
the dying process and assists the family in the grief process.
Hospice provides pain relief for the client, focuses on the coverage of Hospice benefits. The phone number
family during the loss of their loved one, and supports the fam- is 800-MEDICARE or the website is www.medicare.
ily as they work through their grief (Ferrell & Coyle, 2002). gov (search for “Helpful Contacts”). Clients or
End-of-life care is care provided in the last few weeks of life. nurses can call SHIP for any Medicare hospice
Medicare covers the cost of hospice if the client is eligible benefit questions.
for Medicare Part A. The criteria for Medicare Part A is that

SAMPLE NURSING CARE PLAN

The Stroke Client
R.A. has had an altered state of wellness caused by a recede stroke and is living at the local restorative
care hospital. She is distrustful of the new surroundings and is feeling socially isolated from her friends
and family. She has left-sided paralysis and is scheduled for daily physical therapy to regain her strength
and mobility. She walks with a cane.
NURSING DIAGNOSIS 1 Impaired Physical Mobility related to decreased strength and endurance as
evidenced by paralysis of left arm and leg and inability to walk without a cane
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Ambulation: Walking Exercise Therapy: Joint Mobility
Exercise Promotion: Strength Training
Exercise Therapy: Ambulation
Teaching: Prescribed Activity: Exercise
Teaching: Safety

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692 UNIT 9 Nursing Care of the Client: Health Care in the Community

SAMPLE NURSING CARE PLAN (Continued)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
R.A. will regain strength in Maintain the left arm and leg in Prevents contractures and
left arm and leg and walk inde- natural alignment. maintains proper alignment for
pendently with a cane within 6 future use.
weeks. Place pillows to support left arm Prevents pressure on body surfaces
and leg in proper alignment. and maintains extremities in proper
alignment for future use.
Assist with ambulation frequently Client gains strength in extremities
and gradually extend ambulation and improves ambulation skills
time frames. with cane.
Teach safe crutch walking. Teaches client correct use of cane
when ambulating to prevent falls.
Encourage use of left arm and leg Improves client’s self esteem and
for self-care activities. improves self care.
Encourage arm and leg exercises. Client increases strength in
affected arm and leg.

EVALUATION
At the end of 6 weeks, R.A. has full range of motion against gravity and flexes both arm and leg against
resistance. R.A. walks independently with cane and relates ambulating safety precautions to the nurse.

NURSING DIAGNOSIS

Social isolation related to an altered state of wellness while in rehabilitation hospital

NOC: Family Environment: Internal, Social Involvement, Social Support

NIC: Family Involvement Promotion, Socialization Enhancement, Support System Enhancement

CLIENT GOAL
Client’s social isolation will decrease within 48 hours of social activity while in rehabilitation hospital.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Client will have a primary nurse.
1. The relationship between the primary nurse
and client fosters continuity of nursing care
and promotes a caring and trusting
nurse-client relationship.

2. Provide privacy and reduced interruptions 2. Providing privacy and reducing interruptions
through grouping of nursing tasks. encourages family interaction and
communication.

EVALUATION
Is the client feeling less alone? Is the client content with social interactions?

Concept Care Map 20-1

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 CHAPTER 20 Ambulatory, Restorative, and Palliative Care in Community Settings 693

CASE STUDY
E.J., 72 years old, was admitted to Community Hospital for a left below-knee amputation. E.J. was an insulin-depen-
dent diabetic for 35 years. The amputation followed a long and unsuccessful period of treatment for venous stasis
ulcers. E.J. was transferred from the hospital to a rehabilitation hospital on her fourth postoperative day. After
2 weeks at the rehabilitation hospital, she was transferred to a skilled care facility near her home for additional
restorative care and regulation of the diabetes. She is now ready to be discharged to her home. E.J. has a prosthesis
and is able to ambulate with a walker. She performs her ADL with minimal assistance. She was on a sliding scale and
blood glucose monitoring 4 times a day while in the long-term care facility. Her physician has now placed her on
insulin twice a day with daily blood glucose checks. Her vision is somewhat impaired due to the diabetes. E.J. lives
alone in a one-story home in a sage residential area. The discharge planner at the skilled care facility has arranged
continuing care for E.J. through a local home health agency.
The following questions guide your development of a nursing care plan for the case study.
1. Identify the assessment factors that are most important in planning E.J.’s care.
2. List the nursing diagnoses that are applicable to E.J.’s assessment.
3. Describe the complications for which E.J. is at risk.
4. Describe nursing interventions for preventing the complications.
5. What specific actions would you take to prevent a recurrence of venous stasis ulcers?
6. What additional community services does E.J. need?
7. What nursing services (frequency of nurse visits, services from a nursing assistant, other home health services)
would you plan to meet her needs? What services would each person provide?
8. Describe the outcomes you expect for E.J.?

SUMMARY
• Ambulatory care provides the nurse with opportunities to • Home Health Care requires the nurse to be technologically
work with clients of all ages across the health continuum. competent.
• Ambulatory care nurses require a high degree of skill in • The home health care nurse refers clients to community
communication and client education. resources.
• The goal of rehabilitation/restorative care is to assist • The home health care nurse possesses knowledge of
individuals in reaching their optimal physical, mental, and the various federal government forms and data systems
psychosocial functioning level. necessary to carry out the position and ensure planned
• The interdisciplinary health care team assesses, maintains, outcomes and quality of care to client.
and evaluates the abilities of individuals in need of • Palliative care relieves symptoms of the disease and assists
functional therapy. the family in setting and reaching goals, addressing and
• The minimum data set (MDS) is an assessment tool resolving conflict, and putting meaning to the dynamics of
for assessing resident’s physical, psychological, and the illness and dying experience.
psychosocial functioning in a Medicare and Medicaid- • Hospice provides pain relief for the client, focuses on the
certified long term care facility. family during the loss of their loved one, and supports the
• Long-term care facilities provide services to individuals family as they work through their grief.
who are not acutely ill, have continuing health care needs,
and cannot function independently at home.

REVIEW QUESTIONS
1. A reason for the growth in nonacute health care ser- 2. Medicare is a reimbursement system for health care
vices is: (Select all that apply.) providers that:
1. the diminishing supply of physicians. 1. is based upon the client’s personal financial
2. an increase in the number of hospitals in the resources.
country. 2. is available to persons 65 years of age and
3. direct marketing of pharmaceuticals. older or who have been disabled for 2 or
4. the increase in Medicare reimbursement. more years.
5. the population shifts in the United States. 3. pays the full cost of all medical care.
6. the increased interest in alternative therapy. 4. is managed by each state.

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694 UNIT 9 Nursing Care of the Client: Health Care in the Community

3. What client would be the most likely to benefit from 3. clinical nurse specialist.
rehabilitation/restorative care services? 4. social worker.
1. J.B., 64 years old, had a stroke, is responsive and 7. The Minimum Data Set is a government tool to
stable. assess: (Select all that apply.)
2. M.C., 89 years old, has Alzheimer’s disease in the 1. a functional need.
fourth stage. 2. psychosocial need.
3. M.Z., 26 years old, is recovering from 3. medical needs.
pneumonia. 4. discharge planning.
4. R. K., 56 years old, has terminal cancer of 5. psychological patterns.
the lung. 6. effect of medications.
4. As a member of the interdisciplinary health care 8. What main factor determines the choice of housing
team, the LPN/VN: (Select all that apply.) for the older adult?
1. participates in the planning of client care. 1. The facility’s floor plan.
2. plans the appropriate diet for clients. 2. Dietary menu.
3. teaches the new amputee how to walk with a 3. Functional perimeters.
prosthesis. 4. Activity program.
4. advocates the needs of the client. 9. The OASIS
5. provides alternative methods of communication 1. is used to assess a client’s physical, psychological,
for the client with recent stroke. and psychosocial functioning.
6. understands the roles and responsibilities of each 2. is a computerized plan of care that is compatible
discipline. with the home health care electronic system.
5. In the home health care setting, it is essential that 3. provides a uniform method to document a
the LPN/VN possess skills in: (Select all that apply.) client’s disability and medical rehabilitation.
1. total parenteral nutrition. 4. is used to review the agencies’ data results and
2. respiratory therapy treatments. measures home health care outcomes.
3. data collection. 10. A client was just admitted to the rehabilitation
4. planning and providing speech therapy. unit. The nurse’s restorative care goal for the client
5. medication administration. is to:
6. client teaching. 1. restore health.
6. In a long-term care facility, the LPN/VN serves 2. assist in reaching optimal functional level.
as the: 3. send residents home after two weeks of therapy.
1. charge nurse of a unit. 4. restore only ADLs.
2. director of nursing.

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UNIT 10 Applications
Chapter 21 Responding to
Emergencies / 698

Chapter 22 Integration / 725

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 CHAPTER 21
Responding to Emergencies

MAKING THE CONNECTION

Refer to the following chapters to increase your understanding of emergency situations:
Adult Health Nursing
• Respiratory System • Neurological System
• Cardiovascular System • Sensory System
• Gastrointestinal System • Reproductive Systems
• Urinary System • Integumentary System
• Musculoskeletal System • Mental Illness
• Substance Abuse

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Define key terms.
• Describe the emergency medical services.
• Explain the role of the nurse in emergency situations.
• List personnel needed to respond to an in-hospital emergency.
• Discuss the steps in assessing an emergency client.
• Cite the different levels of triage.

KEY TERMS
chain of custody emergency nursing shock
disaster Glasgow Coma Scale trauma
emergency paramedic triage
emergency medical
technician (EMT)

698

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 CHAPTER 21 Responding to Emergencies 699

core emergency preparedness competencies for public health

INTRODUCTION workers:
An emergency can be defined as a medical or surgical • Describe the agency’s role in responding to a range of
condition requiring immediate or timely intervention to emergencies that might arise.
prevent permanent disability or death. Emergency nursing • Describe the chain of command in emergency response.
has developed rapidly over the years in response to the chang- • Identify and locate the agency’s emergency response plan
ing environment and expectations of the community. Many (or the pertinent portion of it).
advancements in emergency care is attributed to the military. • Describe emergency response functions or roles and
To manage vast numbers of injured soldiers, the military demonstrate them in regularly performed drills.
developed a systematic method of treating and responding
to trauma (wound or injury). Casualties caused by wartime • Demonstrate the use of equipment (including personal
situations created the need for advancements in the care of protective equipment) and the skills required in
large numbers of clients with injuries, wounds, and illness. emergency response during regular drills.
Methods of caring for multiple clients were developed and • Demonstrate the correct operation of all equipment used
implemented as a result of military influence. for emergency communication.
In the United States, trauma is the number one killer of • Describe communication roles in emergency response
those younger than age 43 and the fourth leading cause of within your agency, with news media, with the general
death overall (The American Association for the Surgery of public, and with personal contacts.
Trauma, 2007). Motor vehicle collisions kill more than 43,000 • Identify the limits of your own knowledge, skills, and
people each year, with almost 5 million car crash victims cared authority and identify key system resources for referring
for in emergency departments (EDs) (The American Associa- matters that exceed these limits.
tion for the Surgery of Trauma, 2007; CDC, 2009). • Apply creative problem-solving skills and flexible thinking
Emergency nursing is the care of clients who require to the situation, within the confines of your role, and
emergency intervention. The emergency nurse must be evaluate the effectiveness of all actions taken.
capable of rapid assessment and history taking and immedi-
ate intervention formulation and implementation utilizing • Recognize deviations from the norm that might indicate an
the nursing process. This role carries great responsibility. emergency and describe appropriate action.
Throughout the assessment and care of the client, the emer- • Participate in continuing education to maintain up-to-date
gency nurse plans and teaches prevention and health promo- knowledge in relevant areas.
tion, as well as rapidly develops rapport with the client and • Participate in evaluating every drill or response and
family, including assisting with emotional needs. Clinical identify necessary changes to the plan.
knowledge, communication, client teaching, and empathy
skills are essential to effective emergency care. Although LP/
VNs are seldom hired for EDs, they may float or help during
emergency situations; therefore, a brief overview of emer-
APPROACHES TO EMERGENCY
gency nursing is justified. CARE
A disaster is a situation or event of greater magnitude There are three general approaches to emergency care: hospi-
than an emergency that has unforeseen, serious, or immediate tal triage, disaster triage, and the emergency medical services.
threats to public health. They are natural events such as large To care for the emergent client, one first determines the sever-
fires, earthquakes, floods, hurricanes, or tornadoes; or human- ity of illness.
made events such as war, terrorism, or overwhelming contami-
Hospital Triage
nation of the environment (Gebbie & Qureshi, 2002).

Each hospital with an ED has an established “triage” system

EMERGENCY/DISASTER in effect. Triage refers to classification of clients to determine
PREPAREDNESS priority of need and proper place of treatment. Triage is typi-
cally used in the ED to establish priorities and levels of care
To prepare for emergencies or disasters, it is necessary to needed by the clients. Although clients and their families
identify who needs to know how to do what. To this end,
Gebbie and Qureshi (2002) have outlined the following core
competencies for nurses that were modeled after the CDC’s PROFESSIONALTIP
CRITICAL THINKING Golden Rules of Emergency Care
Stress 1. Establish the safety of the scene.
2. Remove the client from danger.
Describe factors that contribute to stress in an 3. Establish airway, breathing, and circulation.
emergency room setting. 4. Manage shock.
5. Attend to eye injuries.
What can nurses do to effectively reduce stress
6. Treat skin injuries.
when working in a stressful environment?
7. Call for help.

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700 UNIT 10 Applications

INFECTION CONTROL within 1 to 2 hours to prevent worsening of their conditions.

Examples of urgent situations include acute abdominal pain
and compound fractures. For nonurgent clients, care can be
Mouth-to-Mouth Resuscitation
M delayed without the risk of permanent consequences. Contu-
sions and sprains are examples of nonurgent complaints.
When delivering care to any client, the nurse is
careful to practice Standard Precautions. Direct
mouth-to-mouth breathing should not be
Disaster Triage and Mass
administered; instead, use of a bag-valve-mask Casualty Incidents
for resuscitation is more effective in both pro- Disaster or mass casualty incident triage systems represent a
tecting the health care worker and the client second approach to emergency care. In the event of a mass
from possible infection and in administering casualty incident (MCI), where there are more victims than
respirations. care providers, these systems are used. The disaster may be
a natural occurrence like a tornado, hurricane, or flood, or
human-made, such as a train accident, chemical spill, or ter-
rorism. In the event of an MCI, an Incident Command System
define emergency according to their perceptions, it is the tri- is established to provide safe and orderly management. Given
age nurse’s responsibility to sort and prioritize the clients as the possibility of large numbers of casualties as a result of disas-
they arrive in the ED. ters, different approaches to triaging from that of the hospital
The simplest method of triaging clients is to use the Amer- system may be used. Another similar system developed for
ican Heart Association’s basic life support principles: Airway, pre-hospital providers is the START (Simple Triage and Rapid
Breathing, and Circulation (ABCs). By using this method, Treatment) system, where the victims are rapidly color coded
clients with airway problems are immediately assessed and based on respirations, perfusion, and mental status (Figure
become a top priority of care. If any of the ABCs are not func- 21-1). A victim is given a red tag if immediate treatment is
tioning, either the Heimlich maneuver or cardiopulmonary needed, such as shock or a severe head injury, and is at risk for
resuscitation (CPR) is initiated. death. Yellow tags are given to victims who have serious injuries
Most hospitals have a triage system established to provide but their respirations are <30 per minute, the capillary refill is
expedient care to those requiring it first. Although the term <2 seconds, and they can follow simple commands. A yellow
emergency department implies emergency care, the client using tag indicates the victim can receive delayed treatment. Green
this department does not always require immediate care. In tags are given to victims with minor injuries. The treatment
2000, there were 108 million visits to hospital EDs (McMahon, for these victims is reassurance and transportation to a facility
2003). The most commonly used triage classifications are when other clients with more urgent needs have been trans-
emergent, urgent, and nonurgent and are recognized by the ferred. A navy tag is given to victims who are dead or whose
Emergency Nurses Association (McMahon, 2003) (Table injuries are so severe they will die soon (BCEMS Web, 2009).
21-1). Emergent clients require immediate care in order to Most communities have disaster/mass casualty commit-
sustain life or limb. Examples of emergent conditions include tees or an emergency management agency (EMA) director.
foreign bodies in the eye, shortness of breath, impending These committees include all hospitals, the emergency medi-
birth, and cardiopulmonary arrest. Urgent clients require care cal services (EMS) system, and citizens needed to alert the
community of an impending or real disaster.
START Triage - Assess, Treat
Table 21-1 Triage Categories Find color, STOP, TAG, MOVE ON

CATEGORY/ Move Walking Wounded

PRIORITY CLIENT NEEDS EXAMPLES No Resp after head tilt
Breathing but
Emergent Immediate Cardiac arrest Unconscious
intervention is Resp > 30
Multiple trauma
required to sustain Perfusion
D Cap refill > 2 sec
life or limb. I
M or No Radial Pulse
E M
M Control bleeding
Urgent Care is required Compound I C
E Mental Status –
within 1 to 2 fractures N E D
Can’t follow simple
hours to prevent O A I
Persistent vomiting commands
R S A
deterioration of and diarrhea T D Otherwise
E E E
condition.
D L
Y L
Remember
COURTESY OF DELMAR CENGAGE LEARNING

Nonurgent Care may be Contusions A R – 30

delayed without Y P–2
Minor sprains and E M – Can do
risk of permanent fractures D
sequelae.

Developed from Military Standard Operating Procedure (SOP) for

General Hospitals. Figure 21-1 START Triage (Courtesy of Critical Illness and
Trauma Foundation, Inc.)

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 CHAPTER 21 Responding to Emergencies 701

Emergency Medical Services

Before admission to the ED, the client usually is cared for MEMORYTRICK
by a first responder or an emergency medical technician
(EMT). An EMT-B (Basic) is a health care professional
trained to provide basic lifesaving measures before arrival at Use the ABCDs of emergency care when assessing
the hospital. An EMT-P (Paramedic) is a more specialized a client in a prehospital setting:
health care professional educated to provide advance life sup-
port to the client requiring emergency interventions (Figure A = Airway – Establish a patent airway.
21-2). Both are part of the EMS and are essential to prehospi- B = Breathing – Provide ventilation; use resusci-
tal care of the emergency client. tation measures as needed.
Principles of first aid, developed for emergency medicine,
are part of the triage process and include what are referred to C = Circulation – Restore and maintain circulation
as the golden rules of emergency care. The first of these rules by restoring cardiac output, con-
cautions the health care worker to assess the physical environ- trolling bleeding, and providing
ment for self-protection. That is, safety at the scene must be adequate fluid volume.
established before rescue is attempted (Figure 21-3). The next D = Disability – Assess for and prevent neuro-
rule is to remove the client from danger, such as that presented
logical disability by using the
by passing vehicles. These first two rules typically apply to
Glasgow Coma Scale.
emergencies occurring outside of an institutional setting.
Once the safety at the emergency scene and of the cli-
ent have been established, assessment turns to the ABCDs of
emergency care—airway, breathing, circulation, and disability.
neurological status using the Glasgow Coma Scale and apply a
Obtain and maintain an open airway. Assess breathing and
neck collar for any head or neck injury (Integrated Publishing:
provide resuscitative breathing as needed. Circulation includes
Medical, 2009). Eye and skin injuries are evaluated next.
starting CPR to restore cardiac output, assessing and control-
ling bleeding, and assessing and treating possible shock. Care
for a potential central nervous system disability by assessing SHOCK

S hock is a condition of profound hemodynamic and meta-

bolic disturbance characterized by inadequate tissue per-
fusion (the body’s inability to meet tissue demand for oxygen)
(Table 21-2). Shock can result from trauma, injury, or insult.
Recognizing and immediately treating shock are critical to the
COURTESY OF DELMAR CENGAGE LEARNING

client’s survival. There are four major types of shock: hypo-

volemic shock, cardiogenic shock, distributive shock, and
obstructive shock (Chavez & Brewer, 2002).
Hypovolemic shock is usually easily recognized. It results
from severe fluid volume depletion through vomiting, dehy-
dration, diarrhea, or blood loss. Severe external bleeding may
be obvious, but internal bleeding, such as that from a gastric
ulcer, is not readily observable.
Figure 21-2 EMTs and paramedics are often the first to
Cardiogenic shock may be caused by several different
arrive at an emergency scene. heart conditions that result in loss of the contractile property
of the heart muscle. The most common of these is acute
myocardial infarction (heart attack). Severe heart failure and
certain arrhythmias may also cause shock.
There are three types of distributive shock: septic, anaphyla-
tic, and neurogenic. In all of these, shock results from vasodilation
and an abnormal fluid distribution within the circulatory system.
Septic shock is usually caused by overwhelming infection.
Certain organisms may cause severe reactions, resulting in col-
lapse of the circulatory system. Toxic shock syndrome, gram-
negative shock, and urogenic shock are types of septic shock.
Anaphylactic shock is a severe allergic reaction to a toxin
to which a client has been exposed. Causes of anaphylactic
reaction include insect bites and certain medications.
Neurogenic shock is the body’s response to extreme pain
or trauma to the spinal cord. As with the other forms of shock,
it results in inadequate supply of oxygen, electrolytes, and
Figure 21-3 Establishing the safety of the scene is the first other essential chemicals to the tissues.
priority in emergency care, as in this scene of a motor vehicle Obstructive shock is the result of indirect pump failure
accident, where rescue workers may be in danger from oncoming that leads to decreased cardiac function and reduced circula-
vehicles. (Courtesy of David J. Reimer, Sr.) tion. Conditions causing obstructive shock include pulmonary

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702 UNIT 10 Applications

Table 21-2 Types of Shock

TYPE CAUSES SIGNS AND SYMPTOMS TREATMENT
Hypovolemic Hemorrhage,* burns Increased heart rate; Replace fluids
hypotension, cold, clammy skin;
profound thirst

Cardiogenic Myocardial infarction* Increased heart rate; Initiate drug therapy for myocardial
hypotension; cold, clammy skin infarction; replace fluids; consider possible
emergency coronary bypass surgery

Septic Overwhelming infection Hot, dry, flushed skin; hypo- Locate source of infection and treat with
tension; increased heart rate broad-spectrum antibiotic; replace fluids

Anaphylactic Medications,* insect Throat edema in conjunction with Manage ABCs; administer epinephrine
bites or stings, foods increasing difficulty breathing; (Adrenalin); administer diphenhydramine
hypotension; increased heart rate hydrochloride (Benadryl)

Neurogenic Spinal cord injury, head Slowed heart rate; hypotension Replace fluids, administer drugs to
trauma increase blood pressure and heart rate

COURTESY OF DELMAR CENGAGE LEARNING

Obstructive Arterial stenosis, Increased heart rate, dyspnea Treat underlying cause
pulmonary embolism,
pulmonary hypertension,
cardiac tamponade

*Most common cause

embolism, pulmonary hypertension, arterial stenosis, and car-

diac tamponade. Pharmacological
In all types of shock, diminished blood flow causes the Initial treatment involves the administration of oxygen and the
signs and symptoms. There is usually no clinical evidence insertion of two large-bore intravenous (IV) lines. Intravenous
of shock in the early stage. There may be an increase in heart lines are instituted to establish lifelines through which life
rate (above client’s baseline), restlessness, and the client may saving drugs and fluids are administered. Fluid resuscitation
have a sense of impending doom. In the compensatory stage, and oxygen delivery are critical to management of the client in
respirations and heart rate increase; pulses may be weak; uri- shock. Medications, including epinephrine, are administered
nary output decreases; skin is cold and clammy, mottled, and to improve circulation.
pale; pupils dilate; bowel sounds are hypoactive, and there is
hyperglycemia. Interventions at this stage reduce the possibil-
ity of permanent damage. If shock advances to the progres- Nursing Management
sive stage, the client’s condition noticeably deteriorates. The The focus is to identify the type of shock and initiate interven-
pulse may be too rapid to count, blood pressure falls below tions as soon as possible. For hypovolemic shock, the treat-
80 mm Hg, peripheral pulses disappear, there is metabolic ment goal is to restore volume. Administer IV solutions such
acidosis, peripheral edema, pulmonary crackles and wheezes as Ringer’s lactate or normal saline, or packed red blood cells,
are heard, and the client may be unresponsive. In the refrac- serum albumin, plasma, or dextran as ordered. Excessive fluids
tory stage, there is too much cell death and tissue damage from dilute clotting factors and worsen bleeding.
inadequate oxygenation. The client does not respond to treat- For cardiogenic shock, treatment focuses on improving
ment. Multiple organ failure occurs, which generally results myocardial function. Medications for hypotension are fre-
in death. quently ordered. Provide oxygen. Monitor the client’s respira-
tory and cardiac status.
Medical–Surgical Septic shock is the most common type of distributive
shock. Administer IV antibiotics and fluids as ordered. Moni-
Management tor vital signs.
Clients in neurogenic shock generally have hypotension,
Medical bradycardia, hypothermia, and dry warm skin. Administer
Management of shock is supportive in nature during initial medications as ordered for hypotension and bradycardia.
resuscitation. The immediate priority is maintenance of the Monitor vital signs. Provide warmth.
ABCs. Active bleeding should then be stopped. Blood is For clients in anaphylactic shock, talk with family (or cli-
administered in the event of major blood loss. After the client ent if able) to identify the cause. After assessing ABCs, admin-
is stabilized, the underlying cause of shock is identified and ister IV fluids, epinephrine, and antihistamines as ordered.
treated. Monitor vital signs.

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 CHAPTER 21 Responding to Emergencies 703

Obstructive shock is managed by identifying the source alert and stabilized, assessment includes obtaining a history
of the obstruction and treating it. Administer fluids cautiously. of the events leading to the injury or illness, including any
Seldom are diuretics used. food consumed or medication taken and any unusual event
(such as a bee sting) that precipitated the shock state. Ask the
client to describe any pain with regard to intensity, location,
NURSING PROCESS and duration.

Assessment Objective Data

Immediate assessment involves evaluating the ABCs. Take
Subjective Data vital signs, because many clients in shock will present with
Determine whether the client is responsive and able to hypotension, tachycardia, tachypnea, and pale, diaphoretic,
respond to questions or is unconscious. When the client is clammy skin.

Nursing diagnoses for a client in shock include the following:

NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Deficient Fluid The client will maintain adequate Initiate and maintain fluid replacement with two large-
Volume related to acute fluid balance. bore IV access lines.
blood loss/vomiting/ Administer blood as ordered.
diarrhea

Ineffective Tissue Perfusion The client will maintain adequate Assess vital signs at least every 30 minutes.
related to decreased tissue perfusion as manifested Administer oxygen per physician order.
oxygen-carrying hemoglobin by stable vital signs.
secondary to blood loss and
fluid depletion

Anticipatory Grieving related The client will cope with illness/ Communicate with client and family. Explain all
to grave nature of illness/ injury by cooperating with care interventions as they occur, to decrease acute
injury provided by health care workers anxiety.
and will discuss outcomes with Allow client and family to express their fears and worries
nurse and family. about the situation. Answer questions about care.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

associated with drowning, such as head and spinal cord

CARDIOPULMONARY injuries (Table 21-3).
EMERGENCIES Foreign-body obstruction of the airway most commonly
occurs in the larger, right main bronchus. The most common

C
source of airway obstruction is the tongue. Other sources of
ardiopulmonary emergencies are those emergencies that airway obstruction include hot dogs, candy, steak, and coins
jeopardize the function of the heart and lungs. These (especially in children).
emergencies can result from trauma or illness. Cardiopulmo- Penetrating or blunt trauma to the chest can cause mul-
nary emergencies such as drowning, foreign body obstruc- tiple injuries. Penetrating injuries are insults that puncture the
tion of the airway, chest trauma, and chest pain are grouped chest, such as gunshot or knife wounds. Blunt trauma is more
together, because the effects, medical management, and nurs- likely caused by falls or by forceful contact with a blunt object,
ing priorities are similar. such as a baseball bat or steering wheel. Injuries associated
Near-drowning episodes occur most frequently in with pneumothorax include cardiac tamponade, fractured
the summer. Many clients will suffer other related injuries ribs, fractured sternum, and flail chest.

Table 21-3 Freshwater versus Saltwater Near-Drowning

COURTESY OF DELMAR CENGAGE LEARNING

TYPE CLIENT SYMPTOMS PATHOPHYSIOLOGY SIGNS

Freshwater Fatigue, anxiety, difficulty Water in lungs causes changes in surfactant, Hypoxia, collapsed
breathing, fear which in turn causes alveolar collapse. alveoli

Saltwater Fatigue, anxiety, difficulty Hypertonic salt water pulls fluid into the Hypoxia, pulmonary
breathing, fear, rales, rhonchi alveoli. edema

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704 UNIT 10 Applications

One of the most common complaints evaluated in the ED

is chest pain. Those clients presenting with the symptom of Pharmacological
chest pain must be clearly and carefully evaluated. Chest pain With the near-drowning client, mannitol (Osmitrol) and furo-
has a multitude of potential causes and can be frightening to semide (Lasix) are occasionally indicated in the event of fluid
the client until the cause is confirmed. overload. Pain medication is essential for the client with chest
injury, because hypoventilation may occur as a result of the
Medical–Surgical pain associated with deep breathing. Pain control is also essen-
tial for the client experiencing chest pain. Pain medications
Management vary from sublingual nitroglycerine to IV morphine sulfate.
Medical Activity
Management of all cardiopulmonary emergencies is directed at Most clients with cardiopulmonary emergencies are initially
maintaining the ABCs. If indicated, intubation is part of resus- confined to bed and must frequently be rolled from side to
citation in cardiopulmonary emergencies. Establishment of an side. Encourage deep breathing and coughing to prevent stasis
IV line is essential for medical management, because the line of fluid and development of pneumonia.
provides access for administration of lifesaving medications.
After resuscitation is achieved, other treatment modali-
ties are instituted. Obtain chest x-rays, electrocardiograms
Nursing Management
(EKGs), and blood tests. Initiate pain control. Morphine sul- Initiate CPR if indicated. Remain with the client to reduce
fate is the drug of choice for clients with these types of emer- anxiety. Administer pain medication as ordered. Suction as
gencies, because morphine decreases both pain and anxiety necessary to keep airway patent. Monitor vital signs and lung
in the client, which, in turn, leads to improved breathing. sounds. Encourage turning and deep breathing.

NURSING PROCESS
PROFESSIONALTIP Assessment
Subjective Data
Flail Chest Evaluate for restlessness, an early sign of hypoxia. Note pain
description. Other areas to include in assessment are fatigue,
A flail chest is defined as instability in the chest anxiety, and level of consciousness. Ability to give a brief
wall. This condition is caused by fracture of three history of events before the cardiopulmonary emergency is
or more ribs in two or more places. With a flail evaluated.
chest, breathing is unique: The flail segment moves Objective Data
inward during inspiration and outward during
Immediately assess airway and breathing. Note any cough,
expiration. This is called paradoxical breathing.
stridor, cyanosis, or inability to talk. Initial vital signs are
essential for a baseline.

Nursing diagnoses for a client with a cardiopulmonary emergency include the

following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Ineffective Airway Clearance Client’s lungs will be clear Maintain airway and breathing with suctioning, if
related to accumulation of bilaterally to auscultation. secretions accumulate.
fluid and blood in the airway Turn client frequently to mobilize secretions.
and to the client’s inability to
Encourage deep breathing and coughing.
cough
Listen to lungs hourly, or more frequently, to evaluate
secretions and suctioning.

Ineffective Breathing Pattern Client will regain spontaneous Initiate CPR, if indicated.
related to injury to the chest respiration within normal rate Administer pain medications as ordered to ease the
and inability to fully expand range and pattern. work of breathing. Note response to pain medications.
the lungs
Remain with the client during episodes of respiratory
distress, because being left alone at these times
escalates both the anxiety and breathing problems.
Explain all procedures.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 21 Responding to Emergencies 705

TIME

NEUROLOGICAL/ R
Size
reaction
B = Brisk
S = Sluggish
NR = No reaction

NEUROSURGICAL
PUPILS
Size C = Eye closed
L
reaction

EMERGENCIES PUPIL
GAUGE

H
(mm)
2 3 4 5 6 7 8 9

ead injuries are the most common type of neurological Eyes

Spontaneously
To speech
4
3
C = Eyes closed
trauma. Spinal cord trauma can also occur as a result of open To pain 2
None 1
injuries sustained in a head injury. Head trauma most often results C
O Oriented 5
from motor vehicle collisions (MVCs) (Figure 21-4). Head inju- M
A Best
Confused 4
T = Intubated
verbal Inappropriate 3
ries vary from very minor contusions to major head trauma. S response Incomprehensible 2
or trach

Clients experiencing any altered level of consciousness C

A
None 1

(LOC) are admitted to the health care system for prompt eval- L
E
Obey commands
Localize pain
6
5 Record best
uation and care. Cerebrovascular accidents (CVA), also called Best
motor Withdrawal 4 response
V = Voice
response Flexion abnormal 3
strokes or “brain attacks,” occur in different areas of the brain Extension to pain 2
S = Shaking
P = Pain
when it becomes starved for oxygen or hypoxic. These events None 1
COMA SCORE TOTAL
are caused by a blood clot (ischemic stroke) or a bleeding

COURTESY OF DELMAR CENGAGE LEARNING

L
I Normal power
blood vessel (hemorrhagic stroke), which causes symptoms M A Mild weakness
• = Same
B R
ranging from mild confusion or a slight lip droop to total unre- M
Severe weakness
Flexion
behavior
S bilaterally
sponsiveness. Establishing the exact time of onset, if possible, M
O
Extension
No response R = right If
is extremely important for prompt and effective treatment. V
E Normal power L = left different
L in
CVAs, or “brain attacks,” require the same initial consider- M
E E
Weakness
Flexion
response
between
ation given to myocardial infarctions, or “heart attacks.” N
T
G
S Extension 2 sides
No response
Another common event causing an altered LOC is low S

blood sugar (hypoglycemia). The client appears lethargic,

intoxicated and combative, or comatose. Prompt restoration Figure 21-5 Neurological Flow Sheet, Including Glasgow
of adequate blood glucose levels and supplemental oxygen Coma Scale
support are critical to protect the brain from further insult.
Other medical emergencies that cause an altered LOC include pressure include a headache; later signs include widened pulse
carbon monoxide poisoning, drug overdose, severe infections, pressure, dilated pupils, and spontaneous emesis without
and electrolyte imbalances. warning. Hiccups are an ominous sign and thus are reported
immediately. Use of the Glasgow Coma Scale, a neurologi-
Medical–Surgical Management cal screening test that measures a client’s best verbal, motor,
and eye response to stimuli, is indicated (Figure 21-5).
Medical
As with all trauma, management is aimed at maintaining the Pharmacological
ABCs. In addition, if head, neck, or spinal cord trauma is sus- Increased cranial pressure and buildup of carbon dioxide
pected, the client is placed on a backboard, with the head and complicate the client’s condition; oxygen most often alleviates
neck immobilized. Blood alcohol level is determined. Intrave- the resultant complications. Thus, administer oxygen immedi-
nous access is initiated early in the resuscitation phase. Radio- ately. Pain management is accomplished through IV access.
logical examination is necessary to determine the extent of
damage. If the client does not have spontaneous respirations, Activity
the injury has probably occurred at C-4 or above, meaning Clients with head injuries are placed in semi-Fowler’s position
that the client will not be able to independently maintain res- to decrease edema and intracranial pressure.
pirations. The client is continuously monitored for increased
intracranial pressure. Early signs of increased intracranial
Nursing Management
Immediately administer oxygen as ordered. Monitor vital signs.
Assess Glasgow Coma Scale score. Maintain the client in a
semi-Fowler’s position or as ordered. Orient to date and time
as needed.
CRITICAL THINKING

Motor Vehicle Crash

You come upon an MVC involving several vehicles

and no emergency response vehicles have yet
arrived. What steps can you take to secure the
accident site and aid the victims until emergency
services arrive?
Figure 21-4 MVCs are the most common cause of head
trauma. (Courtesy of David J. Reimer, Sr.)

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706 UNIT 10 Applications

NURSING PROCESS Objective Data

Assess the client’s vital signs and Glasgow Coma Scale level.
Assessment Note cerebrospinal fluid leaks, such as clear fluid coming
from the nares or ear. Document the client's unequal pupil-
Subjective Data lary response, trouble making self understood, or difficulty
Obtain a history of the accident and the mechanism of injury. swallowing.
Evaluate the client’s perception of what happened and the
client’s emotional response. The client may describe having a
headache and difficulty seeing.

Nursing diagnoses for the client with a neurological/neurosurgical emergency

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Excess Fluid Volume The client will remain conscious, Monitor intracranial pressure.
(Cerebral) related to maintain a Glasgow Coma Scale Maintain the client in semi-Fowler’s position.
accumulation of fluid/blood score of 15, and experience no
in cranium further increase in cranial fluid Document vital signs hourly.
volume. Assess Glasgow Coma Scale level and record hourly.
Administer oxygen.

Impaired Verbal The client will be able to Orient the client frequently to date and time. Explain
Communication related to communicate with the nurse and all nursing interventions.
injury to speech center family. Modify communication methods, such as use of a
message board, depending on the client needs.
Encourage client to verbalize feelings about condition;
offer support.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

tube decompresses the stomach. A peritoneal lavage may

ABDOMINAL EMERGENCIES be performed to check for blood in the abdominal cavity of

A
clients with abdominal trauma. Presence of blood indicates a
bdominal emergencies are diverse in nature. Trauma to need for immediate surgical intervention. A computed tomog-
the upper body and torso can result in multiple abdomi- raphy (CT) scan of the abdomen may be indicated as well.
nal injuries, from a simple contusion and bruising to a rup- Blood work is drawn, and a urinalysis is done. Hematuria is
tured spleen. Clients presenting to the ED with complaints of evaluated, and x-rays may be indicated.
abdominal pain require careful evaluation. Illnesses causing
abdominal pain range from gastroenteritis to gastrointestinal Pharmacological
bleeding. If the client is in severe pain and has been evaluated, narcotics
Abdominal injuries can result from blunt or penetrating are indicated.
trauma. It is important to determine the mechanism of injury,
because certain causes, such as MVCs, often result in multi-
system trauma. Blunt trauma, for instance from falling on the
Nursing Management
abdomen, usually results in injury to internal organs, such as Administer oxygen and follow agency protocol for managing
the kidneys or spleen. Penetrating injuries such as gunshot ABCs. Initiate IV access. Administer analgesics as ordered.
wounds can affect any internal organ. Hemorrhage is a poten- Monitor vital signs, bowel sounds, and abdominal girth.
tial complication of both types of trauma. Administer medications and ambulate as allowed.

Medical–Surgical Management PROFESSIONALTIP

Medical
Initial management of abdominal emergencies is IV access Open Abdominal Wound
with large-bore catheters. Oxygen is administered immedi- If loops of intestines are exposed to outside air,
ately, and standard protocol calls for managing the ABCs. cover with sterile saline-soaked gauze.
Blood products or plasma expanders are administered in the
event of large-volume blood loss. Insertion of a nasogastric

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 CHAPTER 21 Responding to Emergencies 707

Note the times of the client’s last meal, bowel movement,

NURSING PROCESS and urination.
Assessment Objective Data
Subjective Data Assess vital signs, active bleeding, abdominal girth, and
Ask about the location, duration, severity, and radiation weight. Inspect the abdomen for bruises, edema, and
of pain. Obtain history of nausea, vomiting, and diarrhea. wounds.

Nursing diagnoses for the client with an abdominal emergency include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Deficient Fluid Volume The client will stabilize, and vital Establish IV access with at least two large-bore catheters.
related to active bleeding signs and fluid balance will return Monitor vital signs frequently, at least hourly.
to normal.
Evaluate abdominal girth and bowel sounds hourly.

Risk for Infection related to The client will not experience an Administer antibiotics as ordered to reduce the risk of
penetrating injury elevated temperature or show infection.
signs and symptoms of infection. Monitor temperature at least every 2 hours.
Change saturated dressings as needed.
Note amount and quality of any drainage.

Activity Intolerance related to The client will ambulate with Turn client hourly from side to side.
pain and bleeding assistance the evening of or Assist client to ambulate when able to prevent stasis
1 day after surgical correction. of fluid and to diminish the risk of infection.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

GENITOURINARY Medical–Surgical
EMERGENCIES
Management
Medical
R ape is a legal term and is not considered a medical condi-
tion. It is defined as sexual penetration of a forceful and
threatening nature with a nonconsenting person. Included
As with all emergencies, the ABCs must be managed first.
Intravenous access is established, and blood and urine speci-
mens are obtained. Rape crisis intervention is essential for
under this legal term is penetration of persons who are unable the sexual assault victim. Those with straddle injuries are
to consent because of intoxication or mental illness. Alleged evaluated for fractures. If blood is seen at the external urethral
sexual assault is the terminology used by most centers for rape meatus, a urethral tear is suspected, and catheterization is
survivors. Because of the many legal implications and the avoided because it will further damage the urethra. Radiologi-
fact that there are not only physical symptoms, but also long- cal examination is done to confirm injury.
lasting psychological consequences of sexual assault, accurate
and methodical care must be given to the survivors of sexual Surgical
assault. Most communities have hospitals designated to care
for rape survivors. These facilities are staffed with registered Certain injuries such as urethral or vaginal tears may require
nurses and doctors familiar with the medical, psychological, surgical repair.
and legal issues particular to caring for the client who has
experienced a sexual assault. Many facilities now have a Sexual Pharmacological
Assault Nurse Examiner (SANE). These nurses are trained in Douching and bathing for the sexual assault survivor is delayed
collecting and accurately documenting the forensic evidence until all specimens are collected and all examinations are per-
needed to protect the rights of the victim. formed. For the sexual assault client, antibiotics are usually
Straddle injuries are another type of genitourinary emer- prescribed for possible sexually transmitted infection. Blood
gency. These injuries occur when a client falls while straddling tests for baseline human immunodeficiency virus (HIV) and
an object, such as a fence or metal bar, thereby injuring the acquired immunodeficiency syndrome (AIDS) and a preg-
perineum. Though not a very common injury, it is imperative nancy test are usually part of the protocol. In addition, a “morn-
to assess the client and promptly initiate treatment. These ing after” pill, such as diethylstilbestrol diphosphate (DES),
injuries can occur with multiple traumas or as a single injury. may be prescribed in the event of a possible pregnancy.

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708 UNIT 10 Applications

regains the desire to resume activities of daily living. Those with

PROFESSIONALTIP straddle injuries need bed rest and careful observation until
testing is complete. Clients are taught to resume sexual activi-
ties only when they feel physically and emotionally ready.
Chain of Custody
Care is taken in handling the clothing and
belongings of a survivor of sexual assault, as these
Nursing Management
Manage the ABCs and establish IV access. Obtain blood and
items may become valuable in legal proceedings. urine specimens. Monitor output and test urine for blood.
For purposes of potential future litigation, it is thus Make a list of the client’s clothing worn during the assault and
imperative to maintain a strict chain of custody of keep the clothing for evidence in case of legal proceedings.
evidence. The chain of custody is the documentation Instruct client to delay bathing or douching until all examina-
of the transfer of evidence from one worker to the tions are completed and all specimens are collected.
next in a secure fashion. This means that to follow
the rape protocol, each person handling the client’s
clothing or lab work must sign the document used NURSING PROCESS
by the facility to indicate receipt and release of
items. The fewer the names on the chain, the more Assessment
secure the integrity of evidence.
Subjective Data
Obtain a description of the rape or assault. A history of men-
Diet strual cycles, including date of last menstrual period, is vital in
determining the potential for pregnancy.
The client is designated nothing by mouth (NPO) in case
of the need to go to immediate surgery. Fluids can be given
intravenously. Objective Data
Assess all bruises, scrapes, or abrasions caused by the
Activity assault. Make a list of the client’s clothing worn during the
The sexual assault survivor returns to full activity as soon as assault, and keep the clothing for evidence in case of legal
able, although counseling may be needed before the client proceedings.

Nursing diagnoses for the client with genitourinary emergencies include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Urinary Client will void clear urine Closely monitor output.
Elimination related to before discharge and will Test urine for blood using dipstick. Note and report hematuria.
break in urethra regain normal pre-injury
elimination patterns. Offer bladder retraining and encourage client to resume
pre-assault elimination patterns.

Risk for Infection Client will have negative Obtain all specimens as ordered.
(Sexually Transmitted outcomes on all lab Teach the client how and when to obtain further specimens, as
Infection) related to specimens obtained. needed.
alleged sexual assault
Keep the client informed about all test results.

Rape-Trauma Syndrome Client will state awareness Maintain open and nonjudgmental communication with the client.
related to alleged sexual of help groups for therapy Call rape crisis center for immediate referral and assistance for
assault and violence of and follow-up care. the client.
event
Refer the client to crisis help per community offerings.
Teach the client that the trauma does not resolve overnight and
that help is available at all times.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

rapidly, and thus they require immediate attention. Clients with

OCULAR EMERGENCIES objects impaled in the eye must be immediately evaluated by

M
an ophthalmologist. An eyeball may be avulsed, or forcibly torn
ost eye emergencies are urgent to emergent in nature. out of its socket, either by blunt or penetrating trauma; such
Foreign bodies can cause damage to vision very an injury requires immediate referral to and treatment by an

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 CHAPTER 21 Responding to Emergencies 709

ophthalmologist. Retinal detachment is a surgical emergency, Activity

as it is one of the leading causes of accidental blindness.
Because sensory and depth perceptions may be altered when
one eye is patched, activity is limited initially. Clients are
Medical–Surgical Management maintained in semi-Fowler’s position to prevent or alleviate
intraocular edema.
Medical
The primary goal of care is restoring the health of the eye. The
foreign body or impaled object is removed as soon as the cli- Nursing Management
ent’s condition allows and the effects on the eye of removal of Maintain the client in semi-Fowler’s position. Instill eye
the object have been determined. The client’s eye is protected medications and apply an eye patch (sometimes both eyes
until definitive treatment is provided. Protective dressings are patched to decrease eye movement). Assist the client to
are needed. In the event of ocular avulsion, the eyeball is pro- ambulate while wearing an eye patch.
tected with a warm saline dressing. Because both eyes move
together, patching of the opposite eye decreases movement of
the affected eye, allowing it to heal more quickly. NURSING PROCESS
Surgical Assessment
Immediate surgical intervention is needed for retinal detachment.
Subjective Data
Pharmacological Obtain both the client’s perception of what happened to
the eye and a history of the accident, including the time it
As a prophylactic measure, all eye trauma is treated with an occurred. Document care given to an avulsed eye, such as
antibiotic eye medication. placement in a plastic bag with water.
Diet
There are no modifications to the diet of the client with a for- Objective Data
eign body in the eye. Clients with avulsed eyes are kept NPO Assessment includes visual acuity testing and observation of
in case immediate surgical intervention is needed. tearing and/or redness of the eye.

Nursing diagnoses for the client with an ocular emergency include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Disturbed Sensory The client will regain partial Maintain the client in semi-Fowler’s position in cases of ocular
Perception (Visual) preinjury vision. avulsion or retinal detachment.
related to impaired vision Assist the client to walk while wearing an eye patch and discuss
problems that may be encountered and ways to accommodate
decreased vision.
Ask the client to name one resource person to assist with
decreased vision at home.

Risk for Infection related The client will not develop Instill initial eye medication and apply initial eye patch for the client.
to trauma caused by ocular infection. Teach the client to instill eye medication and apply eye patch.
foreign body
Instruct the client to immediately report any visual changes or
drainage.
Be alert and listen to the client’s concerns.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

MUSCULOSKELETAL surrounding tissue. Sprains often occur in the wrist and ankle.
A dislocation is the displacement of a bone from its joint. The
EMERGENCIES most common sites of dislocation are the fingers and toes. A
fracture is a break in the continuity of a bone. In the event of
Musculoskeletal emergencies can vary from simple muscle a long-bone fracture, care also is given to the cardiopulmo-
strains to major trauma. A muscle strain is the overstretch- nary system: Fat emboli from the fracture site can develop
ing of a muscle. A sprain is defined as a twisting of the joint and cause severe respiratory problems if they settle in the
with partial rupture of ligaments, which can cause injury to pulmonary system.

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710 UNIT 10 Applications

Medical–Surgical MEMORYTRICK
Management
Treatment for Strains and Sprains
Medical
Initial treatment of simple strains and sprains are managed by Remember RICE when treating a strain or sprain:
use of the “RICE” formula, meaning rest, ice, compression, and R = Rest
elevation. Fractures are immediately immobilized, with atten-
I = Ice
tion to body areas proximal to the fracture. Radiological exam-
ination is indicated to validate the diagnosis. Dislocations are C = Compression
immediately reduced. Many fractures and dislocations are
E = Elevation
reduced in the ED by the use of procedural sedation. Tetanus
toxoid is given to any client with an open injury.

Surgical muscles and minimize atrophy in cases of immobilization,

teach the client to contract and release those muscles immo-
Some fractures require immediate surgical intervention. Most bilized in the casting.
open, compound fractures fall into this category. Debridement
is often indicated, because most fractures are trauma related,
and dirt and other matter imbed in the wound. Nursing Management
Immobilize the affected part. Administer analgesic as ordered.
Pharmacological Elevate the injured area. Apply ice packs, as ordered. Assess
Pain control is a major consideration in relation to musculo- pulse, skin color, capillary refill, ability to move fingers or toes,
skeletal system injuries. Reduction and immobilization often and sensation in the injured area.
significantly decrease pain. Those clients with minor sprains
and strains respond well to anti-inflammatory medications
such as ibuprofen (Advil, Motrin) and other nonsteroidal anti- NURSING PROCESS
inflammatory drugs (NSAIDs). Those with major or multiple
fractures initially require narcotic relief. Assessment
Diet Subjective Data
Clients with sprains, strains, and simple fractures do not need The client will initially verbalize intense pain, tingling, and
special diets. Those with major fractures and trauma are kept loss of use of the injured part.
NPO pending surgical intervention.
Objective Data
Activity Obvious deformities, edema, cool skin, and decreased capil-
Depending on the site of the fracture, activity may be limited lary refill are present on the affected part. Note breaks in the
because of casting or immobilization. To help strengthen the skin and visual bone fragments.

Nursing diagnoses for the client with a musculoskeletal emergency include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Acute Pain related to The client’s pain Administer pain medications as ordered.
traumatic fracture/ will decrease with Immobilize affected body part. Elevate injured extremity.
dislocation immobilization and pain
Apply ice packs as directed.
medications.
Listen attentively to the client’s concerns and verbalizations of pain.

Ineffective Tissue The client’s pulses will Assess the client’s pulse, skin color, capillary refill, and ability to
Perfusion related to be equal bilaterally, and move the fingers and toes every 30 minutes.
edema and fracture/ capillary refill will be less Ask the client about sensation in the injured body part.
dislocation than 2 seconds at the
Instruct the client to move the toes and fingers.
affected site.
Apply an elastic bandage for compression in cases of a sprain.

Impaired Physical Mobility The client will demonstrate Teach the client to care for the cast.
related to limitations of the ability to mobilize with Teach the client exercises to minimize muscle atrophy and
pain and immobilization cast or other assistive crutch walking, if needed.
of fracture/dislocation devices.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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 CHAPTER 21 Responding to Emergencies 711

SOFT-TISSUE EMERGENCIES Pharmacological

M
All clients with soft-tissue injuries, including those with burns,
inor abrasions, lacerations, puncture wounds, contusions, must be current with regard to immunizations, especially the
bites of all varieties (human, insect, animal, and snake), diphtheria and tetanus (Td) immunizations. Pain medication
and burn injuries fall into the category of soft-tissue injuries. is given to alleviate pain related to lacerations, bites, and burns.
Although most such injuries do not require emergency care, Topical antibiotic agents are applied to all injuries. Silver sul-
some are more severe than others, and some are potentially fadiazine (Silvadene) is the most widely used topical agent for
fatal. Clients will seek medical attention for these injuries burn injuries. Systemic antibiotics are often included in the
because of fear. treatment regimen.

Medical–Surgical Activity
Management
Movement may be somewhat limited depending on the loca-
tion of injury. Because muscle weakness and atrophy occur
Medical rapidly, physical therapy is initiated immediately for immobi-
lized clients.
Skin emergencies require prompt intervention. All injuries
must be cleansed or debrided. Infection is a major consider-
Nursing Management
ation, and prophylactic treatment must therefore be initiated
immediately. If a laceration is large, suturing is necessary. Bites,
unless extremely large, are usually not sutured because of the Determine the client’s immunization status. Use aseptic tech-
increased risk of infection presented by suturing these lacera- nique when cleansing soft-tissue injuries. Administer analge-
tions, which provide an excellent growth medium for bacteria. sic, immunization(s), and antibiotic as ordered. Encourage
Burns sometimes are treated in an ED, with follow-up care the client to keep the wound and dressing dry and clean, but
provided at home. The application of cool water decreases instruct how to remove and change the dressing when dirty
the pain associated with minor burns. The burn is carefully or wet.
debrided with the use of running cool water and then an anti-
septic solution is applied. Because burns are painful, debride-
ment is performed after administration of pain medication.
A silver sulfadiazine (Silvadene) dressing is usually applied after NURSING PROCESS
debridement.
Major burns may require client resuscitation with rapid
EMS transport to a burn center. Initially, the ABCs are
Assessment
established. “Packaging” the client for transport to a burn Subjective Data
unit usually involves insertion of at least two large-bore IV Elicit the client’s report of the injury. Evaluate and document
lines, insertion of a nasogastric tube, intubation, Foley cathe- the client’s level of pain.
terization, sterile wrapping, and temperature regulation/
monitoring.
Snakebites do not always result in envenomation (poi- Objective Data
soning). A rubber band (not a tourniquet) above the site is Obtain vital signs. Assess the wound or damaged area with
the best intervention to control rapid spreading of the venom. regard to depth, location, and size (in centimeters). In the
Most snakebites occur in the foot, so a rubber band is easy to event of a bite, note the location and source of the bite.
apply. In managing snakebites, it is best to establish the ABCs
and, once the type of snake is identified, start antivenom treat-
ment as necessary.

PROFESSIONALTIP

PROFESSIONALTIP Snakebites
In the event of snakebite, it is essential to note the
Animal Bites location of the fang marks and the distance (in
centimeters) between the marks. Doing so helps
Many states require that all instances of clients determine the size of the snake and, thus, the
seeking treatment in an ED for animal bites be likelihood of envenomation, as smaller, younger
reported to animal control officials. Know your snakes typically have not yet learned to control the
state reporting rules and regulations. amount of venom released.

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712 UNIT 10 Applications

Nursing diagnoses for the client with a soft-tissue injury include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Skin Integrity The client’s wound will Prepare client for cleansing and possible suturing of wound.
related to break/wound heal. Assist with possible suturing.
in skin

Risk for Infection related The client’s wound will Cleanse wound thoroughly with soap and water.
to imbedded dirt/bacteria heal without evidence of Administer tetanus intramuscularly (IM) if ordered.
in the wound infection.
Teach the client to keep the wound and sutures dry and clean.
Apply a topical antibiotic and clean dressing, if indicated.
Teach the client to remove and change the dressing if it
becomes dirty or wet.
Tell the client to return for additional care if wound becomes
red, edematous, or painful or exhibits purulent discharge.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

SAMPLE NURSING CARE PLAN

The Client with a Soft-Tissue Injury
E.H., a 23-year-old Hispanic rancher, was brought to the ED after an accident at his ranch. He was riding
his horse and fixing fences. The horse threw E.H. over its head and stomped E.H.’s left upper abdomen
with its right forefoot. E.H., who states that he has never been hurt or previously admitted in the hos-
pital, presents with a large, 6-centimeter-by-3-centimeter and 2-centimeter in depth, jagged laceration
imbedded with dirt and other foreign material. There are no other associated injuries. A large pressure
bandage that is saturated with bright-red blood is controlling the bleeding.

NURSING DIAGNOSIS 1 Deficient Fluid Volume related to active bleeding from traumatic abdomi-
nal laceration as evidenced by a large, jagged laceration measuring 6 centimeters by 3 centimeters and a
large, bulky, saturated dressing
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Fluid Balance Wound Care
Hydration Fluid Monitoring

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

E.H. will lose no more blood. Apply clean pressure dressing. Controls amount of bleeding.
Prepare E.H. for suturing of the Provides E.H. with knowledge of
laceration. what is to happen.
Monitor vital signs. Identifies the client is going into
shock from blood loss. Increased
pulse and respiration and
hypotension require immediate
attention and intervention.

EVALUATION
E.H.’s wound was sutured. The dressing applied after suturing is clean and dry and showed no further
evidence of bleeding at discharge.

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 CHAPTER 21 Responding to Emergencies 713

SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 2 Impaired Skin Integrity related to abdominal injury as evidenced by a
jagged laceration measuring 6 centimeters by 3 centimeters and 2 centimeters in depth
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Tissue Integrity: Skin and Mucous Membranes Wound Care
Wound Healing: Primary Intention Infection Protection

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

E.H. will have regained skin Prepare sterile environment for Prevents additional bacteria from
integrity with sutures. suturing. contaminating the wound.
Assist physician with suturing of The nurse is responsible for
E.H.’s wound. assisting the physician, who is
suturing.

EVALUATION
E.H. had intact skin integrity, with 22 sutures in place.

NURSING DIAGNOSIS 3 Risk for Infection related to laceration as evidenced by dirt and other for-
eign material imbedded in abdominal wound
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)
Treatment Behavior: Illness or Injury Immunization/Vaccination Management
Immune Status Infection Protection

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

E.H.’s wound will not become Administer tetanus booster. All wounds require that the client
infected. be current with regard to tetanus
booster.
Cleanse E.H.’s wound thoroughly Wound is cleansed with the least
after local anesthesia has been discomfort to E.H.
administered.
Remove as much dirt and foreign Prevents inflammation and
material as possible. infection at the wound site.
Cleanse sutured wound and Removes old blood and other
demonstrate care to E.H. debris from the suturing. Teaches
E.H. how to cleanse wound at
home.
Give E.H. explicit directions It is imperative that E.H. takes the
regarding taking oral antibiotics full course of the antibiotics to
after discharge. prevent infection.
Teach E.H. to care for wound. Provides E.H. with knowledge
to remove the dressing when it
becomes wet or dirty and apply a
new and clean dressing.
Teach E.H. the signs and symptoms Provides E.H. with knowledge to
that require a return visit to the identify if the wound becomes
doctor (redness, inflammation, infected.
increased pain, purulent drainage).
(Continues)
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714 UNIT 10 Applications

SAMPLE NURSING CARE PLAN (Continued)

EVALUATION
E.H. was given a tetanus booster because he remembered having received his last at the age of 15. He
verbalized the need to take the complete course of antibiotics when he went home.

NURSING DIAGNOSIS 4
Anxiety related to reaction to fall and large laceration as evidenced by client's verbalizing that
he had never been injured previously
NOC: Anxiety Reduction, Coping
NIC: Anxiety Reduction, Anticipatory Guidance

CLIENT GOAL
E.H. will demonstrate decreased anxiety.

NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Allow E.H. to talk about injury. 1. Gives E.H. the opportunity to verbalize his
fears and thoughts about the injury.
2. Provide explanations for all procedures. 2. Assists E.H. in understanding the reason for
certain procedures and nursing interventions.
3. Give E.H. simple choices to make. 3. Allows him to participate in his care and
gives him some sense of control.

EVALUATION
Is E.H. able to view his injuries with the use of a mirror?
How is E.H. coping with the injuries?
Is E.H. able to assist with the care of his sutures?

POISONING AND DRUG topical, or injection. Poison exposure is difficult to diagnose

and accurate identification of the substance is the most
OVERDOSES important aspect of safe and effective treatment. Poison

P
control centers are the best source of antidote information
oisoning or drug overdose, whether accidental or inten- for the client suffering from poisoning or drug overdose.
tional, is treated as an emergency. Poison is defined as The nationwide Poison Help Hotline (1-800-222-1222) is
any substance that causes harm to the body and may be taste- staffed 24 hours a day, 7 days a week, in the event of a poison
less, odorless, or colorless. There are many types of poison- related emergency, to help identify potential poisons and
ings and drug overdoses with several different entry routes. serve as a resource for medical treatment. In addition to treat-
Ingested poisonings are most common. The nurse obtains ing for poisoning or drug overdose, evaluate the client for any
a clear history of the route of entry: inhalation, ingestion, associated injuries, such as lacerations from a fall.

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 CHAPTER 21 Responding to Emergencies 715

Medical–Surgical PROFESSIONALTIP
Management
Medical Interviewing a Client of Intentional
The ABCs are still the number one client priority. Oxygen Drug Overdose
is immediately initiated and IV access established. In addi-
tion, institute cardiac monitoring and obtain blood and urine The nurse requests additional family members
samples for toxicology screening. Once the client is stabilized to leave the room during the interview so the
with adequate breathing, a protected airway, and sufficient client is more free to answer questions. A client
perfusion of the brain and organs, try to identify the substance of intentional drug overdose may be reluctant to
to minimize or reverse the effects. Treatments for ingestion reveal what was taken. Ask the client or family
include client monitoring and gastric lavage. Treatments for to see the pill bottles if they are available. Look
exposure include flushing the affected area or treating as a soft at the date the prescription was filled and then
tissue injury. calculate how many pills should be in the bottle.
If an excessive number of pills are missing from a
Pharmacological bottle, it is considered suspect for intentional drug
If the substance has been ingested, and institutional protocol overdose. Admission to taking any form of pill or
dictates, administer activated charcoal. Give clients who have drug is recorded and evaluated.
ingested caustic products copious amounts of water to dilute
the substance. Sometimes the health care provider orders
reversal agents, antidotes, and medications with complex
nomograms and regimens of multiple labs to track blood con-
centrations. a calm, supportive, nonjudgmental environment with the cli-
In the event of accidental ingestion of pills or medica- ent and family while administering the prescribed treatment
tion, the client may not be aware that over the counter (OTC) regimen. Continually monitor the client for changes in mental
drugs, herbs or vitamins can cause serious side effects in status or vital signs. Insure that the client and/or family receive
combination with prescription drugs. When interviewing adequate instruction regarding the use of OTC medications or
the client, review all forms of oral medication and supple- supplements.
ments. Elderly clients sometimes see multiple physicians and
receive medications of which other prescribing physicians are
unaware. The nurse utilizes resources and teaches the clients NURSING PROCESS
Assessment
to identify and eliminate these safety hazards.

Diet Subjective Data

The client who has overdosed is typically kept NPO until Ask about the timing and the route of overdose. Evaluate men-
cleared by the health-care provider. tal status to establish whether the exposure was intentional.
Document other incidences related to an overdose, such as an
altercation with a loved one.
NURSING MANAGEMENT
Assess ABCs, initiate IV access, and administer oxygen. Begin Objective Data
cardiac monitoring. Obtain blood and urine samples. Keep The client’s vital signs are critical for baseline data. Try to iden-
client NPO. Obtain a history of the entire incident. Maintain tify the substance involved, as well as the amount.

Nursing diagnoses for the client with an overdose include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Risk for Poisoning The client will recover Manage the ABCs and stabilize the client. Monitor baseline
related to ingestion of with no residual effects of laboratory work and ECG.
toxin poisoning. Administer antidotes to toxins. Document the client’s response.

Risk for Self-Directed The client will not harm self Encourage the client to share reasons for overdose. Maintain a
Violence related to and will participate in help supportive, calm, reassuring environment for the client.
harmful ingestion of toxic groups to work through If overdose was accidental, discuss exposure to toxin and
substance issues. ways to avoid exposure in the future. Teach varying methods of
coping.
Refer to help groups.

(Continues)
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716 UNIT 10 Applications

Nursing diagnoses for the client with an overdose include the following:
(Continued)
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Interrupted Family Client will begin to discuss Encourage client and family to discuss their problems openly
Processes related to problems with family. and supportively and assist them in identifying different
ingestion of harmful toxin methods of coping.
Encourage family counseling.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

ENVIRONMENTAL/ Table 21-4 Degrees of Frostbite Severity

TEMPERATURE DEGREE SYMPTOMS TREATMENT
EMERGENCIES Mild Skin is cold to touch, Use blankets,

E xposure to extremes of heat and cold can be potentially

life threatening. Severe cold, or hypothermia, occurs in
very cold weather and from prolonged submersion in cold
pale, tingling, and
numb, with a prickly
sensation
warm clothing to
warm cold flesh

water. Heart rate and metabolic rate fall, and cardiac arrest
may follow. Frostbite is another potentially dangerous result Moderate Affects deeper body Use gloves,
of exposure to cold (Table 21-4). The most common sites of tissue; skin appears blankets, warm
frostbite are the fingers, toes, ears, and nose. Initially, frost- waxy and is puffy to clothing to
bite causes paleness and numbness to the affected areas. If touch and itchy and warm cold flesh,
exposure continues, frostbite can progress to blistering and burning with pain observe closely
loss of feeling. The client may lose voluntary control over for deeper injuries
the affected body part. Rewarming in an emergency setting
is imperative. Severe Blistering, damage Initiate emergency

COURTESY OF DELMAR CENGAGE LEARNING

Extreme heat also causes potentially serious problems, to all layers of soft rewarming in an ED
especially in very young or elderly clients. As temperature tissue; flesh appears using warm-water
rises, the body’s ability to cool lessens. Table 21-5 compares lifeless and is hard baths at 40.6°C
heat injuries.
to the touch; no pain (105°F); observe
sensation in or ability carefully for
to move frozen area increased edema

Table 21-5 Comparison of Heat Injuries

TYPE SYMPTOMS TREATMENT
Heat cramps Muscle cramps in arms, legs, and Move client to cool, shady area. Slowly administer
abdomen copious amounts of water. Reevaluate.

Heat exhaustion Diaphoresis, with pale, moist, Move client to cool, shady area. Loosen/remove
cool skin, headache, weakness, constrictive clothing. Pour water over client; place client
dizziness; muscle cramps, nausea, near fan. Encourage client to slowly drink water. Elevate
chills, tachypnea, confusion, client’s legs. Reevaluate.
tingling of hands and feet

Heat stroke (a medical Red, flushed, hot, dry skin; no Reduce client’s body temperature by removing client’s
emergency) diaphoresis clothing and pouring cool water over client. Start two
large-bore IV lines. Use fan to cool client. Place client
on cardiac monitor. Elevate client’s legs. Assess client’s
vital signs, especially core (rectal) temperature. Check for
neurological signs (confused, combative, disoriented).
Check client’s core (rectal) temperature frequently.

Developed from U.S. Army Training Support Command Protocols.

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 CHAPTER 21 Responding to Emergencies 717

Medical–Surgical PROFESSIONALTIP
Management
Medical Frostbite
For those exposed to extreme cold, rewarming is essential to
Do not massage or rub frostbite injuries because
resuscitation. The body’s core (rectal) temperature is taken.
Gradual warming is initiated using warm blankets, warmed doing so can increase the severity of damage to
oxygen, warmed IV fluids, warmed nasogastric tubes, and, tissue. Caffeine, alcohol, and smoking are avoided
in extreme instances, warmed enemas. Resuscitation should because they decrease circulation to the damaged
continue until the body has reached a core temperature of at tissue.
least 34.4°C (94°F).
For frostbite, rewarming of the exposed body part is indi-
cated. If the frostbite is severe, rapid rewarming is essential.
This involves placing the frozen area in warm-water baths not as ordered. Warm or cool body as indicated. Monitor cardiac
exceeding 40.6°C (105°F). Tetanus is administered. Acute response.
pain is treated with analgesics.
For heat injuries, rapidly reducing the body’s temperature
is vital. Supplemental oxygen may be administered. Pouring
cool water over the client, chilling IV fluids, and fanning the
client accelerates the cooling process. NURSING PROCESS
Pharmacological Assessment
For heat and cold injuries, establishment of at least two large- Subjective Data
bore IV lines is essential. Supplemental oxygen should be Ask the client to give a history of the heat/cold injury, if able,
administered. Replacement of fluid and electrolytes is essential. and any current medications taken.

Diet
In the event of heat injuries, fluids, especially water, should be Objective Data
encouraged, if the client is able. Measure and document core (rectal) body temperature and
vital signs. Record the client's skin color and temperature.
Nursing Management Initiate cardiac monitoring to track any cardiac response
to the heat or cold stress to the body. Evaluate pupillary
Initiate CPR if needed. Monitor vital signs. Establish IV response because neurological problems may result from
access. Provide oxygen and administer fluid and electrolytes the heat/cold injury.

Nursing diagnoses for the client with a temperature/environmental injury

include the following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Hypothermia related The client will regain normal Administer supplemental oxygen.
to exposure to cold core body temperature. Monitor cardiac response carefully. If CPR is in progress,
environment/long continue until the client’s core temperature reaches 94°F and
submersion in cold water cardiac status is evaluated.
Administer warmed IV fluids. Place warmed blankets on the
client.

Hyperthermia related to The client will regain normal Remove the client’s clothing. Pour cool water over the client.
environmental exposure core body temperature. Use large fan to cool the client.
to heat
Administer chilled IV fluids and supplemental oxygen.
Initiate cardiac monitoring.
Evaluate client’s neurological status with reference to
orientation to time, person, and place.
Measure core temperature every 30 minutes to assess progress.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

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718 UNIT 10 Applications

CRITICAL THINKING
MULTIPLE-SYSTEM TRAUMA

M
Multiple-System Trauma
ultiple-system trauma is injury sustained in more than
one body system. During the initial care of the emergent
Under what circumstances might a client present
client, the mechanism of injury is determined. Blunt injuries
and penetrating trauma are most likely to result in multiple- with multiple-system trauma? How would you pro-
system involvement. ceed with the assessment of such a client? What
immediate actions would the nurse take to main-

Medical–Surgical tain the stability of this client?

Management
Medical NURSING PROCESS
Immediate management of the ABCs is imperative. Bleeding
is stopped by the use of pressure applied to the wound. Two
to four large-bore IV lines are started. Remove all clothing for
Assessment
visualization of bleeding and injuries. Obtain blood and urine Subjective Data
specimens. Radiographic studies are performed. A tetanus Assess for level of consciousness and orientation to time, per-
booster also is administered. son, and place. Evaluate verbalizations of pain. Ask the client
for an account of the accident.
Nursing Management
Assess and manage ABCs. Establish IV access. Remove the Objective Data
client’s clothing for visualization of injuries. Obtain blood and Airway, breathing, and circulation are immediately assessed.
urine specimens. Assess level of consciousness. Monitor vital Assess vital signs and neurological status by use of the Glas-
signs and neurological status. gow Coma Scale. Assess and control active bleeding.

Nursing diagnoses for the client with multiple-system trauma include the
following:
NURSING DIAGNOSES PLANNING/OUTCOMES NURSING INTERVENTIONS
Impaired Spontaneous The client will breathe Maintain open airway. Initiate rescue breathing. Ventilate per
Ventilation related to without assistive devices. CPR protocol.
major trauma and severe Assist with insertion of endotracheal tube.
hypotension
Maintain pulse oximetry reading at 94% to 99%.
Start multiple large-bore IV lines.

Powerlessness related The client will survive the Explain all nursing/medical interventions to client.
to the inability to sustain emergency and within several Provide emotional and physiological support to client and family
life without emergency hours be able to indicate as much as possible throughout resuscitation.
interventions simple choices about care.
Allow the client to make simple choices about care.

Evaluation: Evaluate each outcome to determine how it has been met by the client.

TERRORISM attack on a domestic nuclear weapon facility. The effects of

either example would be severe and widespread.

T errorist acts can appear in many forms; the events of

September 11, 2001, is one example. Nuclear, chemical,
and biological terrorism are other forms.
The source of radiation on contaminated clients is on the
body or clothing, or has been ingested, or absorbed through a
skin opening. The amount of radiation absorbed determines the
effects on the client. Absorbed radiation, now measured by the
gray (Gy), is equal to 100 Rads (old measurement) (Kilpatrick,
■ NUCLEAR TERRORISM 2002). When less than 0.75 Gy are absorbed, clients are not

A
likely to have any symptoms, clients with 8 Gy would die, and
ccording to Kilpatrick (2002), the threat of nuclear 30 Gy is always fatal. The Occupational Safety and Health
terrorism is real. One example is the use of a radiation Administration (OSHA) requires that hospitals have an emer-
dispersal device (RDD), a so-called dirty bomb, which has gency plan for treating clients contaminated with radioactive
nuclear waste in a conventional bomb. Another example is an substances. A decontamination area is set up in or near the ED.
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 CHAPTER 21 Responding to Emergencies 719

The client who absorbs more than 0.75 Gy can develop

acute radiation syndrome (ARS). Symptoms of ARS depend
Vesicant Agents
on the dose of radiation and include: Sulfur mustard (HD), lewisite (L), and phosgene oxime (CX)
are in the vesicant group. Phosgene oxime causes skin lesions
• Hematopoietic. Deficiency of WBCs and platelets leading not vesicles, as do the other two. These agents are more lethal
to bleeding, anemia, infections, impaired wound healing, than pulmonary agents and cyanide agents because they can
and immunodeficiency remain in the environment for weeks, providing a continuing
• Gastrointestinal. Loss of mucosal barrier and cells lining source of exposure to populations. Sulfur mustard smells like
intestines leading to fluid and electrolyte loss, vomiting, mustard or garlic, lewisite smells like geraniums, and phosgene
diarrhea, loss of normal flora, and sepsis oxime has a peppery smell.
• Cerebrovascular/CNS. Cerebral edema, hyperpyrexia, All three agents affect the skin, eyes, and airway. Sulfur
hypotension, confusion, and disorientation mustard, in large quantities, damages the bone marrow.
• Skin. Loss of epidermis and possibly dermis Lewisite is immediately irritating, causing vesicles that prog-
Signs and symptoms in one or more of these areas appear ress to severe tissue necrosis and sloughing. Symptoms from
immediately after exposure. This is the prodromal phase. In a sulfur mustard exposure appear in 4 to 8 hours, but cellular
day or so, all symptoms generally disappear for a few days to damage begins in 2 minutes (Reilly & Deason, 2003; Arm-
a few weeks. This is the latent phase. Next is the illness phase, strong, 2002). Supportive care is primary treatment.
in which the signs and symptoms reappear and intensify. After
the peak of the illness phase, the client either begins to recover
or dies from infection or other complications.
Incapacitating Agents
BZ, a glycolate anticholinergic compound, and Agent 15, a BZ
“copy” made by Iraq, impair rather than kill or seriously injure
■ CHEMICAL TERRORISM victims (Armstrong, 2002). The effects are understimulation

S
of organs similar to those of high doses of atropine. Hyper-
everal types of agents can be used in chemical terror- thermia, hallucinations, illusions, and erratic behavior are the
ism, including nerve agents, pulmonary agents, cyanide greatest risks. The antidote is physostigmine sulfate (Eserine
agents, vesicant agents, and incapacitating agents. All clients sulfate) or physostigmine salicylate (Antilirium).
exposed to chemical agents must be decontaminated.
■ BIOTERRORISM
Nerve Agents
Nerve agents include taubin (GA), sarin (GB), sonan,
cyclosarin (GF), and one called VX (Armstrong, 2003; Yer-
gler, 2002; Reilly & Deason, 2003). These are the most toxic
B ioterrorism is deliberate releasing of pathogenic micro-
organisms such as viruses, bacteria, fungi, or toxins
into a community. Many biologic agents are easily made and
of chemical agents and cause death within minutes. Clinical disseminated and can potentially injure or kill many people.
effects depend on dose and route of exposure, i.e., inhalation, The CDC has categorized these agents into three categories
skin contact, or ingestion. Inhalation is the most dangerous. (Persell et al., 2002).
These agents cause acetylcholine to accumulate either by pre- • Category A agents are easily disseminated or transmitted,
venting its breakdown or by desensitizing the receptor sites. have a high mortality, cause public panic, and require
Symptoms range from increased saliva production, chest special public health management.
pressure, rhinorrhea, and vomiting to muscle weakness, incon- • Category B agents usually spread through water and food,
tinence, and convulsions. Symptoms may take up to 18 hours have moderate morbidity and low mortality.
to appear with low exposure.
• Category C agents have not yet been weaponized (put into
The antidotes are atropine and pralidoxime (2-PAM).
a form for mass destruction) but cause high morbidity and
Seizures are treated with diazepam (Valium).
mortality.

Pulmonary Agents The category A agents are the ones considered most
likely to be used in a bioterrorism attack. Included are anthrax,
Pulmonary agents include chlorine (CL), phosgene (CG), smallpox, plague, botulism, viral hemorrhagic fevers (VHF),
diphosgene (DP), and chloropicrin (PS). These agents, when and tularemia. Many of these diseases begin with flu-like
inhaled, destroy the alveoli and capillary bed, resulting in symptoms and are difficult to identify early. Knowledge about
pulmonary edema. There may be a 2- to 24-hour latent period these diseases, careful observation for the sudden appearance
before pulmonary edema occurs. The fluid in the lungs leads of a disease or symptoms occurring at an unusual time, and
to hypovolemia and hypotension (Armstrong, 2002; Reilly & some critical thinking may help identify a bioterrorist attack.
Deason, 2003). An example is if many people suddenly have flu symptoms in
the middle of summer (Steinhauer, 2002).
Cyanide Agents
Hydrogen cyanide (AC) and cyanogen chloride (CR), which Anthrax
forms cyanide when metabolized, can be either ingested or Anthrax is caused by Bacillus anthracis. It may manifest as a
inhaled. Cyanide prevents the transfer of oxygen from the cutaneous, inhalation, or gastrointestinal disease. Cutaneous
blood to tissues. A client in severe respiratory distress but not anthrax develops when spores enter a break in the skin. A
cyanotic probably was exposed to cyanide. It has a pungent pruritic macule or papule becomes vesicular and then forms
odor like bitter almonds or peaches. Death occurs in 5 to 10 a black, depressed scab. It is completely curable with treat-
minutes when exposed to a high concentration. Amyl nitrite is ment. Inhalation anthrax has an incubation period of up to 60
the antidote (Reilly & Deason, 2003). days. Mild flulike symptoms improve for 1 to 2 days and are
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
720 UNIT 10 Applications

followed by acute, severe dyspnea; stridor; and cyanosis. Gas-

trointestinal anthrax is unlikely because aerosolizing anthrax is
Viral Hemorrhagic Fevers
easier than sabotaging food supplies. VHF includes Ebola, Lassa, Marburg, Crimean-Congo, Argen-
Use Standard Precautions. No isolation is necessary. tine, Yellow fever, and Dengue fever. Fever onset is sudden
Treatment recommendations include ciprofloxacin (Cipro) or with signs and symptoms of circulatory compromise. All are
doxycycline calcium (Vibramycin, Monodox) given orally for infectious by aerosol except for Dengue fever. Ebola, Marburg,
cutaneous anthrax. These two drugs are initially given IV for Lassa, and Crimean-Congo can be spread from person to per-
inhalation anthrax along with one or two other antimicrobi- son, especially during later stages of the disease.
als, such as rifamin (Rifadin), vancomycin HCl (Vancocin), Isolation in a negative-pressure room is recommended.
imipenem (Primaxin), penicillin, ampicillin, clindomycin Caregivers use a personal respirator, gown, gloves, face shield,
HCl (Clocin), or clarithromycin (Biaxin) (Steinhauer, 2002). and shoe and head covers. Care is supportive. There is no
Later, clients are given the medications orally. treatment or proven cure.

Smallpox Tularemia
Smallpox, caused by variola virus, is easily transmitted from Tularemia, caused by Francisella tularensis, is not nearly as
person to person by direct contact or inhalation of respiratory deadly as anthrax or plague. Inhalation of the bacteria is the
droplets. It has an incubation period of 7 to 19 days and is likely route used in bioterrorist acts. Terrorists are believed
most contagious during the first week. This disease produces to have developed antibiotic-resistant strains, so the number
lesions in a body area in the same level of development. They of fatalities could be high (Persell et al., 2002). There are cur-
progress from macules to vesicles to pustules and then scabs. rently no methods of rapid identification.
Smallpox can be transmitted until all scabs fall off. This is Standard Precautions are followed. For small outbreaks,
unlike chicken pox, which has some lesions at each level of parenteral therapy with either streptomycin or gentamicin sul-
development in a body area at the same time. fate (Garamycin) is recommended. When there are large out-
Vaccination after exposure may decrease disease severity breaks or for postexposure prophylaxis, oral doxycycline calcium
if given within 3 to 4 days of exposure. Standard Precautions, (Vibramycin) or ciprofloxacin (Cipro) are the drugs of choice.
as well as isolation, airborne, and contact precautions, must be Refer to Table 21-6 for isolation guidelines for biological agents.
observed. Treatment is supportive with adequate hydration.
All laundry and wastes must be autoclaved before washing or
incinerating (Persell et al., 2002). LEGAL ISSUES
Plague Emergency medicine allows medical personnel to care for
clients without obtaining informed consent. In life-threatening
Plague, also called “black death,” is caused by Yersinia pastis. and emergency situations, consent is implied. In addition,
When it is transmitted from an infected rodent to humans by an the Good Samaritan Law, one of the laws and regulations
infected flea bite, it is called bubonic plague. Transmission from enforced for the benefit of both the caregiver and the client,
an infected individual to an uninfected individual by inhalation provides protection against malpractice to persons who stop
of respiratory droplets is called pneumonic plague. Terrorists at the scene of an accident and render care. It should be noted,
would probably aerosolize the bacteria to cause pneumonic however, that the Good Samaritan Law offers protection
plague. Respiratory symptoms are the main manifestation. only to those who provide safe and appropriate care; it does
The incubation period for pneumonic plague is 1 to not protect those charged with gross negligence or willful
6 days. Clients must be treated with antibiotics within 24 misconduct.
hours of the first symptoms. Recommended antibiotics are There are other legal issues specific to emergency care.
streptomycin IM or gentamicin sulfate (Garamycin). For Several injuries/illnesses are reported to proper authorities.
postexposure prophylaxis, doxycycline calcium (Vibramycin), For instance, most states require that police be notified of
ciprofloxacin (Cipro), or tetracycline HCl (Sumycin, Tetra- MVCs, assaults, or rape. Likewise, animal control authorities
cyn) may be used. require that animal bite reports be filed to facilitate follow-up
Standard Precautions including gown, gloves, mask, and on the possibility of rabies.
eye protection are used. Droplet precautions are followed
for the first 48 hours of antibiotic therapy and until clinical
improvement occurs.
DEATH IN THE EMERGENCY
Botulism DEPARTMENT
Botulism is caused by a toxin made by Clostridium botulinum, Death can occur in the ED at any time as a result of trauma,
which paralyzes muscles. The toxin, one of the most poison- sudden illness, or even extended illness. This creates a deli-
ous substances known, is usually food borne. Terrorists would cate situation, because the death is usually unexpected. Fam-
probably aerosolize the toxin for inhalation. The absorbed ily members may have a difficult time dealing with sudden
toxin irreversibly blocks cholinergic synapses, resulting in death. If their loved one is being resuscitated in the ED, there
bilateral descending paralysis. There is no elevation of tem- is little time for health care personnel to comfort the family
perature, and clients retain complete cognitive functioning, because the personnel are very busy providing care to the
although they may appear comatose. client. In the event of sudden death, the family is usually in
Standard Precautions are used. Passive immunization a state of shock and will need further assistance to cope with
with botulinum antitoxin may be used if botulism is recog- the death of their loved one. Special support groups are avail-
nized early. Care is supportive and may involve intensive care. able for this assistance and are contacted for the family.

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 CHAPTER 21 Responding to Emergencies 721

Table 21-6 Isolation Guidelines for Biological Agents

Viral hemorrhagic fever

Pneumonic plague

Biological Toxins
Bacterial Agents

Bubonic plague

Venez, equine
encephalitis
Brucellosis

Tularemia

Smallpox
Glanders

Botulism
Viruses
Cholera
Anthrax

Q fever

Ricin
Isolation Precautions
Standard precautions for all X X X X X X X X X X X X X
aspects of patient care
Contact precautions (gown and Xc Xa Xa X X
gloves; wash hands after each
patient encounter)
b
Airborne precautions (negative X X
pressure room and N-95 masks
for all individuals entering the
room)
Droplet precautions (surgical X
mask)

Patient Placement
No restrictions X X X X X X X X X
c a
Cohort like patients when X X X X X X
private room unavailable
Private room Xc Xa Xa X X X
Negative pressure X Xb
Door closed at all times X Xb

Patient Transport
No restrictions X X X X X X X X X X
c a a a a
Limit movement to essential X X X X X X
medical purposes only
Place mask on patient to Xa Xa Xb
minimize dispersal of droplets

Discontinuation of Isolation
48 hours of appropriate antibiotic X
and clinical improvement
Until all scabs separate X
Until skin decontamination
completed (1 hour contact time)
Duration of illness Xc Xa Xa X

a
Contact precautions needed only if the patient has skin involvement (bubonic plague: draining bubo) or until decontamination of skin is complete.
b
A surgical mask and eye protection should be worn if you come within three feet of patient. Airborne precautions are needed if patient has cough, vomiting,
diarrhea, or hemorrhage.
c
Contact precautions needed only if the patient is diapered or incontinent.
Adapted by R. Daniels, L. H. Nicoll, & L. J. Nosek, 2007, from Biological weapons and emergency preparedness, Part I, by R. Stilp, 2004. Retrieved June 27,
2006, from nsweb.nursingspectrum.com

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722 UNIT 10 Applications

CASE STUDY
J.D. fell from a fishing boat into deep, cold water. He was wearing a life vest and was rescued within 10 minutes,
at which time he was immediately dried, placed in a blanket, and brought to the ED. He is alert and oriented to
person, time, and place, but is shivering uncontrollably and pale in color. His core temperature is 93°F.
The following questions will guide your development of a nursing care plan for the case study.
1. List the assessments according to the priority of performance.
2. Identify the priority nursing diagnoses for J.D.
3. List nursing interventions according to the priority of performance.
4. Identify the treatment outcomes for J.D.

SUMMARY
• Clients in shock need immediate assessment and is immediately identified so that prompt treatment is
intervention. initiated.
• Rapid assessment and observation of ABCs is essential in • Major trauma is a life-threatening and unexpected
treating all cardiovascular emergencies. occurrence for both client and loved ones.
• Evaluation of abdominal emergencies include taking • Terrorism is a viable threat and emergency nurses need to
a history of the onset of pain because this is critical to be knowledgeable about possible biological, chemical and
outcome and survival. nuclear exposure agents, symptoms of exposed victims,
• Ocular emergencies can be a threat to vision and thus and nursing interventions for each situation.
require immediate assessment and treatment. • Nurses must be aware of the legal issues related to
• Musculoskeletal and soft-tissue injuries are painful but emergency care, such as Good Samaritan Laws and
manageable with rapid assessment and treatment. mandated reporting.
• In cases of poisoning or drug overdoses, the ABCs are first
established, then the agent to which the client was exposed

REVIEW QUESTIONS
1. Triage is a system of: 1. Deficient Fluid Volume.
1. identifying clients by disease. 2. Risk for Aspiration.
2. prioritizing client care. 3. Risk for Infection.
3. counting clients waiting for care. 4. Disturbed Body Image.
4. medical diagnosing. 5. Interventions for a client in shock include:
2. A client with a small branch sticking out of the right 1. pain control and assessment of vital signs.
midchest arrives at the ED during a hurricane. There 2. administration of oxygen and IV fluids.
is bubbling and oozing at the site. Medical personnel 3. insertion of a nasogastric tube.
should first: 4. calling the physician.
1. remove the branch and save it. 6. For which client should the nurse provide care first?
2. administer pain medication to the client. 1. A client who needs her dressing changed.
3. start the ABCs of CPR. 2. A client who needs to be suctioned.
4. stop the bleeding and take vital signs. 3. A client who needs to be medicated for incisional
3. An example of a nonurgent client is one with: pain.
1. CPR in progress. 4. A client who is incontinent and needs to be
2. fractures of both legs. cleaned.
3. heat stroke. 7. An adult suffered a diving accident and is brought in
4. a sprained ankle. by an ambulance intubated and on a backboard with
4. The ambulance brings a client with a large, bleeding a cervical collar. What is the nurse’s first action when
laceration of the upper leg to the ED. Vital signs are the client arrives at the hospital?
as follows: blood pressure 78/62 mm Hg, pulse 112 1. Take the client's vital signs.
beats/min, and respirations 26 breaths/min. A prior- 2. Check the lungs for equal breath sounds
ity nursing diagnosis is: bilaterally.

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 CHAPTER 21 Responding to Emergencies 723

3. Insert a large bore IV line according to physician 1.

Check the airway.
orders. 2.
Connect the client to the cardiac monitor.
4. Perform a neurologic check using the Glasgow 3.
Identify the pills the client swallowed.
Coma Scale. 4.
Lavage the stomach contents according to
8. An adult is brought in by ambulance after a motor physician orders.
vehicle crash. He is unconscious and on a backboard, 10. What symptoms are third in the sequence of signs
with his neck immobilized. He is bleeding profusely and symptoms of nuclear exposure?
from a large gash on his right thigh. What is the 1. Signs and symptoms reappear and intensify.
nurse’s second priority action in caring for the client? 2. After the peak of the symptoms, the client begins
1. Stop the bleeding. to recover.
2. Check the airway. 3. Signs and symptoms appear immediately after
3. Connect the client to a cardiac monitor. exposure.
4. Cleanse the wound. 4. Symptoms disappear for a few day or weeks.
9. A client is brought to the emergency room after tak-
ing an overdose of several different types of pills.
What choice is the last priority for the nurse?

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Chavez, J., & Brewer, C. (2002). Stopping the shock slide. RN, 65(9), Gilbert-Palmer, D. (2002). Preparing for bioterrorism. Nursing2002,
30–34. 32(2), 36–43.
Coleman, E. (2001). Anthrax. AJN, 101(12), 48–52. Pettinicchi, T. (1998). Lightning strike. Nursing98, 28(7), 33.
Coleman, E. (2002). Tularemia. AJN, 102(6), 65–69. Quinn, S. (1998). ED triage. RN, 61(9), 53–60.
Coleman, E., & Yergler, M. (2002). Botulism. AJN, 102(9), 44–47. Ramponi, D. (2000). Go with the flow during an eye emergency.
Critical Illness and Trauma Foundation, Inc. (2001). START. Nursing2000, 30(8), 54–56.
Retrieved July 24, 2009 from http://www.citmt.org/start/flowchart Rebmann, T., Carrico, R., & English, J. (2002). Are you prepared for a
.htm#Simplified bioterrorist attack? Nursing2002, 32(9), 32hn1–32hn6.
Daniels R., Nosek, L., & Nicoll, L. (2007). Contemporary medical- Reilly, C., & Deason, D. (2002). Plague: A naturally occurring bacterial
surgical nursing. Clifton Park, NY: Delmar Cengage Learning. species can be weaponized AJN, 102(11), 47–50.
Easter, A. (2002). Ebola. AJN, 102(12), 49–52. Reilly, C., & Deason, D. (2002). Smallpox: Eradicated more than 20
Estes, M. (2010). Health assessment & physical examination (4th ed.). years ago, this killer is again causing concern. Will you know it when
Clifton Park, NY: Delmar Cengage Learning. you see it? AJN, 102(2), 51–55.
Gebbie, K., & Qureshi, K. (2002). Emergency and disaster Reilly, C., & Deason, D. (2003). How would you respond to a chemical
preparedness: Core competencies for nurses. AJN, 102(1), 46–51. release? Nursing2003, 33(1), 36–42.
Harrison, T., Gustafson, E., & Dixon, J. (2003). Radiologic emergency: Ruffolo, D. (2002). Hypothermia in trauma. RN, 65(2), 46–51.
Protecting schoolchildren & the public. AJN, 103(5), 41–48. Schulmerich, S. (1999). When nature turns up the heat. RN, 62(8),
Hayes, L. (2000). Poison emergency. Nursing2000, 30(9), 34–39. 35–38.
Huston, C. (2001). Dog bite. Nursing2001, 31(7), 88. Sibley, C. (2002). Smallpox: Vaccination revisited. AJN, 102(9),
Integrated Publishing: Medical. (2009). Primary survery. Retrieved July 26–32.
27, 2009 from http://www.tpub.com/content/medical/14295/ Siwula, C. (2003). Managing pediatric emergencies. Nursing2003,
css/14295_144.htm 33(2), 48–51.

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724 UNIT 10 Applications

Sommers, M. (1998). Missed injuries. RN, 61(10), 28–31. The American Association for the Surgery of Trauma. (2007).
Spratto, G., & Woods, A. (2009). 2009 PDR nurses’ drug handbook. Introduction. Retrieved July 24, 2009 from http://www.aast.org/
Clifton Park, NY: Delmar Cengage Learning. TraumaFacts/dynamic.aspx?id=964
Stacy, P. (1998). On-scene care. RN, 61(9), 50–52. TRAUMA! (1998). RN, 61(9), 49.
Steffen, K. (2003). When your trauma patient is over 65. Nursing2003, Veenema, T. (2002). The smallpox vaccine debate. AJN, 102(9), 33–38.
33(4), 53–56. Veenema, T., & Daram, P. (2003). Radiation. AJN 103(5), 32–40.
Steinhauer, R. (2002). Bioterrorism. RN, 65(3), 48–54. Wiebelhaus, P., & Hansen, S. (2001). Burn emergencies. Nursing2001,
Talbert, S., & Talbert, P. (1998). Flight nursing: Summary of 31(1), 36-41.
strategies for managing severe traumatic brain injury during early Woods, A. (2002). New threat from an ancient microbe: Anthrax.
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254–257. Yergler, M. (2002). Nerve gas attack. AJN, 102(7), 57–60.

RESOURCES
Agency for Toxic Substances and Disease Registry, International Nursing Coalition for Mass Casualty
http://www.atsdr.cdc.gov Education, http://www.nursing.vanderbilt.edu
American Association of Critical Care Nurses Johns Hopkins University, Center for Civilian
(AACN), http://www.aacn.org Biodefense Strategies, http://www.jhu.edu/
American Association of Poison Control Centers, Oak Ridge Institute for Science and Education,
http://www.aapcc.org/DNN/ Radiation Emergency Assistance Center/
American Red Cross, http://www.redcross.org Training Site, http://www.orau.gov/reacts
Centers for Disease Control and Prevention, Salvation Army USA National Headquarters,
http://www.cdc.gov http://www.salvationarmyusa.org
Emergency Nurses Association (ENA), U. S. Food and Drug Administration,
http://www.ena.org http://www.fda.gov

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 CHAPTER 22
Integration

MAKING THE CONNECTION

Through careful study of Adult Health Nursing, a knowledge base is developed in prepa-
ration for the critical thinking exercises in this chapter. Each critical thinking exercise
begins with an index of the body systems relevant to the case study. Refer back to these
chapters as needed while working through the case study.

LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
• Integrate how a condition affects several body systems and causes
multiple clinical problems.

INTRODUCTION Table 22-1 Grid for Reviewing the

The format of this chapter is different than previous chap- Case Study Disease
ters. Multiple system disease processes are presented in
a case study format. Answering the case study questions DISEASE
enhances problem-solving techniques and critical thinking Pathophysiology
skills. Information learned in previous chapters is integrated
into the case studies to develop a holistic view of the disease
as it affects multiple systems. The student examines the
interweaving of pathophysiology causing the disease process
and develops the nursing process for the disease. An exam- Incidence/Risk
ple is diabetes that affects other body systems such as the factors
integumentary, nervous, musculoskeletal, cardiac, vascular,
blood, gastrointestinal, urinary, and reproductive.
Read the case study, and then analyze how the condition Diagnostic tests
affects other body systems. It may be helpful to first outline
the condition presented in the case study by making a grid of
the signs and symptoms, pathophysiology, diagnostic studies,
and nursing interventions. Refer to the grid when answering Signs and symptoms
the questions (see Table 22-1).
COURTESY OF DELMAR CENGAGE LEARNING

The case study questions can be completed alone, in

a study group, or in a classroom setting. When completed,
share the answers and charts with the entire group to enhance
everyone’s learning experience. Remember, each student Nursing interventions
or group of students arrives at the answers or present the
answers in a different manner. The process followed is less
important than the opportunity to integrate all aspects of the

725

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726 UNIT 10 Applications

condition and use critical thinking skills, as long as sound, Etiologies A

logical nursing judgment is utilized in obtaining an appropri-
ate answer. This is an opportunity to think creatively and
freely. Immobility in prolonged
supine position

SYSTEMS REVIEWED IN
DIABETES MELLITUS Skeletomuscular changes Cardiovascular changes
MULTISYSTEM CASE STUDY
Muscular activity Vascular changes
• Cardiovascular system
• Urinary system
Muscule mass B Venous emptying
• Neurological system
• Sensory system Protein catabolism Venous E
• Endocrine system thrombosis
• Reproductive systems Bone reabsorption
• Integumentary system Pulmonary F
emboli
Osteoporosis C

DIABETES MELLITUS CASE STUDY Pathological

fractures
Altered gas
exchange
M.B., a 46-year-old insurance salesman, is admitted to the Joint mobility Vasodilation
hospital with the diagnosis of diabetes type 1.
• List the etiological risk factors for diabetes type 1. Shortened ligaments Hypotension G
• Brainstorm subjective and objective data that would be & tendons D
included in the assessment of M.B.
• Develop a patho-flow diagram identifying the symptoms
M.B. may have been experiencing on admission and relate
Figure 22-1 An example of a patho-flow diagram of
skeletomuscular and cardiovascular changes caused by immobility.
the pathophysiology of diabetes to the symptoms (see the Complete the following instructions corresponding to the letters
examples of a patho-flow diagram in Figure 22-1 and an located at specific points along the pathophysiologic sequence of
interrelationship chart in Figure 22-2). events. A, List the risk conditions that may lead to immobility. B,
• What diagnostic tests could the physician have ordered to Name the assessment data at this point. C, List the interventions
confirm the diagnosis of diabetes? that would minimize calcium loss. D, Name the outcome criteria
• Relate the possible results of the diagnostic tests to the associated with effective nursing interventions at this point. E,
pathophysiological cause of the results on the patho-flow State the assessment data at this point. F, List the interventions
diagram. that may prevent the development of this complication. G, List the
nursing interventions to minimize this consequence. (Courtesy of
• If M.B. had been diagnosed with diabetes type 2, how the Journal of Nursing Education.)
would the pathophysiology and nursing care vary?
A couple of days after M.B. was diagnosed with diabetes, Benign Adult
he said to the nurse, “One of my friends at work said there are prostatic respiratory
a lot of future problems with diabetes. I am concerned about hypertrophy distress
this. What are some of the problems? What can I do to keep syndrome
these problems from occurring?”
• What would be appropriate responses of the nurse? Urinary
• List local resources or support groups where M.B. and his tract Sepsis
family could be referred. infection (II)
(I)
The discharge teaching included insulin administration,
diet, exercise, foot care, and eye exams.
• What is important to include in the discharge teaching
regarding: Diabetes
Glaucoma
• insulin administration mellitus
• diet
• exercise
• foot care
Amputated
• eye exams left toe
• Develop a care plan for M.B.
Eight years after M.B. was diagnosed with diabetes, he
had a routine physical examination. At that time his blood Figure 22-2 Interrelationships of Conditions and
pressure (BP) was 174/96. The physician monitored the Symptoms (Courtesy of the Journal of Nursing Education.)
Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 CHAPTER 22 Integration 727

BP for 3 weeks and then placed M.B. on enalapril maleate has +3 edema in his feet and ankles. B.W.’s primary diagnosis is
(Vasotec). His urine had a trace of albumin. hematemesis with a secondary diagnosis of cirrhosis.
• What common complication of diabetes could be • Brainstorm other subjective and objective data that are
occurring to cause M.B. to have hypertension? Explain the important to include in the assessment of B.W.
pathophysiology of the complication. • Relate the pathophysiology of cirrhosis to the assessed
• What is the action of Vasotec in lowering BP? symptoms and other symptoms B.W. may have
• What is the rationale for placing M.B. on enalapril experienced. Develop a patho-flow chart relating the
maleate (Vasotec) rather than propranolol hydrochloride symptoms to the pathological cause.
(Inderal), verapamil (Calan), or clonidine hydrochloride • List diagnostic tests that would be appropriate for the
(Catapres)? health care provider to order for B.W. What abnormal
• What other complications could have a circulatory laboratory results would be typical of cirrhosis?
etiology? • Relate the possible results of the diagnostic tests to the
• What could be the possible long-term renal complication developed patho-flow chart.
from diabetes mellitus? • Besides alcohol abuse, what are some other causes of cirrhosis?
• Explain the pathophysiology of renal complications as they • List complications of cirrhosis caused by chronic alcohol
relate to diabetes. Relate these to the patho-flow diagram abuse.
previously developed. • Explain the pathophysiology of portal hypertension as it
One evening, M.B. was massaging his foot while watching relates to cirrhosis. Relate these to the patho-flow chart
television. He noticed an ulcerated area between his third and previously developed.
fourth toe. • List diuretics that may be ordered for B.W. to decrease the
• State possible reasons M.B. may not have felt pain from ascites.
the ulcerated area. Relate these to the patho-flow diagram • How does the action of lactulose (Cephulac) lower the
previously developed. level of ammonia in the blood?
During a yearly physical, M.B. relates difficulty obtaining • What other complications result from portal
an erection. hypertension?
• Explain the rationale for this complication. • Explain the rationale for the complication of pleural
• What nursing interventions are appropriate at this time? effusion.
In later years, M.B. may experience some symptoms from • Identify possible nursing diagnoses for B.W.
autonomic neuropathies. • What nursing interventions would be appropriate at this
• List symptoms that may occur and relate the symptoms to time?
the pathophysiological etiology. • Develop a care plan for B.W.
• If B.W.’s condition improved and he was scheduled for
discharge, what is important to include in the discharge
teaching regarding:
SYSTEMS REVIEWED IN • bleeding tendencies
CIRRHOSIS MULTISYSTEM CASE • exercise
STUDY • nutrition
• skin care
• Respiratory system
• Develop diet instructions for B.W. according to various
• Cardiovascular system cultural influences.
• Hematologic and lymphatic systems • List local resources/support groups where B.W. and his
• Gastrointestinal system family could be referred.
• Urinary system B.W.’s daughter says, “I wish Dad would have quit drink-
• Musculoskeletal system ing years ago. I was always embarrassed by his behavior when
• Neurological system he had too much to drink. His life could have had so much
• Endocrine system potential.”
• Integumentary system • What would be appropriate therapeutic responses of the
nurse?

CIRRHOSIS CASE STUDY SYSTEMS REVIEWED IN

B.W., a 60-year-old male client, is admitted to the hospital with HYPERTENSION, CONGESTIVE
hematemesis. He has a history of alcohol abuse. B.W.’s wife and HEART FAILURE, AND CHRONIC
two daughters accompany him. B.W. is 5’10” tall and weighs
140 lbs. His vital signs are temperature (T) 98.2°F, apical pulse RENAL FAILURE MULTISYSTEM
(AP) 98 and slightly irregular, respiration (R) 24 breaths/min, CASE STUDY
and BP 152/88. He is lethargic, confused, and jaundiced.
When the nurse assesses his lung sounds, she hears pulmonary • Respiratory system
crackles in all lobes. His abdominal girth measures 44 inches. • Cardiovascular system
His wife states he has not gone to the bathroom all morning. He • Hematologic and lymphatic systems
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728 UNIT 10 Applications

• Gastrointestinal system • Explain to M.B. the cause for her hiccups.

• Urinary system • What are some medical and nursing interventions to
• Musculoskeletal system relieve the distress of constant hiccups?
• Neurological system
• Endocrine system
• Reproductive systems SYSTEMS REVIEWED IN
• Integumentary system PARKINSON DISEASE CASE STUDY
• Immune system
• Respiratory system
• Gastrointestinal system
• Urinary system
HYPERTENSION, CONGESTIVE • Musculoskeletal system
HEART FAILURE, AND CHRONIC • Neurological system
RENAL FAILURE CASE STUDY • Sensory system
• Integumentary system
M.B has a 20-year history of hypertension. She has been
noncompliant in taking her antihypertensive medications
that were prescribed by her physician. She recently developed
symptoms of congestive heart failure and renal failure. PARKINSON DISEASE CASE STUDY
• Brainstorm some reasons for M.B.’s noncompliance. P.K. is a 76-year-old man who was exposed to several chemi-
• Name some medications that may have been prescribed cals during his farming career. For the last 7 years, he has
to treat M.B.’s hypertension. List the advantage and walked with his arms flexed, leaning forward with his head
disadvantage of each medication. bowed. Recently, he has had difficulty rising from a chair and
• Using Table 8-4, Effects of Chronic Renal Failure by Body balancing himself when he walks. He fell twice when doing
System, develop a concept map showing the relationship odd jobs around the house. He started making a “to-do list”
of hypertension to the effects of renal failure on each listed because he has difficulty remembering. He goes to the store
system. for three items but returns with only two. His wife noticed that
• What is the relationship between hypertension, increased he has a slight tremor in his hand when he eats and often rolls
peripheral resistance, cardiac hypertrophy, and congestive his forefinger and thumb together in a circular motion.
heart failure? • Use deductive reasoning and identify P.K.’s possible
• What is the relationship of blood pressure (hypotension diagnosis.
and hypertension) and renal failure? • With these symptoms, what diagnostic tests may the
• What is the relationship between the heart’s decreasing doctor order?
ability to pump blood through the blood vessels and P.K. shared his symptoms with his family physician. After
pulmonary edema? some tests were completed and results of referrals to specialists
• Explain the relationship between fluid in the alveoli and were returned, the physician told P.K. he was suspecting Par-
dyspnea. kinson disease. P.K. said, “Tell me about Parkinson disease.”
• Physiologically, what is occurring in M.B.’s body to cause • Relate what a nurse could teach P.K. about Parkinson
an increased rate of respiration? disease.
• List laboratory results that would indicate that M.B. is • List objective and subjective data needed to make an
developing chronic renal failure. appropriate and thorough assessment on P.K.
• List symptoms that would indicate M.B. is developing • List etiological causes of Parkinson disease. What possible
chronic renal failure. etiological factors does P.K. have?
• List subjective and objective data for which the nurse • Explain the function of dopamine, a neurotransmitter, to
would assess for symptoms of chronic renal failure. the symptoms displayed in a client with Parkinson disease.
• List laboratory results that would indicate that M.B. is • List drugs that interfere in the synthesis and storage of
developing congestive heart failure. dopamine.
• List symptoms that would indicate M.B. is developing • List the signs and symptoms of Parkinson disease. Think
congestive heart failure. Give the cause/etiology for each of a client with Parkinson disease, and relate his or her
symptom. symptoms to the textbook symptoms.
• List subjective and objective data for which the nurse • Develop a patho-flow map or concept map relating the
would assess for symptoms of congestive heart failure. pathophysiology of Parkinson disease to the systems that
• Identify possible nursing diagnoses for M.B. could be affected and the typical symptoms of that system.
• List nursing interventions and give rationale for each • List drugs that P.K. may receive to control symptoms of
intervention. Parkinson disease. List the symptoms and side effects that
M.B.’s abdomen is distended, and she has lost her appetite need monitoring with each of the drugs listed.
for the last 2 days. She has had hiccups constantly for 2 hours. P.K. is becoming more rigid, having difficulty swallowing
She says, “I am so tired of these hiccups. Why am I having food, falling frequently, reaching for items to assist in ambulat-
them?” ing, experiencing frequent incontinence, complaining of his

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 CHAPTER 22 Integration 729

eyes itching, and having severe memory loss. His voice has thromboplastin time (APTT) for J.D. The results of the CBC
become soft, and his speech is slurred. are hemoglobin (Hgb) 13.0 g/dL, hematocrit (HCT) 40%,
• List P.K.’s autonomic symptoms. white blood cells (WBCs) 75,000, red blood cells (RBCs) 3.5
• Develop diet instructions for P.K. and his wife. M/mL, platelets 130 K/mL. The fibrin degradation fragment is
25 mg/mL, and the APTT is 45 sec.
• What possible surgical procedures could be done to relieve
P.K.’s symptoms. • Complete the lab values chart and compare normal lab
values with J.D.’s results.
• Develop a nursing care plan for P.K. listing nursing
diagnoses, goals, and nursing interventions to address each
symptom. CBC TEST NORMAL J.D.’S RESULTS
• Using the Internet, research new therapies for Parkinson VALUES
disease, and share them with other students.
Hgb 13.0 g/dL
After a year, P.K. is unable to walk and is lifted from his
bed to his wheelchair. He is unable to verbally communicate. HCT 40%
He no longer has bladder control. When he was fed his lunch, WBC 75 K/mL
he started coughing and perhaps aspirated some food. RBC 3.5 M/mL
• List appropriate subjective and objective data needed in a Platelet count 130 K/mL
nursing assessment.
Fibrin degradation 25 mg/mL
• Reevaluate the previously developed nursing care plan and
fragment
revise appropriately.
APTT 45 sec

SYSTEMS REVIEWED IN • What hematologic diagnosis does J.D.’s lab results suggest?
HEMATOLOGIC DISORDER • What lab results, either ones ordered or not ordered, rule
MULTISYSTEM CASE STUDY out thrombocytopenia, myeloma, Hodgkin disease, and
non-Hodgkin’s lymphoma?
• Respiratory system • According to your data-gathering skills, what is the next
• Cardiovascular system confirmative diagnostic test the health care provider would
• Hematologic system order?
• Lymphatic system The health-care provider orders a chest x-ray and a skel-
• Gastrointestinal system etal bone x-ray. With J.D.’s potential diagnosis, what do you
• Urinary system think the x-rays will reveal?
The health-care provider completes a bone biopsy on J.D.
• Musculoskeletal system and the results confirm the diagnosis of leukemia. The health
• Neurological system care provider determines that J.D. has AML.
• Integumentary system • What other symptoms could J.D. have with AML?
• Normally increased WBCs fight off an infection. Explain
the reason the increased WBCs are not able to fight the
HEMATOLOGIC DISORDER CASE bacteria causing J.D.’s infection.
STUDY • J.D. has bone pain. Explain the pathophysiology of the
bone pain.
J.D., a 69-year-old man, visits the health care clinic. When seen by • J.D. has dyspnea with slight exertion. Explain the
the health-care provider, he states he has had a cold for 4 weeks pathophysiology of the dyspnea.
and cannot seem to get over it. He also mentions that the bones • The health-care provider places J.D. on a bland, high-protein,
in his legs are “hurting.” The nurse notes on his chart that he has high-carbohydrate diet. Following the health care provider’s
a productive cough and nasal drainage. He states he is tired all orders, develop a nutritious diet for J.D. for 3 days.
the time and cannot seem to get rested. His skin is pale, and he • What are the treatment options for J.D.?
became short of breath walking from the waiting room to the • What type of chemotherapy is used for AML?
exam room. His vital signs are T 100.2°F, P 92 beats/min, R 22
breaths/min, SaO2 90, and weight is 140 lbs, a decrease of 10 • Explain the steps of bone marrow transplantation.
pounds since his last visit 3 months ago. During his physical exam • J.D.’s gums are bleeding. What nursing assessments and
the health care provider notes two open sores in J. D’s mouth, nursing interventions are appropriate at this time?
petechiae on his lower extremities, an ecchymosed spot on his • What nursing interventions are taken when starting or
right lower arm, and swollen lymph nodes in his neck and groin. removing J.D.’s IV?
• From the listed symptoms, what do you suspect is J.D.’s After the chemotherapy treatments, J.D.’s condition goes
diagnosis? into remission for 3 months. Then, he starts having headaches,
• What diagnostic tests are appropriate for the health care and blurred vision. He recently fell when rising from a chair.
provider to order for J.D.? • What do these symptoms indicate?
The health care provider ordered a complete blood count • What safety precautions should the nurse take since these
(CBC), fibrin degradation fragment, and activated partial symptoms occurred?

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730 UNIT 10 Applications

• What nursing assessment and nursing interventions are • What are some possible therapeutic responses from the nurse?
appropriate at this time? • Develop a concept map relating the different body systems
• J.D. states “I know the leukemia is active again. Are there to the possible symptoms and to the pathophysiology
any other treatments I can have?” causing the symptoms. Then map nursing interventions
• What other treatment options does J.D. have? for each symptom.

SUMMARY
This may be the first time anatomy and physiology were the student to make clinical decisions, much the way it is done
related to a disease process, or understanding was gained in the clinical environment. Analyzing and synthesizing skills
as to why clients have particular symptoms with a specific were used to work through these questions. Perhaps a renewed
disease or condition. Ill clients rarely have only one problem interest and amazement at the complexity of the body was
but several inter-related problems. These exercises provide gained while discovering the inter-relatedness of the body
an opportunity to think through situations before they are systems. Hopefully, these integration exercises and the criti-
encountered in a clinical situation. The case studies asked cal thinking experience are catalysts to becoming a proficient,
pertinent questions, evaluated clinical situations, and allowed critical thinking nurse.

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 APPENDIX A
NANDA-I Nursing
Diagnoses 2009–2011

Domain 1 Deficient Fluid Volume Domain 4

Health Promotion Excess Fluid Volume Activity Rest
Ineffective Health Maintenance Risk for Deficient Fluid Volume Insomnia
Ineffective Self Health Management Risk for Imbalanced Fluid Volume Disturbed Sleep Pattern
Impaired Home Maintenance Sleep Deprivation
Readiness for Enhanced Domain 3 Readiness for Enhanced Sleep
Immunization Status Elimination and Exchange Risk for Disuse Syndrome
Self Neglect Functional Urinary Incontinence Deficient Diversional Activity
Readiness for Enhanced Nutrition Overflow Urinary Incontinence Sedentary Lifestyle
Ineffective Family Therapeutic Reflex Urinary Incontinence Impaired Bed Mobility
Regimen Management Impaired Physical Mobility
Stress Urinary Incontinence
Readiness for Enhanced Self Health Impaired Wheelchair Mobility
Management Urge Urinary Incontinence
Risk for Urge urinary Delayed Surgical Recovery
Domain 2 Incontinence Impaired Transfer Ability
Nutrition Impaired Urinary Elimination Impaired Walking
Ineffective Infant Feeding Pattern Readiness for Enhanced Urinary Disturbed Energy Field
Imbalanced Nutrition: Less Than Elimination Fatigue
Body Requirements Urinary Retention Activity Intolerance
Imbalanced Nutrition: More Than Bowel Incontinence Risk for Activity Intolerance
Body Requirements Constipation Risk for Bleeding
Risk for Imbalanced Nutrition: More Perceived Constipation Ineffective Breathing Pattern
Than Body Requirements Risk for Constipation Decreased Cardiac Output
Impaired Swallowing Diarrhea Ineffective Peripheral Tissue Perfusion
Risk for Unstable Blood Glucose Level Dysfunctional Gastrointenstinal Risk for Decreased Cardiac Tissue
Neonatal Jaundice Motility Perfusion
Risk for Impaired Liver Function Risk for Dysfunctional Gastrointestinal Risk for Ineffective Cerebral Tissue
Risk for Electrolyte Imbalance Motility Perfusion
Readiness for Enhanced Fluid Balance Impaired Gas Exchange Risk for Ineffective Gastrointestinal

From NANDA-I Nursing Diagnoses: Definitions & Classification, 2009–2011, by North American Nursing Diagnosis Association International, 2009. Ames, IA:
Wiley-Blackwell. Copyright 2010. Reprinted with permission.

A-1

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A-2 APPENDIX A

Perfusion Readiness for Enhanced Parenting

Risk for Ineffective Renal Perfusion Risk for Impaired Parenting
Risk for Shock Risk for Impaired Attachment
Impaired Spontaneous Ventilation Dysfunctional Family Processes
Dysfunctional Ventilatory Weaning Response Interrupted Family Processes
Readiness for Enhanced Self-Care Readiness for Enhanced Family Processes
Bathing Self-Care Deficit Effective Breastfeeding
Dressing Self-Care Deficit Ineffective Breastfeeding
Feeding Self-Care Deficit Interrupted Breastfeeding
Toileting Self-Care Deficit Parental Role Conflict
Readiness for Enhanced Relationship
Domain 5 Ineffective Role Performance
Perception/Cognition Impaired Social Interaction
Unilateral Neglect
Impaired Environmental Interpretation Syndrome Domain 8
Wandering Sexuality
Disturbed Sensory Perception (Specify: Visual, Auditory, Sexual Dysfunction
Kinesthetic, Gustatory, Tactile, Olfactory) Ineffective Sexuality Pattern
Acute Confusion Readiness for Enhanced Childbearing Process
Chronic Confusion Risk for Disturbed Maternal/Fetal Dyad
Risk for Acute Confusion
Deficient Knowledge Domain 9
Readiness for Enhanced Knowledge Coping/Stress Tolerance
Impaired Memory Post-Trauma Syndrome
Readiness for Enhanced Decision-Making Risk for Post-Trauma Syndrome
Ineffective Activity Planning Rape-Trauma Syndrome
Impaired Verbal Communication Relocation Stress Syndrome
Readiness for Enhanced Communication Risk for Relocation Stress Syndrome
Anxiety
Domain 6 Death Anxiety
Self-Perception Risk-Prone Health Behavior
Risk for Compromised Human Dignity Compromised Family Coping
Hopelessness Defensive Coping
Disturbed Personal Identity Disabled Family Coping
Risk for Loneliness Ineffective Coping
Readiness for Enhanced Power Ineffective Community Coping
Powerlessness Readiness for Enhanced Coping
Risk for Powerlessness Readiness for Enhanced Community Coping
Readiness for Enhanced Self-Concept Readiness for Enhanced Family Coping
Situational Low Self-Esteem Ineffective Denial
Chronic Low Self-Esteem Fear
Risk for Situational Low Self-Esteem Grieving
Disturbed Body Image Complicated Grieving
Risk for Complicated Grieving
Domain 7 Impaired Individual Resilience
Role Relationships Readiness for Enhanced Resilience
Caregiver Role Strain Risk for Compromised Resilience
Risk for Caregiver Role Strain Chronic Sorrow
Impaired Parenting Stress Overload

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 APPENDIX A A-3

Autonomic Dysreflexia Risk for Impaired Skin Integrity

Risk for Autonomic Dysreflexia Risk for Suffocation
Disorganized Infant Behavior Impaired Tissue Integrity
Risk for Disorganized Infant Behavior Risk for Trauma
Readiness for Enhanced Organized Infant Behavior Risk for Vascular Trauma
Decreased Intracranial Adaptive Capacity Self-Mutilation
Risk for Suicide
Domain 10 Risk for Other-Directed Violence
Life Principles Risk for Self-Directed Violence
Readiness for Enhanced Hope Contamination
Readiness for Enhanced Spiritual Well-Being Risk for Contamination
Decisional Conflict Risk for Poisoning
Moral Distress Latex Allergy Response
Noncompliance Risk for Latex Allergy Response
Impaired Religiosity Risk for Imbalanced Body Temperature
Readiness for Enhanced Religiosity Hyperthermia
Risk for Impaired Religiosity Hypothermia
Spiritual Distress Ineffective Thermoregulation
Risk for Spiritual Distress
Domain 12
Domain 11 Comfort
Safety/Protection Readiness for Enhanced Comfort
Risk for Infection Impaired Comfort
Ineffective Airway Clearance Nausea
Risk for Aspiration Acute Pain
Risk for Sudden Infant Death Syndrome Chronic Pain
Impaired Dentition Social Isolation
Risk for Falls
Risk for Injury Domain 13
Risk for Perioperative-Positioning Injury Growth/Development
Impaired Oral Mucous Membrane Adult Failure to Thrive
Risk for Peripheral Neurovascular Dysfunction Delayed Growth and Development
Ineffective Protection Risk for Disproportionate Growth
Impaired Skin Integrity Risk for Delayed Development

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Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 APPENDIX B
Recommended
Immunization
Schedules

B-1

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B-2 APPENDIX B

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 APPENDIX B B-3

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 Recommended Adult Immunization Schedule
B-4

UNITED STATES · 2009

Note: These recommendations must be read with the footnotes that follow
containing number of doses, intervals between doses, and other important information.
Figure 1. Recommended adult immunization schedule, by vaccine and age group
VACCINE AGE GROUP 19–26 years 27–49 years 50–59 years 60–64 years >65 years

Td booster
APPENDIX B

Tetanus, diphtheria, pertussis Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
(Td/Tdap)1,* every 10 yrs

Human papillomavirus (HPV)2,* 3 doses (females)

Varicella3,* 2 doses

Zoster4 1 dose

Measles, mumps, rubella (MMR)5,* 1 or 2 doses 1 dose

Influenza6,* 1 dose annually

Pneumococcal (polysaccharide)7,8 1 or 2 doses 1 dose

Hepatitis A9,* 2 doses

Hepatitis B10,* 3 doses

Meningococcal11,* 1 or more doses

*Covered by the Vaccine Injury Compensation Program.

For all persons in this category who meet the age Recommended if some other risk factor is No recommendation
requirements and who lack evidence of immunity present (e.g., on the basis of medical,
(e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications)
no evidence of prior infection)

Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by
telephone, 800-822-7967.
Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of
Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at www.cdc.gov/vaccines or from the CDC-INFO Contact Center at
800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.

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Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
 Figure 2. Vaccines that might be indicated for adults based on medical and
other indications
Asplenia 12
Immuno- HIV infection 3,12,13 Diabetes, (including
Kidney failure,
compromising heart disease, elective
end-stage renal Health-care
Pregnancy conditions chronic splenectomy Chronic liver
INDICATION disease, personnel
(excluding human CD4+ T lympho- lung disease, and terminal disease
cyte count receipt of
immunodeficiency chronic complement
hemodialysis
virus [HIV]) 13 <200 >200 alcoholism component
VACCINE cells/μL cells/μL deficiencies)

Tetanus, diphtheria, pertussis

Td Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
(Td/Tdap)1,*

Human papillomavirus (HPV)2,* 3 doses for females through age 26 yrs

Varicella3,* Contraindicated 2 doses

Zoster4 Contraindicated 1 dose

Measles, mumps, rubella (MMR)5,* Contraindicated 1 or 2 doses

1 dose TIV
Influenza6,* 1 dose TIV annually or LAIV
annually

Pneumococcal (polysaccharide)7,8 1 or 2 doses

Hepatitis A9,* 2 doses

Hepatitis B10,* 3 doses

Meningococcal11,* 1 or more doses

*Covered by the Vaccine Injury Compensation Program.
For all persons in this category who meet the age Recommended if some other risk factor is No recommendation
requirements and who lack evidence of immunity present (e.g., on the basis of medical,
(e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications)
no evidence of prior infection)

These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older, as of January 1, 2009.
Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines,

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APPENDIX B

including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices
(www.cdc.gov/vaccines/pubs/acip-list.htm).

CS200484-A
The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory
Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Department of Health and Human Services
B-5

Obstetricians and Gynecologists (ACOG), and the American College of Physicians (ACP). Centers for Disease Control and Prevention
 Footnotes
B-6

Recommended Adult Immunization Schedule—UNITED STATES · 2009

For complete statements by the Advisory Committee on Immunization Practices (ACIP), visit www.cdc.gov/vaccines/pubs/ACIP-list.htm.

1. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination

Tdap should replace a single dose of Td for adults aged 19 through 64 years who have not received a dose of Tdap previously.
Adults with uncertain or incomplete history of primary vaccination series with tetanus and diphtheria toxoid-containing vaccines should begin or complete a primary vaccination series. A primary series for adults is
3 doses of tetanus and diphtheria toxoid-containing vaccines; administer the first 2 doses at least 4 weeks apart and the third dose 6–12 months after the second. However, Tdap can substitute for any one of the doses of
Td in the 3-dose primary series. The booster dose of tetanus and diphtheria toxoid-containing vaccine should be administered to adults who have completed a primary series and if the last vaccination was received 10 or
APPENDIX B

more years previously. Tdap or Td vaccine may be used, as indicated.

If a woman is pregnant and received the last Td vaccination 10 or more years previously, administer Td during the second or third trimester. If the woman received the last Td vaccination less than 10 years
previously, administer Tdap during the immediate postpartum period. A dose of Tdap is recommended for postpartum women, close contacts of infants aged less than 12 months, and all health-care personnel with direct
patient contact if they have not previously received Tdap. An interval as short as 2 years from the last Td is suggested; shorter intervals can be used. Td may be deferred during pregnancy and Tdap substituted in the
immediate postpartum period, or Tdap may be administered instead of Td to a pregnant woman after an informed discussion with the woman.
Consult the ACIP statement for recommendations for administering Td as prophylaxis in wound management.
2. Human papillomavirus (HPV) vaccination
HPV vaccination is recommended for all females aged 11 through 26 years (and may begin at 9 years) who have not completed the vaccine series. History of genital warts, abnormal Papanicolaou test, or positive
HPV DNA test is not evidence of prior infection with all vaccine HPV types; HPV vaccination is recommended for persons with such histories.
Ideally, vaccine should be administered before potential exposure to HPV through sexual activity; however, females who are sexually active should still be vaccinated consistent with age-based recommendations.
Sexually active females who have not been infected with any of the four HPV vaccine types receive the full benefit of the vaccination. Vaccination is less beneficial for females who have already been infected with one or
more of the HPV vaccine types.
A complete series consists of 3 doses. The second dose should be administered 2 months after the first dose; the third dose should be administered 6 months after the first dose.
HPV vaccination is not specifically recommended for females with the medical indications described in Figure 2, "Vaccines that might be indicated for adults based on medical and other indications." Because HPV
vaccine is not a live-virus vaccine, it may be administered to persons with the medical indications described in Figure 2. However, the immune response and vaccine efficacy might be less for persons with the medical
indications described in Figure 2 than in persons who do not have the medical indications described or who are immunocompetent. Health-care personnel are not at increased risk because of occupational exposure, and
should be vaccinated consistent with age-based recommendations.
3. Varicella vaccination
All adults without evidence of immunity to varicella should receive 2 doses of single-antigen varicella vaccine if not previously vaccinated or the second dose if they have received only one dose unless they
have a medical contraindication. Special consideration should be given to those who 1) have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of persons with
immunocompromising conditions) or 2) are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college
students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers).
Evidence of immunity to varicella in adults includes any of the following: 1) documentation of 2 doses of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980 (although for health-care personnel and
pregnant women, birth before 1980 should not be considered evidence of immunity); 3) history of varicella based on diagnosis or verification of varicella by a health-care provider (for a patient reporting a history of or
presenting with an atypical case, a mild case, or both, health-care providers should seek either an epidemiologic link with a typical varicella case or to a laboratory-confirmed case or evidence of laboratory confirmation,
if it was performed at the time of acute disease); 4) history of herpes zoster based on health-care provider diagnosis or verification of herpes zoster by a health-care provider; or 5) laboratory evidence of immunity or
laboratory confirmation of disease.
Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy
and before discharge from the health-care facility. The second dose should be administered 4–8 weeks after the first dose.
4. Herpes zoster vaccination
A single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a prior episode of herpes zoster. Persons with chronic medical conditions may be vaccinated
unless their condition constitutes a contraindication.
5. Measles, mumps, rubella (MMR) vaccination
Measles component: Adults born before 1957 generally are considered immune to measles. Adults born during or after 1957 should receive 1 or more doses of MMR unless they have a medical contraindication,
documentation of 1 or more doses, history of measles based on health-care provider diagnosis, or laboratory evidence of immunity.
A second dose of MMR is recommended for adults who 1) have been recently exposed to measles or are in an outbreak setting; 2) have been vaccinated previously with killed measles vaccine; 3) have been
vaccinated with an unknown type of measles vaccine during 1963–1967; 4) are students in postsecondary educational institutions; 5) work in a health-care facility; or 6) plan to travel internationally.

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Mumps component: Adults born before 1957 generally are considered immune to mumps. Adults born during or after 1957 should receive 1 dose of MMR unless they have a medical contraindication, history of
 mumps based on health-care provider diagnosis, or laboratory evidence of immunity.
A second dose of MMR is recommended for adults who 1) live in a community experiencing a mumps outbreak and are in an affected age group; 2) are students in postsecondary educational institutions; 3) work in
a health-care facility; or 4) plan to travel internationally. For unvaccinated health-care personnel born before 1957 who do not have other evidence of mumps immunity, administering 1 dose on a routine basis should be
considered and administering a second dose during an outbreak should be strongly considered.
Rubella component: 1 dose of MMR vaccine is recommended for women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless
of birth year, rubella immunity should be determined and women should be counseled regarding congenital rubella syndrome. Women who do not have evidence of immunity should receive MMR upon completion or
termination of pregnancy and before discharge from the health-care facility.
6. Influenza vaccination
Medical indications: Chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal or hepatic dysfunction, hemoglobinopathies, or
immunocompromising conditions (including immunocompromising conditions caused by medications or human immunodeficiency virus [HIV]); any condition that compromises respiratory function or the handling of
respiratory secretions or that can increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, or seizure disorder or other neuromuscular disorder); and pregnancy during the influenza season. No data
exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia.
Occupational indications: All health-care personnel, including those employed by long-term care and assisted-living facilities, and caregivers of children less than 5 years old.
Other indications: Residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (e.g., in-home household contacts and caregivers of
children aged less than 5 years old, persons 65 years old and older and persons of all ages with high-risk condition[s]); and anyone who would like to decrease their risk of getting influenza. Healthy, nonpregnant adults
aged less than 50 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special care units can receive either intranasally administered live, attenuated influenza
vaccine (FluMist®) or inactivated vaccine. Other persons should receive the inactivated vaccine.
7. Pneumococcal polysaccharide (PPSV) vaccination
Medical indications: Chronic lung disease (including asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver diseases, cirrhosis; chronic alcoholism, chronic renal failure or nephrotic syndrome;
functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); immunocompromising conditions; and cochlear implants and
cerebrospinal fluid leaks. Vaccinate as close to HIV diagnosis as possible.
Other indications: Residents of nursing homes or long-term care facilities and persons who smoke cigarettes. Routine use of PPSV is not recommended for Alaska Native or American Indian persons younger than
65 years unless they have underlying medical conditions that are PPSV indications. However, public health authorities may consider recommending PPSV for Alaska Natives and American Indians aged 50 through 64
years who are living in areas in which the risk of invasive pneumococcal disease is increased.
8. Revaccination with PPSV
One-time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for persons with
immunocompromising conditions. For persons aged 65 years and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination.
9. Hepatitis A vaccination
Medical indications: Persons with chronic liver disease and persons who receive clotting factor concentrates.
Behavioral indications: Men who have sex with men and persons who use illegal drugs.
Occupational indications: Persons working with hepatitis A virus (HAV)-infected primates or with HAV in a research laboratory setting.
Other indications: Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A (a list of countries is available at wwwn.cdc.gov/travel/contentdiseases.aspx) and any person
seeking protection from HAV infection.
Single-antigen vaccine formulations should be administered in a 2-dose schedule at either 0 and 6–12 months (Havrix®), or 0 and 6–18 months (Vaqta®). If the combined hepatitis A and hepatitis B vaccine
(Twinrix®) is used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose schedule, administered on days 0, 7 and 21 to 30 followed by a booster dose at month 12 may be used.
10. Hepatitis B vaccination
Medical indications: Persons with end-stage renal disease, including patients receiving
hemodialysis; persons with HIV infection; and persons with chronic liver disease.
Occupational indications: Health-care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids.
Behavioral indications: Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than 1 sex partner during the previous 6 months); persons seeking evaluation
or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; and men who have sex with men.
Other indications: Household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff members of institutions for persons with developmental disabilities; international
travelers to countries with high or intermediate prevalence of chronic HBV infection (a list of countries is available at wwwn.cdc.gov/travel/contentdiseases.aspx); and any adult seeking protection from HBV infection.

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APPENDIX B

Hepatitis B vaccination is recommended for all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services;
health-care settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and
nonresidential daycare facilities for persons with developmental disabilities.
If the combined hepatitis A and hepatitis B vaccine (Twinrix®) is used, administer 3 doses at
B-7
 0, 1, and 6 months; alternatively, a 4-dose schedule, administered on days 0, 7 and 21 to 30 followed by a booster dose at month 12 may be used.
Special formulation indications: For adult patients receiving hemodialysis or with other immunocompromising conditions, 1 dose of 40 μg/mL (Recombivax HB®) administered on a 3-dose schedule or 2 doses of 20
B-8

μg/mL (Engerix-B®) administered simultaneously on a 4-dose schedule at

0, 1, 2 and 6 months.
11. Meningococcal vaccination
Medical indications: Adults with anatomic or functional asplenia, or terminal complement component deficiencies.
Other indications: First-year college students living in dormitories; microbiologists who are routinely exposed to isolates of Neisseria meningitidis; military recruits; and persons who travel to or live in countries in
which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December–June]), particularly if their contact with local populations will be prolonged.
Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj.
Meningococcal conjugate (MCV) vaccine is preferred for adults with any of the preceding indications who are aged 55 years or younger, although meningococcal polysaccharide vaccine (MPSV) is an acceptable
APPENDIX B

alternative. Revaccination with MCV after 5 years might be indicated for adults previously vaccinated with MPSV who remain at increased risk for infection (e.g., persons residing in areas in which disease is epidemic).
12. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used
Hib vaccine generally is not recommended for persons aged 5 years and older. No efficacy data are available on which to base a recommendation concerning use of Hib vaccine for older children and adults.
However, studies suggest good immunogenicity in persons who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy; administering 1 dose of vaccine to these persons is not contraindicated.
13. Immunocompromising conditions
Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and influenza [trivalent inactivated influenza vaccine]), and live vaccines generally are avoided in persons with immune deficiencies
or immunocompromising conditions. Information on specific conditions is available at www.cdc.gov/vaccines/pubs/acip-list.htm.

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 APPENDIX C
Abbreviations, Acronyms,
and Symbols

⬎ greater than AIDS acquired immunodeficiency syndrome

⬍ less than AJN American Journal of Nursing
dram ALFA Assisted Living Federation of America
ounce ALT alanine aminotransferase
minum AMA against medical advice
ā before AMA American Medical Association
AAPB Association of Applied Psychophysiology ANA American Nurses Association
and Biofeedback ANA antinuclear antibody
AARP American Association of Retired Persons AoA Administration on Aging
AASM American Academy of Sleep Medicine AP anterior/posterior
AAT animal-assisted therapy AP apical pulse
AATH American Association for Therapeutic Humor APIC Association for Practitioners in Infection
ABC airway, breathing, circulation Control and Epidemiology
ABD abdominal APRN advance practice registered nurse
ABG arterial blood gases APS Adult Protective Services
ABO blood types APS American Pain Society
a.c. before meals APTT activated partial thromboplastin time
ACIP Advisory Committee on Immunization AROM active range of motion
Practices AS left ear
ACS American Cancer Society ASA acetylsalicylic acid
ACTH adrenocorticotropic hormone ASO antireptolysin-O
AD Alzheimer’s disease AST aspartate aminotransferase
AD right ear AT axillary temperature
ad lib freely, as desired ATC around the clock
ADA Americans with Disabilities Act ATP adenosine triphosphatase
ADH antidiuretic hormone AU both ears
ADLs activities of daily living B1 thiamine
ADN associate degree nurse (nursing) B2 riboflavin
AEB as evidenced by B6 pyridoxine
AFP alpha-fetoprotein B12 cobolomine
AHA American Hospital Association BBA Balanced Budget Act
AHCA American Health Care Association BE base excess
AHCPR Agency for Health Care Policy and Research bid twice a day
AHNA American Holistic Nurses’ Association BMD bone mineral density
AHRQ Agency for Healthcare Research and Quality BMI body mass index
AI adequate intake BMR basal metabolic rate
C-1

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C-2 APPENDIX C

BP blood pressure COBRA Comprehensive Omnibus Budget

BPH benign prostatic hypertrophy Reconciliation Act
BPM beats per minute COOH carboxyl group
BSA body surface area COPD chronic obstructive pulmonary disease
BSE breast self-examination CPAP continuous positive airway pressure
BSI body substance isolation CPNP Council of Practical Nursing Programs
BSN bachelor of science in nursing CPR cardiopulmonary resuscitation
BUN blood urea nitrogen CPR computerized patient record
c cup Cr chromium
c– with CRNA Certified Registered Nurse Anesthetist
C Celsius CRP C-reactive protein
Ca calcium C&S culture and sensitivity
Ca++ calcium ion CSF cerebrospinal fluid
CaCl2 calcium chloride CSM circulation, sensation, motion
C/A complementary/alternative CT computed tomography
CAD coronary artery disease Cu copper
CAI computer-assisted instruction CVA cerebrovascular accident
CAM complementary/alternative medicine CVC central venous catheter
C&S culture and sensitivity D5W dextrose 5% in water
cap capsule D&C dilatation and curettage
CARF Commission on Accreditation of DAR document, action, response
Rehabilitation Facilities dc discontinue
CAT computed axial tomography DDB Disciplinary Data Bank
CAT computerized adaptive testing DDS doctor of dental surgery
CBC complete blood count DEA Drug Enforcement Agency
CBD common bile duct DHHS Department of Health and Human Services
CBE charting by exception DIC disseminated intravascular coagulation
cc cubic centimeter DICC dynamic infusion cavernosometry and
CCRC continuing care retirement community cavernosography
CCU coronary care unit dL deciliter
CDC Centers for Disease Control and DMD doctor of dental medicine
Prevention DNA deoxyribonucleic acid
CEA carcinoembryonic antigen DNR do not resuscitate
CEPN-LTC™ Certification Examination for Practical and DO doctor of osteopathy
Vocational Nurses in Long-Term Care DPAHC durable power of attorney for health care
CEU continuing education unit dr dram, or
CHAP Community Health Accreditation DRG diagnosis-related group
Program DRI dietary reference intake
CHD coronary heart disease DSM-IV Diagnostic and Statistical Manual of Mental
CHF congestive heart failure Disorders, 4th edition
CHIP Children’s Health Insurance Program DST dexamethasone suppression test
CHO carbohydrate (carbon, hydrogen, oxygen) DT delirium tremens
CHON protein (carbon, hydrogen, oxygen, nitrogen) DTaP diphtheria, tetanus, acellular pertussis
CK or CPK creatine kinase or creatine phosphokinase DTP diphtheria, tetanus, pertussis
Cl chlorine, chloride DVT deep vein thrombosis
Cl– chloride ion EAR estimated average requirement
CLTC certified in long-term care ECF extended care facility
cm centimeter ECF extracellular fluid
CMS Centers for Medicare and Medicaid Services ED emergency department
CN cranial nerve EDTA ethylenediaminetetraacetic acid
CNA certified nursing assistant EEG electroencephalograph
CNM certified nurse midwife EGD esophagogastroduodenoscopy
CNO community nursing organization EKG (ECG) electrocardiogram
CNS central nervous system ELISA enzyme-linked immunosorbent assay
CNS clinical nurse specialist elix elixir
Co cobalt EMG electromyogram
CO2 carbon dioxide EMLA eutectic (cream) mixture of local anesthetics
CO2– carbon dioxide ion EMS emergency medical services

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 APPENDIX C C-3

EMT emergency medical technician HFA Hospice Foundation of America

EMT-P emergency medical technician-paramedic Hg mercury
EPA Environmental Protection Agency Hgb hemoglobin
EPO exclusive provider organization Hgbs hemoglobins
ER emergency room HICPAC Hospital Infection Control Practices Advisory
ERCP endoscopic retrograde Committee
cholangiopancreatogram HIS hospital information system
ERG electroretinogram HIV human immunodeficiency virus
ERT estrogen replacement therapy HLA human leukocyte antigen
ESR erythrocyte sedimentation rate HMO health maintenance organization
ET ear (tympanic) temperature HPO4 phosphate
EVAD explantable venous access device HR heart rate
F fahrenheit HRSA Health Resources and Services
FAS fetal alcohol syndrome Administration
FBS fasting blood sugar h.s. hour of sleep
FCA False Claims Act I iodine
FDA Food and Drug Administration IADLs instrumental activities of daily living
Fe iron I&O intake and output
FeSO4 iron sulfate IASP International Association for the Study
fl fluid of Pain
Fl fluorine ICF intermediate care facility
FOBT fecal occult blood test ICF intracellular fluid
FSH follicle-stimulating hormone ICN International Council of Nurses
ft foot or feet ICU intensive care unit
FVD fluid volume deficit ID identification
g gram ID intradermal
GAO General Accounting Office IgG immunoglobulin G
GAS general adaptation syndrome IgM immunoglobulin M
GCS Glasgow Coma Scale IHCT interdisciplinary health care team
g/dL grams per deciliter IM intramuscular
GED general education development in inch
GER gastroesophageal reflux INR International Normalized Ratio
GFR glomerular filtration rate I&O intake and output
GGT (GGTP) gammaglutamy transpeptidase IOL intraocular lens
GH growth hormone IOM Institute of Medicine
GHB glycosylated hemoglobin ITT insulin tolerance test
GI gastrointestinal IV intravenous
gr grain IVAD implantable vascular access device
gtt drop IVP intravenous push, intravenous pyelogram
GTT glucose tolerance test IVPB intravenous piggyback
gtt/min drops per minute JCAHO Joint Commission on Accreditation of
GU genitourinary Healthcare Organizations
h hour(s) K potassium
H+ hydrogen ion K+ potassium ion
H2CO3 carbonic acid kcal kilocalorie
H2O water KCl potassium chloride
H&H hemoglobin and hematocrit kg kilogram
HB5AG hepatitis B surface antigen KS ketosteroids
HBV hepatitis B virus KUB kidneys/ureters/bladder
HCFA Health Care Financing Administration KVO keep vein open
hCG human chorionic gonadotropin L liter
HCl hydrochloric acid, hydrochloride LAS local adaptation syndrome
HCO3– bicarbonate ion lb pound
Hct hematocrit LDH lactic dehydrogenase
HCV hepatitis C virus LDL low density lipoprotein
HDL high density lipoprotein LE lupus erythematosus
HDV hepatitis D virus LES lower esophageal sphincter
Hep B hepatitis B LFT liver function test

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C-4 APPENDIX C

LH luteinizing hormone NANDA North American Nursing Diagnosis

LLQ left lower quadrant Association
LMP last menstrual period NaOH sodium hydroxide
L/min liters per minute NAPNE Natonal Association of Practical Nurse
LOC level of consciousness Education
LP lumbar puncture NAPNES National Association for Practical Nurse
LP/VN licensed practical/vocational nurse Education and Services
LPN licensed practical nurse NCCAM National Center for Complementary and
LUQ left upper quadrant Alternative Medicine
LVN licensed vocational nurse NCHS National Center for Health Statistics
m meter NCLEX ®
National Council Licensure Examination
m2 square meter ®
NCLEX-PN National Council Licensure Examination—
MAO monoamine oxidase Practical Nurse
MAOI monoamine oxidase inhibitor ®
NCLEX-RN National Council Licensure Examination—
MAR medication administration record Registered Nurse
mcg (or ␮g) microgram NCLD National Center for Learning Disabilities
MD doctor of medicine NCOA National Council on Aging
MDI metered-dose inhaler NCSBN National Council of State Boards of Nursing
MDR multidrug-resistant NCVHS National Committee on Vital and Health
MDR-TB multidrug-resistant tuberculosis Statistics
MDS minimum data set NF National Formulary
mEq milliequivalent NFLPN National Federation of Licensed Practical
mEq/L milliequivalents per liter Nurses, Inc.
mg milligram NG nasogastric
mg/dL milligrams per deciliter NH2 amino group
Mg magnesium NHO National Hospice Organization
Mg++ magnesium ion NIA National Institute on Aging
MgCl magnesium chloride NIC Nursing Interventions Classification
MgSO4 magnesium sulfate NIH National Institutes of Health
MI myocardial infarction NIOSH National Institute of Occupational Safety and
min minute Health
mL milliliter NIS nursing information system
mm3 cubic millimeter NLEA Nutrition, Labeling, and Education Act
mm Hg millimeters of mercury NLN National League for Nursing
mmol/L millimoles per liter NLNAC National League for Nursing Accrediting
MMR measles, mumps, rubella Commission
Mn manganese NMDS nursing minimum data set
Mo molybdenum NOC Nursing Outcomes Classification
MOM Milk of Magnesia NP nurse practitioner
mOsm/kg milliosmoles/kilogram NPDB National Practitioner Data Bank
MRI magnetic resonance imaging NPO nil per os, Latin for “nothing by mouth”
MRSA methicillin-resistant staphylococcus NREM non-rapid eye movement
aureus NS normal saline
MS morphine sulfate NSAID nonsteroidal anti-inflammatory drug
MSDS material safety data sheet NSF National Sleep Foundation
MUGA multi-gated acquisition O2 oxygen
N2 nitrogen OAM Office of Alternative Medicine
Na sodium O&P ova and parasite
Na+ sodium ion OBRA Omnibus Budget Reconciliation Act
Na2SO4 sodium sulfate OD right eye
NaCl sodium chloride OH- hydroxyl
NA not applicable OR operating room
NADSA National Adult Day Services Associations ORIF open reduction/internal fixation
NaH2PO4 sodium dihydrogen phosphate OS left eye
Na2HPO4 disodium phosphate OSHA Occupational Safety and Health
NAHC National Association for Home Care Administration
NaHCO3 sodium bicarbonate OT occupational therapist
NaHPO4 sodium monohydrogen phosphate OT oral temperature

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 APPENDIX C C-5

OTC over-the-counter PVD peripheral vascular disease

OU both eyes q quaque, Latin for “every”
oz ounce qd every day
p̄ after qh every hour
P phosphorus qid four times a day
P pulse qod every other day
PA physician’s assistant qs quantity sufficient
PA posterioanterior q2h every 2 hours
PaCO2 partial pressure of carbon dioxide qt quart
PaO2 partial pressure of oxygen R (Resp) respiration
Pap Papanicolaou test RAIU radioactive iodine uptake
p.c. after meals RAST radio allergosorbent test
PCA patient-controlled analgesia RBC red blood count, red blood cell
PCO2 partial pressure of carbon dioxide RD registered dietician
(PaCO2) RDA recommended dietary allowance
PCP primary care provider REM rapid eye movement
PCR polymerase chain reaction RF rheumatoid factor
PCV pneumococcal conjugate vaccine RLQ right lower quadrant
PDPH postdural puncture headache RLS restless leg syndrome
PEG percutaneous endoscopic gastrostomy RN registered nurse
PERRLA pupils equal, round, reactive to light and RNA ribonucleic acid
accommodation RNFA registered nurse first assistant
PET positron emission tomography ROM range of motion
PFT pulmonary function test ROS review of systems
pH potential hydrogen RPCH rural primary care hospital
PICC peripherally inserted central catheter RPh registered pharmacist
PIE problem, implementation, evaluation RPR rapid plasma reagin
PKU phenylketonuria RR recovery room
PLMS periodic limb movements in sleep RSV respiratory syncytial virus
PMI point of maximum intensity R/T related to
PMR progressive muscle relaxation RT rectal temperature
PMS premenstrual syndrome RT respiratory therapist
PNI psychoneuroimmunology RTI respiratory tract infection
PNS peripheral nervous system RUGS resource utilization group system
po per os, Latin for “by mouth” RUQ right upper quadrant
PO2 (PaO2) partial pressure of oxygen RWJF Robert Wood Johnson Foundation
PO4– – phosphate ion s̄ without
POMR problem-oriented medical record S sulfur
POR problem-oriented record SAMe S-adenosylmethionine
PPBS post prandial blood sugar SaO2 oxygen saturation
PPE personal protective equipment SBC school-based clinic
PPG post prandial glucose SC/SQ subcutaneous
PPO preferred provider organization SCHIP State Children’s Health Insurance Program
PPS prospective payment system Se selenium
PRA plama renin activity SGOT serum glutamate oxaloacetate transaminase
PRL prolactin level SGPT serum glutamic pyruvic transaminase
PRN pro re nata, Latin for “as required” SL sublingual
PRO peer review organization SNF skilled nursing facility
PROM passive range of motion SOAP subjective data, objective data, assessment, plan
PSA prostate specific antigen SOAPIE subjective data, objective data, assessment,
PSDA Patient Self-Determination Act plan, implementation, evaluation
PSP phenolsulfonphtalein SOAPIER subjective data, objective data, assessment,
pt pint plan, implementation, evaluation, revision
PT physical therapist SPF sun protection factor
PT prothrombin time s̄s̄ one half
PTH parathyroid hormone SSA Social Security Administration
PTSD post-traumatic stress disorder STAT statim, Latin for “immediately”
PTT partial thromboplastin time STD sexually transmitted disease

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C-6 APPENDIX C

supp suppository UAP unlicensed assistive personnel

susp suspension UIS Universal Intellectual Standards
SW social worker UL upper intake level
T temperature UMLS Universal Medical Language
T3 triiodothyronine System
T4 thyroxine UNOS United Network for Organ Sharing
tab tablet U-100 100 units insulin per cc
TAC tetracaine, adrenaline, cocaine UPP urethra pressure profile
TB tuberculosis URQ upper right quadrant
Tbsp tablespoon USDHHS United States Department of Health and
Td tetanus/diphtheria Human Services
TDD telecommunication device for the deaf USP United States Pharmacopeia
TEFRA Tax Equity Fiscal Responsibility Act USPHS United States Public Health Service
TENS transcutaneous electrical nerve stimulation UTI urinary tract infection
TF tube feeding VA Veterans Administration, Veterans Affairs
THA total hip arthroplasty VAD ventricular assist device, vascular access
TIA transient ischemic attack device
TIBC total iron binding capacity VAS Visual Analog Scale
t.i.d. three times a day VDRL venereal disease research laboratory
TMJ temporomandibular joint VLDL very low-density lipoprotein
t.o. telephone order VMA vanilymandelic acid
TPN total parenteral nutrition VRE vancomycin-resistant enterococci
TPR temperature, pulse, respirations VS vital signs
Tr or tinct tincture WASP white, Anglo-Saxon, Protestant
TRH thyrotropin-releasing hormone WBC white blood cell, white blood count
TSE testicular self examination WHO World Health Organization
TSH thyroid-stimulating hormone WNL within normal limits
tsp teaspoon WPM words per minute
U unit wt weight
U/L unit per liter YWCA Young Women’s Christian Association
UA routine urinalysis Zn Zinc

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 APPENDIX D
English/Spanish Words
and Phrases

Being able to say a few words or phrases in the client’s language is one way to show that you care. It lets the client know that you
as a nurse are interested in the individual. There are three rules to keep in mind regarding the pronunciation of Spanish words.
• If a word ends in a vowel, or in n or s, the accent is on the next to the last syllable.
• If the word ends in a consonant other than n or s, the accent is on the last syllable.
• If the word does not follow these rules, it has a written accent over the vowel of the accented syllable.
Courtesy phrases, names of body parts, and expressions of time and numbers are included in this section for quick reference.
The English version will appear first, followed by the Spanish translation and Spanish pronunciation.

Courtesy Phrases
Please Por favor Por fah-vor
Thank-you Grácias Grah-the-as
Good morning Buénos dias Boo-ay-nos dee-as
Good afternoon Buénas tardes Boo-ay-nas tar-days
Good evening Buénas noches Boo-ay-nas no-chays
Yes/No Si/no See/no
Good Bien Be-en
Bad Mal Mahl
How many? ¿Cuántos? ¿Coo-ahn-tos?
Where? ¿Dónde? ¿Don-day?
When? ¿Cuándo? ¿Cooahn-do?

Body Parts
abdomen el abdomen el ab-doh-men
ankle el tobillo el to-beel-lyo
anus el ano el ah-no
anvil (incus) el yunque el yoon-kay
appendix el apéndice el ah-pen-de-thay
aqueous humor el humor acuoso el oo-mor ah-coo-o-so
bladder la vejiga lah vay-nee-gah
brain el cerebro el thay-ray-bro
breast el pecho el pay-cho
buttock la nalga lah nahl-gah
calf la pantorrilla lah pan-tor-reel-lyah
cervix la cerviz lah ther-veth
cheek la mejilla lah may-heel-lyah D-1

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D-2 APPENDIX D

chin la barbilla lah bar-beel-lyah

choroid la coroidea lah co-ro-e-day-ah
ciliary body el cuerpo ciliar el coo-err-po the-le-ar
clitoris el clítoris el clee-to-ris
coccyx el coxis el coc-sees
conjunctiva la conjuntiva lah con-hoon-teevah
cornea la córnea lah cor-nay-ah
penis el pene el pay-nay
prostate gland la próstata lah pros-ta-tah
pupil la pupila lah poo-pee-lah
rectum el recto el rec-to
retina la retina lah ray-tee-nah
sclera la esclerótica lah es-clay-ro-te-cah
scrotum el escroto el es-cro-to
seminal vesicle la vesícula seminal lah vay-see-coo-lah say-me-nahl
shoulder el hombro el om-bro
small intestine el intestino delgado el in-tes-tee-no del-gah-do
spinal cord la médula espinal lah may-doo-lah es-pe-nahl
spleen el bazo el bah-tho
stirrup (stapes) el estribo el es-tree-bo
stomach el estómago el es-toh-mah-go
temple la sien lah se-ayn
testis el testículo el tes-tee-coo-lo
thigh el muslo el moos-lo
thorax el tórax el to-rax
tongue la lengua lah len-goo-ah
trachea la tráquea lah trah-kay-ah
upper extremities las extremidades superiores las ex-tray-me-dahd-es soo-pay-re-or-es
ureter el uréter el oo-ray-ter
uterus el útero el oo-tay-ro
vagina el vagina lah vah-hee-nah
vitreous humor el humor vítreo el oo-mor vee-tray-o
wrist la muñeca lah moo-nyay-cah

Expressions of Time, Calendar, and Numbers

after meals después de comer des-poo-es day co-merr
at bedtime al acostarse al ah-cos-tar-say
before meals antes de comer ahn-tes day co-merr
daily el diario el de-ah-re-o
date la fecha lah fay-chah
day el dia el dee-ah
every hour a cada hora ah cah-dah o-rah
hour (time) la hora lah o-rah
how often cada cuánto tiempo cah-dah coo-ahn-to te-em-po
noon el mediodia el may-de-o-dee-ah
now ahora ah-o-rah
once una vez oo-nah veth
today hoy oh-e
tomorrow mañana mah-nyah-nah
tonight esta noche es-tah no-chay
week la semana lah say-mah-nah
year año a-nyo
Sunday el domingo el do-meen-go
Monday el lunes el loo-nes
Tuesday el martes el mar-tes
Wednesday el miércoles el me-err-co-les
Thursday el jueves el hoo-ayves
Friday el viernes el ve-err-nes

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 APPENDIX D D-3

Saturday el sábado el sah-bah-do

zero cero thay-ro
one uno oo-no
two dos dose
three tres trays
four cuatro coo-ah-tro
five cinco theen-co
six seis say-ees
seven siete se-ay-tay
eight ocho o-cho
nine nueve noo-ay-vay
ten diez de-eth

Nursing Care Sentences and Questions

What is your name? Please do not try to lower or climb over the
¿Como se llama usted? side rail.
¿Co-mo say lyah-mah oos-ted? Por favor no pretenda bajarlos (barjarlas) o treparse
sobre ellos.
I am a student nurse. Por fah-vor no pray-ten-dah ba-har-los o
Soy estudiente enfermera(o). tray-par-say so-bray ayl-lyos.
Soy es-too-de-ahn-tay en-fer-may-ra(o).
The head nurse is . . .
My name is . . . La jefa de enfermeras es . . .
Mi nombre es . . . La hay-fay day en-fer-may-ras es . . .
Mee nom-bray es . . .
Do you need more blankets or another pillow?
Do you need a wheelchair? ¿Necesita usted más frazadas u orta almohada?
¿Necesita usted una silla de rueda? ¿Nay-thay-si-ta oos-ted mahs frah-thad-dahs oo
¿Nay-thay-se-ta oos-ted oo-nah seel-lyah day o-trah al-mo-ah-dah?
roo-ay-dah?

How do you feel? You may not smoke in the room.

¿Como se siente? No se puede fumar en el cuarto.
¿Co-mo say se-ayn-tah? No say poo-ay-day foo-mar en el coo-ar-to.

When is your family coming? Do you want me to turn on (turn off ) the lights?
¿Cuándo viene su familia? ¿Quiere usted que encienda (apague) la luz?
¿Coo-ahn-do vee-en-nah soo fah-mee-le-ah? ¿Ke-ay-ray oos-ted day en-the-en-dah (a-pah-gay)
lah looth?
This is the call light.
Esta es la luz para llamar a la enfermera. Are you thirsty?
Es-tah es lah looth pah-ra lyah-mar a lah ¿Tiene usted sed?
en-fer-may-ra. ¿Tee-en-nah oos-ted sayd?

If you need anything, press the button. Are you allergic to any medication?
Si usted necesita algo, oprima el botón. ¿Es usted alérgico(a) a alguna medicina?
See oos-ted nay-thay-se-ta ahl-go o-pre-ma el ¿Es oos-ted ah-lehr-hee-co(a) ah ah-goo-nah
bo-tone. nay-de-thee-nah?

Do not turn without calling the nurse. You may take a bath.
No se voltee sin llamar a la enfermera. Usted puede bañarse.
No say vol-tay seen lyah-mar a lah en-fer-may-ra. Oos-ted poo-ay-day bah-nyar-say.

The side rails on your bed are for your protection. Do not lock the door, please.
Los rieles del costado están para su protección. No cierre usted la puerta con llave, por favor.
Los re-el-es del cos-tah-do es-tahn pah-ra soo No the-err-ray oos-ted lah poo-err-tah con lyah-vay
pro-tec-the-on. por fah-vor.

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D-4 APPENDIX D

Call if you feel faint or in need of help. Where do you feel the pain?
Llame si usted se siente débil o si necesita ayuda. ¿Dónde siente usted el dolor?
Lyah-mah see oos-ted say se-ayn-tah day-bil o see ¿Don-day se-ayn-tah oos-ted el do-lor?
nay-thay-se-ta ah-yoo-dah.
Point to where it hurts.
Call when you have to go to the toilet. Apunte usted por favor, adonde le duele.
Llame cuando tenga que ir al inodoro. Ah-poon-tay oos-ted por fah-vor ah-don-day
Lyah-mah coo-ahn-do ten-gah kay eer al in-o-do-ro. lay doo-ay-le.

I will give you an enema. Show me where it hurts.

Le pondré una enema. Enséñeme usted donde le duele.
Lay pon-dray oo-nah ay-nay-mah. En-say-nah-may oos-ted don-day lay doo-ay-le.

Turn on your left (right) side. Is the pain sharp or dull?

Voltese a su lado izquierdo (derecho). ¿Es agudo o sordo el dolor?
Vol-tay-say ah soo lah-do ith-ke-er-do(dah) ¿Es ah-goo-do o sor-do el do-lor?
(day-ray-cho[cha]).
Do you know where you are?
Here is an appointment card. ¿Sabe usted donde esta?
Aqui tiene usted una tarjeta con la información escrito. ¿Sah-bay oos-ted don-day es-tah?
Ah-kee tee-en-nah oos-ted oo-nah tar-hay-tah con lah
in-for-mah-the-on es-cree-to. You are in the hospital.
Usted está en el hospital.
You are going to be discharged (released) today. Oos-ted es-tah en el os-pee-tahl.
A usted le van a dar de alta hoy.
Ah oos-ted lay vahn ah dar day ahl-tah oh-e. You will be okay.
Usted va a estar bien.
How did this illness begin? Oos-ted vah a es-tar be-en.
¿Como empezó esta enfermedad?
¿Co-mo em-pa-tho es-tah en-fer-may-dahd? Do you have any drug reactions?
¿Tiene usted alguna sensibilidad a productos
Is the pain better after the medicine? químicos?
¿Siente usted alivio depués de tomar la medicina? ¿Te-en-nah oos-ted al-goo-nah sen-se-be-le-dahd a
¿Se-ayn-tah oos-ted al-lee-ve-o des-poo-es day to-mar lah pro-dooc-tos kee-me-cos?
may-de-thee-nah?
Have you seen another doctor or native healer for this
Where is the pain?
problem?
¿Que la duele? (or) Dónde le duele?
¿Ha visto usted a otro médico o curandero tocante a este
¿Kay lah doo-ay-le? (or) Don-day lay doo-ay-le?
problema?
¿Ah vees-to oos-ted a o-tro may-de-co o coo-ran-day-ro
Do you have pains in your chest?
to-cahn-tay a es-ah pro-blay-mah?
¿Tiene usted dolores in el pecho?
¿Tee-en-nah oos-ted do-lor-es en el pay-cho?
Have you vomited?
¿Ha vomitado usted?
Are you in pain now?
¿Ah vo-me-tah-do oos-ted?
¿Tiene usted dolores ahora?
¿Tee-en-nah oos-ted do-lor-es ah-o-rah?
Do you have any difficulty in breathing?
Is it constant pain or does it come and go? ¿Tiene usted alguna dificultad para respirar?
¿Es un dolor constante o va y vuelve? ¿Te-en-nah oos-ted ah-goo-nah de-fe-cool-tahd pah-ra
¿Es oon do-lor cons-tahn-tay o vah ee voo-el-vah? res-pe-rar?

Is there anything that makes the pain better? Do you smoke?

¿Hay algo que lo alivie? ¿Fuma usted?
¿Ah-ee ahl-go kay lo al-le-ve? ¿Foo-mar oos-ted?

Is there anything that makes the pain worse? How many per day?
¿Hay algo que lo aumente? ¿Cuántos al dia?
¿Ah-ee ahl-go kay lo ah-oo-men-tay? ¿Coo-ahn-tos al dee-ah?

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 APPENDIX D D-5

For how many years? We will put a tube in your bladder so that you can
¿Por cuántos años? urinate.
¿por coo-ahn-tos a-nyos? Le pondremos un tubo en la vejiga para que puede orinar.
Lay pon-dray-mos un too-be en lah vay-hee-gah pah-rah kay
Do you awaken in the night because of shortness of poo-ay-day o-re nar.
breath?
¿Se despierta usted por la noche por falta de When was your last menstrual period?
respiración? ¿Cuándo fue se última menstruación?
¿Say des-pee-err-tah oos-ted por lah no-chay por fahl-tah ¿Coo-ahn-do foo-ay soo ool-te-mah
day res-pe-rah-the-on? mens-troo-ah-the-on?

Is any part of your body swollen? Are you bleeding heavily?

¿Tiene usted alguna parte del cuerpo hinchada? ¿Está sangrando mucho?
¿Te-en-nah oos-ted ah-goo-nah par-tay del ¿Es-tah san-grahn-do moo-cho?
coo-err-po in-chah-da?
Take off your clothes, please
How much water do you drink daily? Desvístase usted, por favor.
¿Cuántos vasos de agua bebe usted diariamente? Des-ves-tah-say oos-ted por-fah-vor.
¿Coo-ahn-tos vah-sos day ah-goo-ah bay-be oos-ted
de-ah-re-ah-men-tay? Just relax.
Relaje usted el cuerpo.
Are you nauseated? Ray-lah-he oos-ted el coo-err-po.
¿Tiene náusea?
¿Te-en-nah nah-oo-say-ah? I am going to listen to your chest.
Voy a escucharle el pecho.
Are you going to vomit? Voye a es-coo-char-lay el pay-cho.
¿Va a vomitar?
¿Vah a vo-me-tar? Let me feel your pulse.
Déjeme tomarle el pulso.
When was your last bowel movement? Day-ha-me to-bar-lay el pool-so.
¿Cuánto tiempo hace que evacúa usted?
¿Coo-ahn-to te-em-po ah-the kay ay-vah-coo-ah I am going to take your temperature.
oos-ted? Voy a tomarle la temperatura.
Voye a to-mar-lay lah tem-pay-rah-too-rah.
Do you have diarrhea?
¿Tiene usted diarrea? Lie down, please.
¿Te-en-nah oos-ted der-ar-ray-ah? Acuéstese, por favor.
Ah-coo-es-tah-say por fah-vor.
How much do you urinate?
¿Cuánto orina usted? Do you understand?
¿Coo-ahn-to o-re-nah oos-ted? ¿Me comprende usted?
¿May com-pren-day oos-ted?
Did you urinate?
¿Orinó usted? That’s right.
¿O-re-no oos-ted? Así. Bien.
Ah-see. Be-en.
What color is your urine?
¿De qué color es la orina? You are doing very well.
¿Day kay co-lor es lah o-re-nah? Usted va muy bien.
Oos-ted vah moo-e be-en.
Call when you have to go to the toilet.
Llame usted cuando tenga que ir al inodoro. Do not take any medicine from home.
Lyah-mah oos-ted coo-ahn-do ten-gah kay eer al No tome usted ninguna medicina traída de su casa.
in-o-do-ro. No to-may oos-ted nin-goon-ay may-de-thee-nah
trah-ee-dah day soo cah-sah.
I need a urine specimen from you.
Necesito una muestra de orina de usted. I am going to give you an injection.
Nay-thay-se-to oo-nah moo-ays-trah day o-re-nah day Voy a ponerle ana inyección.
oos-ted. Voye a po-nerr-lay oo-nah in-yec-the-on.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
D-6 APPENDIX D

Take a sip of water. Do you feel dizzy?

Tome usted un traguito de agua. ¿Se siente vertigo?
To-may oos-ted un trah-gee-to day ah-goo-ah. ¿Say see-ayn-tah verr-to-go?

Very good. That was fine. Please lie still.

Muy bien. Excelente. Quédese inmóvil, por favor.
Moo-e be-en. Ex-thay-len-tay. Kay-day-say in-mo-veel por fah-vor.

Don’t be nervous. You must drink lots of liquids.

No se ponga nervioso(a). Usted debe tomar muchos líquidos.
No say pon-gah ner-ve-o-so(ah). Oos-ted day-bay to-mar moo-chos lee-ke-dos.

References
Kelz, R. K. (1982.) Conversational Spanish for Medical Personnel. Clifton Park, NY: Delmar Cengage Learning.
Velazquez de la Cadena, M., Gray, E., & Iribas, J. (1985). New Revised Velazquez Spanish and English Dictionary. Clinton, NJ: New
Win Publishing, Inc.

Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 GLOSSARY

A acquired immunodeficiency syndrome

(AIDS) Progressively fatal disease that destroys the
abduction Lateral movement away from the body
immune system and the body’s ability to fight infection;
ability Competence in an activity
caused by the human immunodeficiency virus (HIV)
abortion Termination of pregnancy before the age of
acrocyanosis Blue coloring of hands and feet
fetal viability, usually 24 weeks
actively suicidal Descriptor of an individual intent
abruptio placenta Premature separation, from the
upon hurting or killing him- or herself and who is in
wall of the uterus, of normally implanted placenta
imminent danger of doing so
absorption Passage of a drug from the site of
activities of daily living Basic care activities that
administration into the bloodstream; process whereby
include mobility, bathing, hygiene, grooming, dressing,
the end products of digestion pass through the epithelial
eating, and toileting
membranes in the small and large intestines and into the
acupressure Technique of releasing blocked energy
blood or lymph system
abuse Incident involving some type of violation to the
within an individual when specific points (tsubas)
client; misuse, excessive, or improper use of a substance, the along the meridians are pressed or massaged by the
absence of which does not cause withdrawal symptoms practitioner’s fingers, thumbs, and heel of the hands
acanthosis nigricans A velvety hyperpigmented acupuncture Technique of application of needles
patch on the back of neck, in axilla, or anticubital area and heat to various points on the body to alter the
found in children with type 2 diabetes energy flow
accreditation Process by which a voluntary, acute pain Has a sudden onset, relatively short
nongovernmental agency or organization appraises and duration, mild to severe intensity, with a steady decrease
grants accredited status to institutions, programs, services, in intensity over several days or weeks
or any combination of these that meet predetermined adaptation Ongoing process whereby individuals
structure, process, and outcome criteria use various responses to adjust to stressors and change;
acculturation Process of learning beliefs, norms, and change resulting from assimilation and accommodation
behavioral expectations of a group adaptive energy Inner forces that an individual uses
acid Any substance that in a solution yields hydrogen to adapt to stress (phrase coined by Selye)
ions bearing a positive charge adaptive measure Measure for coping with stress
acidosis Condition characterized by an excessive that requires a minimal amount of energy
number of hydrogen ions in a solution addiction Overwhelming preoccupation with
acme Peak of a contraction obtaining and using a drug for its psychic effects; used
acquired immunity Formation of antibodies interchangeably with dependence
(memory B cells) to protect against future invasions of an adhesion Internal scar tissue from previous surgeries
already experienced antigen or disease processes
G-1

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G-2 GLOSSARY

adjuvant medication Drug used to enhance the alkalosis Condition characterized by an excessive loss
analgesic efficacy of opioids, treat concurrent symptoms of hydrogen ions from a solution
that exacerbate pain, and provide independent analgesia allergen Type of antigen commonly found in the
for specific types of pain environment
adult day care Centers that provide a variety of allogeneic From a donor of the same species
services in a protective setting for adults who are unable to alopecia Partial or complete baldness or loss of hair
stay alone but who do not need 24-hour care; the centers alternative therapy Therapy used instead of
are located in a separate unit of a long-term care facility, in conventional or mainstream medical practices
a private home, or are freestanding ambulatory care A facility that provides clients
adventitious breath sound Abnormal sound, diagnostic treatment, medical treatment, preventive care,
including sibilant wheezes (formerly wheezes), sonorous and rehabilitative care on an outpatient basis
wheezes (formerly rhonchi), fine and course crackles ambulatory surgery Surgical operation performed
(formerly rales), pleural friction rubs, and stridor under general, regional, or local anesthesia, involving less
affect Outward expression of mood or emotions than 24 hours of hospitalization
affective domain Area of learning that involves amenorrhea Absence of menstruation
attitudes, beliefs, and emotions amnesia Inability to remember things
afferent nerve pathway Ascending spinal cord amniocentesis Withdrawal of amniotic fluid to
pathway that transmits sensory impulses to the brain obtain a sample for specimen examination
afferent pain pathway Ascending spinal cord amnion Inner fetal membrane originating in the
afterpains Discomfort caused by the contracting blastocyst
uterus after the infant’s birth amniotomy Artificial rupture of the membranes
age appropriate care Nursing care that takes into amphiarthrosis Articulation of slightly movable
consideration the client’s physical, mental, emotional, and joints such as the vertebrae
spiritual developmental levels amputation Removal of all or part of an extremity
age of viability Gestational age at which a fetus anabolism Constructive process of metabolism
could live outside the uterus, generally considered to be whereby new molecules are synthesized and new tissues
24 weeks are formed, as in growth and repair
agent Entity capable of causing disease analgesia Pain relief without producing anesthesia
agglutination Clumping together of red blood cells analgesic Substance that relieves pain
agglutinin Specific kind of antibody whose analyte Substance that is measured
interaction with antigens is manifested as agglutination anaphylaxis Type I systemic reaction to allergens
agglutinogen Any antigenic substance that causes anasarca Generalized edema
agglutination by the production of agglutinin anesthesia Absence of normal sensation
agnosia Inability to recognize, either by sight or anesthesiologist Licensed physician educated
sound, familiar objects such as a hairbrush and skilled in the delivery of anesthesia who also adds to
agnostic Individual who believes that the existence of the knowledge of anesthesia through research or other
God cannot be proved or disproved scholarly pursuits
agranulocytosis Acute condition causing a severe anesthetist Qualified RN, dentist, or medical doctor
reduction in the number of granulocytes (basophils, who administers anesthetics
eosinophils, and neutrophils) aneurysm Weakness in the wall of a blood vessel
Airborne Precautions Measures taken in addition anger control assistance Nursing intervention
to Standard Precautions and for clients known to have or aimed at facilitating the expression of anger in an adaptive
suspected of having illnesses spread by airborne droplet and nonviolent manner
nuclei angina pectoris Chest pain caused by a narrowing
airborne transmission Transfer of an agent to a of the coronary arteries
susceptible host through droplet nuclei or dust particles angiocatheter Intracatheter with a metal stylet
suspended in the air angioedema Allergic reaction consisting of edema of
Aldrete Score Scoring system for objectively subcutaneous tissue, mucous membranes, or viscera
assessing the physical status of clients recovering from angiogenesis Formation of new blood vessels
anesthesia; serves as a basis for dismissal from the angiography Visualization of the vascular structures
postanesthesia care unit (PACU) and ambulatory surgery; through the use of fluoroscopy with a contrast medium
also known as the postanesthetic recovery score angioma Benign vascular tumor involving skin and
algor mortis Decrease in body temperature after subcutaneous tissue; most are congenital
death, resulting in lack of skin elasticity anion Ion bearing a negative charge

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 GLOSSARY G-3

annulus Valvular ring in the heart arthroplasty Replacement of both articular surfaces
anorexia Loss of appetite within a joint capsule
anosognosia Lack of awareness of own neurological ascites Abnormal accumulation of fluid in the
deficits peritoneal cavity
anthrax An acute, infectious disease caused by the asepsis Absence of pathogenic microorganisms
bacterium Bacillus anthracis, which has an incubation aseptic technique Collection of principles used
period of 2-60 days; it is an Important potential agent for to control and/or prevent the transfer of pathogenic
bioterrorism microorganisms from sources within (endogenous) and
anthropometric measurements Measurements outside (exogenous) the client
of the size, weight, and proportions of the body aspiration Procedure performed to withdraw fluid
antibody Immunoglobulin produced by the body that has abnormally collected or to obtain a specimen;
in response to bacteria, viruses, or other antigenic also inhalation of secretion or fluids into the pulmonary
substances; destroys antigens system
anticipatory grief Occurrence of grief before an assent Voluntary agreement to participate in a
expected loss actually occurs research project or to accept treatment
anticipatory guidance Information, teaching, and assisted living A facility that combines housing and
guidance given to a client in anticipation of an expected services for persons who require assistance with activities
event of daily living
antigen Any substance identified by the body as asthma Condition characterized by intermittent
nonself airway obstruction due to antigen antibody reaction
antineoplastic Agent that inhibits the growth and astigmatism Asymmetric focus of light rays on the
reproduction of malignant cells retina
antioxidant Substance that prevents or inhibits ataxia Inability to coordinate voluntary muscle
oxidation, a chemical process wherein a substance is action
joined to oxygen atelectasis Collapse of a lung or a portion of a lung
antipyretic Drug used to reduce an abnormally high atheist Individual who does not believe in God or any
temperature other deity
anxiety Subjective response that occurs when a atherosclerosis Cardiovascular disease of fatty
person experiences a real or perceived threat to well- deposits on the inner lining, the tunica intima, of vessel
being; a diverse feeling of dread or apprehension walls
anxiolytic Antianxiety medication atom Smallest unit of an element that still retains the
aphasia Absence of speech; often the result of a brain properties of that element and that cannot be altered by
lesion any chemical change
apheresis Removal of unwanted blood components atresia Absence or closure of a body orifice
appendicitis Inflammation of the vermiform attachment Long-term process that begins during
appendix pregnancy and intensifies during the postpartum period,
appropriate for gestational age Infant’s weight which establishes an enduring bond between parent and
falls between the 90th and 10th percentile for gestational child, and develops through reciprocal (parent-to-child
age and child-to-parent) behaviors
areflexia Absence of reflexes attitude Manner, feeling, or position toward a person
aromatherapy Therapeutic use of concentrated or thing
essences or essential oils extracted from plants and flowers attribute Characteristic that belongs to an individual
arousal State of wakefulness and alertness audible wheeze Wheeze that can be heard without
arterial blood gases Measurement of levels of the aid of a stethoscope
oxygen, carbon dioxide, pH, partial pressure of oxygen auditory hallucination Perception by an individual
(PO2 or PaO2), partial pressure of carbon dioxide (PCO2 that someone is talking when no one in fact is there
or PaCO2), saturation of oxygen (SaO2), and bicarbonate auditory learner Person who learns by processing
(HCO3) in arterial blood information through hearing
arteriography Radiographic study of the vascular augmentation of labor Stimulation of uterine
system following the injection of a radiopaque dye contractions after spontaneously beginning but having
through a catheter unsatisfactory progress of labor
arteriosclerosis Cardiovascular disease wherein aura Peculiar sensation preceding a seizure or
plaque forms on the inside of artery walls, reducing the migraine; may be a taste, smell, sight, sound, dizziness, or
space for blood flow just a “funny feeling”

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G-4 GLOSSARY

auscultation Physical examination technique that biologic response modifier Agent that destroys
involves listening to sounds in the body that are created malignant cells by stimulating the body’s immune
by movement of air or fluid system
autoimmune disorder Disease wherein the body biological agent Living organism that invades a
identifies its own cells as foreign and activates mechanisms host, causing disease
to destroy them biological clock Internal mechanism in a living
autologous From the same organism (person) organism capable of measuring time
automatism Mechanical, repetitive motor behavior biopsy Excision of a small amount of tissue
performed unconsciously bioterrorism the purposeful use of a biological
autonomic nervous system That part of the preparation for the purposes of harming, killing large
peripheral nervous system consisting of the sympathetic numbers of people, and/or instilling fear in large numbers
and parasympathetic nervous systems and controlling of people
unconscious activities blanching White color of the skin when pressure is
autonomy Self-direction; ethical principle based on applied
the individual’s right to choose and the individual’s ability blastic phase Intensified phase of leukemia that
to act on that choice resembles an acute phase in which there is an increased
autopsy Examination of a body after death by a production of white blood cells
pathologist to determine cause of death blastocyst Cluster of cells that will develop into the
autosomal Pertaining to a condition transmitted by a embryo
nonsex chromosome bloody show Expulsion of cervical secretions, blood-
awareness Capacity to perceive sensory impressions tinged mucus, and the mucus plug that blocked the cervix
through thoughts and actions during pregnancy
azotemia Nitrogenous wastes present in the blood body image Individual’s perception of physical self,
including appearance, function, and ability
B body mass index Measurement used to ascertain
bacteremia Condition of bacteria in the blood whether a person’s weight is appropriate for height;
bactericide Bacteria-killing chemicals; found in tears calculated by dividing the weight in kilograms by the
ballottement Rebounding of the floating fetus when height in meters squared
pushed upward through the vagina or abdomen body mechanics Use of the body to safely and
bands Immature neutrophils efficiently move or lift objects
barium Chalky-white contrast medium bodymind Inseparable connection and operation of
Barrier Precautions Use of personal protective thoughts, feelings, and physiologic functions
equipment, such as masks, gowns, and gloves, to create a bonding Rapid process of attachment, parent to
barrier between the person and the microorganisms and infant, that takes place during the sensitive period, the first
thus prevent transmission of the microorganism 30 to 60 minutes after birth
basal metabolism Energy needed to maintain borborygmi High-pitched, loud, rushing sounds
essential physiologic functions when a person is at produced by the movement of gas in the liquid contents of
complete rest; the lowest level of energy expenditure the intestine
base Substance that when dissociated produces ions bradycardia Heart rate less than 60 beats per minute
that will combine with hydrogen ions in an adult
baseline level Lab value that serves as a reference bradykinesia Slowness of voluntary movement and
point for future value levels speech
behavioral tolerance Compensatory adjustments bradypnea Respiratory rate of 10 or fewer breaths per
of behavior made under the influence of a particular minute
substance Braxton-Hicks contractions Irregular, intermittent
benign Not progressive; favorable for recovery contractions felt by the pregnant woman toward the end
bereavement Period of grief that follows the death of of pregnancy
a loved one breakthrough pain Sudden, acute, temporary pain
bioavailability Readiness to produce a drug that is usually precipitated by a treatment, a procedure, or
effect unusual activity of the client
biofeedback Measures physiologic responses that brief dynamic therapy Short-term psychotherapy
assist individuals to improve their health by using signals that focuses on resolving core conflicts deriving from
from their own bodies personality and living situations

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 GLOSSARY G-5

bronchial sound Loud, high-pitched, hollow- catharsis Process of talking out one’s feelings; “getting
sounding breath sound normally heard over the sternum; things off the chest” through verbalization
longer on expiration than inspiration cation Ion bearing a positive charge
bronchiectasis Lung disorder characterized by cavitation Process whereby a cavity is created in
chronic dilation of the bronchi the lung tissue through the liquefaction and rupture of a
bronchitis Inflammation of the bronchial tree primary tubercle
accompanied by hypersecretion of mucus ceiling effect Medication dosage beyond which no
bronchovesicular sound Breath sound normally further analgesia occurs
heard in the area of the scapula and near the sternum; cellular immunity Type of acquired immunity
medium in pitched blowing sound, with inspiratory and involving T-cell lymphocytes
expiratory phases of equal length Centers for Disease Control & Prevention
bruxism Grinding of teeth during sleep (CDC) An agency of the federal government that
buffer Substance that attempts to maintain pH range, provides for the investigation, identification, prevention,
or hydrogen ion concentration, in the presence of added and control of diseases; it plays an important role in
acids or bases preparing for, and disseminating information about,
burnout State of physical and emotional exhaustion possible terrorist attacks
occurring when caregivers use up their adaptive energy central line Venous catheter inserted into the
butterfly needle Wing-tipped needle superior vena cava through the subclavian or internal or
external jugular vein
C central nervous system System of the brain and
cachectic Being in a state of malnutrition and wasting spinal cord
cachexia State of malnutrition and protein wasting cephalalgia Headache; also known as cephalgia
calculus Concentration of mineral salts in the body cephalhematoma Collection of blood between the
leading to the formation of stone periosteum and the skull of a newborn; appears several
calorie Amount of heat required to raise the hours to a day after birth, does not cross suture lines,
temperature of 1 gram of water 1 degree Celsius and is caused by the rupturing of the periosteal bridging
cancer Disease resulting from the uncontrolled growth veins due to friction and pressure during labor and
of cells, which causes malignant cellular tumors delivery
capitated rate Preset fee based on membership cephalopelvic disproportion Condition in which
rather than services provided; payment system used in the fetal head will not fit through the mother’s pelvis
managed care certification Voluntary process that establishes and
caput succedaneum Edema of the newborn’s scalp evaluates standards of care; mandatory for any health care
which is present at birth, may cross suture lines, and is services receiving federal funds
caused by head compression against the cervix cerumen Earwax
carcinogen Substance that initiates or promotes the cervical dilatation Enlargement of the cervical
development of cancer opening (os) from 0 to 10 cm (complete dilatation)
carcinoma Cancer occurring in epithelial tissue cesarean birth Birth of an infant through an incision
cardiac cycle Cycle of an impulse going completely in the abdomen and uterus
through the conduction system of the heart, and the Chadwick’s sign Purplish-blue color of the cervix
ventricles contracting and vagina noted about the eighth week of pregnancy
cardiac output Volume of blood pumped per minute chain of custody Documentation of the transfer of
by the left ventricle evidence (of a crime) from one worker to the next in a
cardiac tamponade Collection of fluid in the secure fashion
pericardial sac hindering the functioning of the heart chain of infection Describes the development of
carrier Person who harbors an infectious agent but has an infectious process
no symptoms of disease chalazion Cyst of the meibomian glands
caseation Process whereby the center of the primary chancre Clean, painless, syphilitic primary ulcer
tubercle formed in the lungs as a result of tuberculosis appearing 2 to 6 weeks after infection at the site of body
becomes soft and cheese-like due to decreased perfusion contact
catabolism Destructive process of metabolism change Dynamic process whereby an individual’s
whereby tissues or substances are broken into their response to a stressor leads to an alteration in behavior
component parts change agent Person who intentionally creates and
cataplexy Sudden loss of muscle control implements change

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G-6 GLOSSARY

chemical agent Substance that interacts with a host, chronobiology Science of studying biorhythms
causing disease Chvostek’s sign Abnormal spasm of the facial
chemical name Precise description of the drug’s muscles in response to a light tapping of the facial nerve
chemical formula chyme Acidic, semi-fluid paste found in the
chemical restraint Medication used to control gastrointestinal tract
client behavior circadian rhythm Biorhythm that cycles on a daily
chemical warfare agents Poisonous chemicals basis
and gases that are used to harm or kill a large number circulating nurse RN responsible and accountable
of persons; examples of chemical agents include nerve for management of personnel, equipment, supplies, the
agents, blood agents, choking or vomiting agents, and environment, and communication throughout a surgical
blister or vesicant agents procedure
Chemical, Biological, Radiological/Nuclear, circumcision Surgical removal of the prepuce
and Explosive Enhanced Response Force (foreskin), which covers the glans penis
Package A program of the National Guard that circumoral cyanosis Bluish discoloration
responds rapidly, following a call by the governor, and can surrounding the mouth
be at the scene of a disaster, ready to function in 6 hours; cirrhosis Chronic degenerative changes in the liver
it can also include a surgical suite, if needed cells and thickening of surrounding tissue
chemoreceptor Receptor that monitors the levels of claiming process Process whereby a family
carbon dioxide, oxygen, and pH in the blood identifies the infant’s “likeness to” and the “differences
chemotherapy Use of drugs to treat illness, from” family members, and the infant’s unique qualities
especially cancer clean object Object on which there are
Cheyne-Stokes respirations Breathing microorganisms that are usually not pathogenic
characterized by periods of apnea alternating with periods cleansing Removal of soil or organic material from
of dyspnea instruments and equipment used in providing client care
child abuse Any intentional act of physical, client behavior accident Mishap resulting from
emotional, or sexual abuse or neglect committed by a the client’s behavior or actions
person responsible for the care of a child clinical Observing and caring for living clients
child life specialist Health care professional with closed reduction Repair of a fracture done without
extensive knowledge of psychology and early childhood surgical intervention
development coarse crackle Moist, low-pitched crackling and
chloasma Darkening of the skin of the forehead and gurgling lung sound of long duration
around the eyes during pregnancy; also called the “mask codependent Description for persons who live based
of pregnancy” on what others think of them
cholecystitis Inflammation of the gallbladder cognition Intellectual ability to think
cholelithiasis Presence of gallstones or calculi in the cognitive behavior therapy Treatment
gallbladder approach aimed at helping a client identify stimuli that
cholesterol Sterol produced by the body and used in cause the client’s anxiety, develop plans to respond to
the synthesis of steroid hormones those stimuli in a nonanxious manner, and problem-
chorea Condition characterized by abnormal, solve when unanticipated anxiety-provoking situations
involuntary, purposeless movements of all musculature of arise
the body cognitive domain Area of learning that involves
chorion Outer fetal membrane formed from the intellectual understanding
trophoblast cognitive reframing Stress-management technique
chronic acute pain Discomfort that occurs almost whereby the individual changes a negative perception of
daily over a long period, months or years, and may never a situation or event to a more positive, less threatening
stop; also known as progressive pain perception
chronic nonmalignant pain Discomfort that coitus (copulation) Sexual act that delivers sperm
occurs almost daily, has been present for at least 6 months, to the cervix by ejaculation of the erect penis
and ranges from mild to severe in intensity; also known as cold stress Excessive heat loss
chronic benign pain colic Condition of acute abdominal pain
chronic pain Discomfort usually defined as long colonization Multiplication of microorganisms on or
term (lasting 6 months or longer), persistent, nearly within a host that does not result in cellular injury
constant, or recurrent pain producing significant negative colostomy Opening created anywhere along the large
changes in a person’s life intestine

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 GLOSSARY G-7

colostrum Antibody-rich yellow fluid secreted by the through a fomite, or close contact with contaminated
breasts during the last trimester of pregnancy and the first secretions
2–3 days after birth; gradually changes to milk contraception Measure taken to prevent pregnancy
comedone Whitehead or blackhead contracture Permanent shortening of a muscle
command hallucination Perception by an contrast medium Radiopaque substance that
individual of a voice or voices telling the individual to do facilitates roentgen (x-ray) imaging of the body’s internal
something, usually to himself and/or someone else structures
communicable agent Infectious agent transmitted convalescent stage Time period in which acute
to a client by direct or indirect contact, via vehicle, vector, symptoms of an infection begin to disappear until the
or airborne route client returns to the previous state of health
communicable disease Disease caused by a convection Loss of heat by the movement of air
communicable agent copulation Sexual act that delivers sperm to the cervix
comorbidity Simultaneous existence of more than by ejaculation of the erect penis
one disease process within an individual cotyledon Subdivision of the maternal side of the
complementary therapy Therapy used in placenta
conjunction with conventional medical therapies couvade Development of physical symptoms by the
complete protein Protein containing all nine expectant father such as fatigue, depression, headache,
essential amino acids backache, and nausea
complicated grief Grief associated with traumatic crackle Abnormal breath sound that resembles a
death such as death by accident, violence, or homicide; popping sound, heard on inhalation and exhalation; not
survivors often have more intense emotions than those cleared by coughing
associated with normal grief crenation Condition wherein cells decrease in size,
compound Combination of atoms of two or more shrivel and wrinkle, and are no longer functional when in a
elements hypertonic solution
compromised host Person whose normal body crepitus Grating or crackling sensation or sound
defenses are impaired and is therefore susceptible to cretinism Congenital lack of thyroid hormones
infection causing defective physical development and mental
computed tomography Radiological scanning retardation
of the body with x-ray beams and radiation detectors to crisis Acute state of disorganization that occurs when
transmit data to a computer that transcribes the data into usual coping mechanisms are no longer adequate; stressor
quantitative measurement and multidimensional images that forces an individual to respond and/or adapt in some
of the internal structures way
conditioning Teaching a person a behavior until it crisis intervention Specific technique used to help a
becomes an automatic response; method of conserving person regain equilibrium
adaptive energy critical thinking The disciplined intellectual
conduction Loss of heat by direct contact with a process of applying skillful reasoning, imposing
cooler object intellectual standards and self-reflective thinking as a
conductive hearing loss Condition characterized guide to a belief or action
by the inability of sound waves to reach the inner ear cross-tolerance Decreased sensitivity to other
confabulation The making up of information to fill substances in the same category
in memory gaps crowning When the largest diameter of the fetal head
congruence Agreement between two things is past the vulva
conjunctivitis Inflammation of the conjunctiva cryotherapy Use of cold applications to reduce
consciousness State of awareness of self, others, and swelling
surrounding environment cryptorchidism Failure of one or both testes to
constipation Condition characterized by hard, descend
infrequent stools that are difficult or painful to pass cultural assimilation Process whereby members of
Contact Precautions Measures taken in addition a minority group are absorbed by the dominant culture,
to Standard Precautions for clients known to have or taking on characteristics of the dominant culture
suspected of having illnesses easily spread by direct client cultural diversity Differences among people
contact or by contact with fomites resulting from ethnic, racial, and cultural variations
contact transmission Transfer of an agent culture Integrated, dynamic structure of knowledge,
from an infected person to a host by direct contact with attitudes, behaviors, beliefs, ideas, habits, customs,
that person, indirect contact with an infected person languages, values, symbols, rituals, and ceremonies that

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G-8 GLOSSARY

are unique to a particular group of people; growing of development Behavioral changes in skills and
microorganisms to identify a pathogen functional abilities
curative To heal or restore health dialysate Solution used in dialysis, designed to
curing Ridding one of disease approximate the normal electrolyte structure of plasma
cutaneous pain Discomfort caused by stimulating and extracellular fluid
the cutaneous nerve endings in the skin dialysis Mechanical means of removing nitrogenous
cyanosis Bluish discoloration of the skin and mucous waste from the blood by imitating the function of the
membranes observed in lips, nail beds, and earlobes nephrons; involves filtration and diffusion of wastes, drugs,
cycling Alteration in mood between depression and and excess electrolytes and/or osmosis of water across a
mania semipermeable membrane into a dialysate solution
cystitis Inflammation of the urinary bladder diarthrosis Freely movable joint
cystocele Downward displacement of the bladder into didactic Systematic presentation of information
the anterior vaginal wall diet therapy Treating disease or disorder with
cytology Study of cells special diet
dietary prescription/order Order written by the
D physician for food, including liquids
differentiation Acquisition of characteristics or
dawn phenomenon Early morning glucose functions different from those of the original
elevation produced by the release of growth hormone diffusion Process whereby a substance moves from an
death rattle Noisy respirations in the period preceding area of higher concentration to an area of lower concentration
death caused by a collection of secretions in the larynx digestion Mechanical and chemical processes that
debride To remove dead or damaged tissue or foreign convert nutrients into a physically absorbable state
material from a wound diplopia Double vision
decerebration Severing of the spinal cord dirty object Object on which there is a high number
decidua The endometrium after implantation of microorganisms, some that are potentially pathogenic
decomposition Chemical reaction wherein the disability An individual’s lack of ability to complete
bonding between atoms in a molecule is broken and an activity in the normal manner
simpler products are formed disaster A situation or event of greater magnitude
decrement Decreasing intensity of a contraction than an emergency and that has unforeseen, serious, or
defense mechanism Unconscious functions immediate threats to public health
protecting the mind from anxiety disciplined Trained by instruction and exercise
deglutition Swallowing of food disenfranchised grief Grief not openly
dehiscence Complication of wound healing wherein acknowledged, socially sanctioned, or publicly shared
the wound edges separate disinfectant Chemical solution used to clean
dehydration Condition wherein more water is lost inanimate objects
from the body than is being replaced disinfection Elimination of pathogens, with the
delirium Cognitive changes or acute confusion of exception of spores, from inanimate objects
rapid onset (less than 6 months) dislocation Injury in which the articular surfaces of a
delusion False belief that misrepresents reality joint are no longer in contact
dementia Organic brain pathology characterized by disorientation State of mental confusion in which
losses in intellectual functioning and a slow onset (longer awareness of time, place, self, and/or situation is impaired
than 6 months) disseminated intravascular coagulation
dental caries Cavities Abnormal stimulation of the clotting mechanism causing
dependence Reliance on a substance to such a degree small clots throughout the vascular system and widespread
that abstinence causes functional impairment, physical bleeding internally, externally, or both
withdrawal symptoms, and/or psychological craving for distraction Technique of focusing attention on
the substance; see also addiction stimuli other than pain
depersonalization Treating an individual as an distress Subjective experience that occurs when
object rather than as a person stressors evoke an ineffective response
depolarization Contraction of the heart distribution Movement of drugs from the blood into
depression State wherein an individual experiences various tissues and body fluids
feelings of extreme sadness, hopelessness, and helplessness diverticula Sac-like protrusion of the intestinal wall
detoxification Elimination of a substance from the that results when the mucosa herniates through the bowel
body wall

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 GLOSSARY G-9

diverticulitis Inflammation of one or more ecchymosis Large, irregular hemorrhagic area on the
diverticula skin; also called a bruise
diverticulosis Condition in which multiple eclampsia Convulsion occurring in pregnancy-
diverticula are present in the colon induced hypertension
domestic violence Aggression and violence ectopic pregnancy Pregnancy in which the fertilized
involving family members ovum is implanted outside the uterine cavity
dominant culture The group whose values prevail edema Detectable accumulation of increased
within a given society interstitial fluid
Down syndrome Congenital chromosomal effacement Thinning of the cervix
abnormality; also called trisomy 21 efferent nerve pain pathway Descending spinal
Droplet Precautions Measures taken in addition cord pathway that transmits sensory impulses from the
to Standard Precautions for clients known to have or brain
suspected of having serious illnesses spread by large effluent Liquid output from an ileostomy
particle droplets electrocardiogram Graphic recording of the heart’s
drug allergy Hypersensitivity to a drug electrical activity
drug incompatibility Undesired chemical or electroconvulsive therapy Procedure whereby
physical reaction between a drug and a solution, between clients are treated with pulses of electrical energy
a drug and the container or tubing, or between two drugs sufficient to cause brief convulsions or seizures
drug interaction Effect one drug can have on electroencephalogram Graphic recording of the
another drug brain’s electrical activity
drug tolerance Reaction that occurs when the electrolyte Compound that, when dissolved in
body is accustomed to a specific drug that larger doses are water or another solvent, dissociates (separates) into ions
needed to produce the desired therapeutic effects (electrically charged particles)
ductus arteriosus Fetal vessel connecting the element Basic substance of matter
pulmonay artery to the aorta emancipated minor Child who has the legal
ductus venosus Branch of the umbilical vein that competency of an adult because of cicumstances involving
enters the inferior vena cava marriage, divorce, parenting of a child, living independently
duration Length of one contraction, from the without parents, or enlistment in the armed services
beginning of the increment to the conclusion of the embolus Mass, such as a blood clot or an air bubble,
decrement that circulates in the bloodstream
dysarthria Difficult and defective speech due to a embryonic phase Development occuring during the
dysfunction of the muscles used for speech first 2 to 8 weeks after fertilization of a human egg
dysfunctional grief Persistent pattern of intense emergency Medical or surgical condition requiring
grief that does not result in reconciliation of feelings immediate or timely intervention to prevent permanent
dysfunctional labor Labor with problems of the disability or death
contractions or of maternal bearing down emergency medical technician (EMT) Health
dysmenorrhea Painful menstruation care professional trained to provide basic lifesaving
dyspareunia Painful intercourse measures prior to arrival at the hospital
dysphagia Difficulty in swallowing emergency nursing Care of clients who require
dysplasia Abnormal development emergency interventions
dyspnea Difficulty breathing as observed by labored emotional lability Loss of emotional control
or forced respirations through the use of accessory empathy Capacity to understand another person’s
muscles in the chest and neck feelings or perception of a situation
dysrhythmia Irregularity in the rate, rhythm, or emphysema Lung disease wherein air accumulates in
conduction of the electrical system of the heart the tissues of the lungs
dystocia Long, difficult, or abnormal labor caused by empowerment A process through which an
any of the four major variables (4 Ps) that affect labor individual is enabled to change situations, and uses
dysuria Difficult or painful urination resources, skills, and opportunities to do so
empty calories Calories that provide few nutrients
encephalitis Inflammation of the brain
E encoding Laying down tracks in areas of the brain to
early deceleration Reduction in fetal heart rate that enhance the ability to recall and use information
begins early in the contraction and virtually mirrors the encopresis Passage of watery colonic contents around
uterine contraction a hard fecal mass

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G-10 GLOSSARY

endemic Occurring continuously in a particular erythematous Characterized by redness of the skin

population and having low mortality erythrocytapheresis Procedure that removes
endocrine Group of cells secreting substances directly abnormal red blood cells and replaces them with healthy
into the blood or lymph circulation and affecting another ones
part of the body erythropoiesis Production of red blood cells and
endometriosis Growth of endometrial tissue on their release by the red bone marrow
structures outside of the uterus, within the pelvic cavity eschar Dry, dark, leathery scab composed of denatured
endorphins Group of opiate-like substances produced protein
naturally by the brain that raise the pain threshold, produce ethnicity Cultural group’s perception of itself or a
sedation and euphoria, and promote a sense of well-being group identity
endoscopy Visualization of a body organ or cavity ethnocentrism Assumption of cultural superiority
through a scope and inability to accept another culture’s ways
energetic-touch therapy Technique of using the euglycemia Normal blood glucose level
hands to direct or redirect the flow of the body’s energy euphoric Characterized by elation out of context to
fields and enhance balance within those fields the situation
engagement Condition of the widest diameter of the eupnea Easy respirations with a rate that is age-
fetal presenting part (head) entering the inlet to the true appropriate
pelvis eustress Stress that results in positive outcomes
engorgement Distentions and swelling of the breasts evaporation Loss of heat when water is changed to a
in the first few days following delivery vapor
engrossment Parents’ intense interest in and evisceration Complication of wound healing
preoccupation with the newborn characterized by a complete separation of wound edges,
enriched Descriptor for food in which nutrients that accompanied by visceral protrusion
were removed during processing are added back in exacerbation Increase in the symptoms of a disease
enteral instillation Administration of drugs exclusive provider organization Organization
through a gastrointestinal tube wherein care must be delivered by providers in the plan in
enteral nutrition Feeding method meaning both the order for clients to receive any reimbursement
ingestion of food orally and the delivery of nutrients through excretion Elimination of drugs or waste products
a gastrointestinal tube, but generally meaning the latter from the body
entrainment Infant’s ability to move in rhythm to the Expeditionary Medical Support A total package
parent’s voice that includes everything necessary to screen, treat, and
enzyme Globular protein produced in the body that release clients to other facilities for longer-term care
catalyzes chemical reactions within the cells exposure Contact with an infected person or agent
enzyme-linked immunosorbent assay Basic extended care facility The term refers to any
screening test currently used to detect antibodies to HIV facility that provides care for a long period of time. It
epidemic Infecting many people at the same time and has no concrete definition and could refer to either an
in the same geographic area intermediate or skilled nursing facility
epidural analgesia Analgesics administered via a external respiration Exchange of gases between
catheter that terminates in the epidural space the atmosphere and the lungs
episiotomy Incision in the perineum to facilitate external version Manipulation of the fetus through
passage of the baby the mother’s abdomen to a presentation facilitating birth
epispadias Placement of the urinary meatus on the extracellular fluid Fluid outside of the cells;
top of the penis includes interstitial, intravascular, synovial, cerebrospinal,
epistaxis Hemorrhage of the nares or nostrils; also and serous fluids; aqueous and vitreous humor; and
known as nosebleed endolymph and perilymph
Epstein’s pearls Small, whitish-yellow epithelial extravasation Escape of fluid into the surrounding
cysts found on the hard palate tissue
equipment accident Accident resulting from the
malfunction or improper use of medical equipment
F
erythema Redness of the skin due to increased blood
flow to the area faith Confident belief in the truth, value, or
erythema toxicum neonatorum Pink rash with trustworthiness of a person, idea, or thing
firm, yellow-white papules or pustules found on the chest, false labor Contractions that do not cause the cervix
abdomen, back, and/or buttocks of a newborn to dilate

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 GLOSSARY G-11

family-centered care A philosophy of caring flora Microorganisms that occur or have adapted to
recognizing the centrality of the family in the child’s life and live in a specific environment, such as intestinal, skin,
including the family’s contribution and involvement in the vaginal, or oral flora
plan of care and its delivery (Potts & Mandleco, 2000) flow rate Volume of fluid to infuse over a set period
fasciculation Involuntary twitching of muscle fibers of time
fat-soluble vitamin Vitamin requiring the fluoroscopy Immediate, serial images of the body’s
presence of fats for its absorption from the gastrointestinal structure or function
tract into the lymphatic system and for cellular fomite Object contaminated with an infectious agent
metabolism: vitamins A, D, E, and K fontanelle Membranous area where sutures meet on
fee for service System in which the health care the fetal skull
recipient directly pays the provider for services as they are foramen ovale Flap opening in the atrial septum
provided that allows only right-to-left movement of blood
feedback Response from the receiver of a message so forceps Metal instruments used on the fetal head to
that the sender can verify the message provide traction or to provide a method of rotating the
Ferguson’s reflex Spontaneous, involutary urge to fetal head to an occiput-anterior position
bear down during labor foremilk Watery first milk from the breast, high in
fertilization Union of an ovum and a sperm lactose, like skim milk, and effective in quenching thirst
fetal attitude Relationship of fetal body parts to formal teaching Teaching that takes place at a
one another, either flexion or extension specific time, in a specific place, and on a specific topic
fetal biophysical profile Assessment of five fortified Descriptor for food in which nutrients not
variables: fetal breathing movement, fetal movements naturally occurring in the food are added to it
of body or limbs, fetal tone (flexion/extension of fracture Break in the continuity of a bone
extremities), amniotic fluid volume, and reactive NST free radical Unstable molecule that alters genetic codes
fetal lie Relationship of the cephalocaudal axis of and triggers the development of cancer growth in cells
the fetus to the cephalocaudal axis of the mother, either frequency Time for the beginning of one contraction
longitudinal or transverse to the beginning of the next contraction
fetal phase Intrauterine development from 8 weeks friction Force of two surfaces moving against one
to birth another
fetal position Relationship of the identified fulguration Procedure to destroy tissue with long,
landmark on the presenting part to the four quadrants of high-frequency electric sparks
the mother’s pelvis fundus Top of the uterus
fetal presentation Determined by the fetal lie and funic souffle Sound of the blood pulsating through
the part of the fetus that enters the pelvis first the umbilical cord; rate the same as the fetal heartbeat
fibrinolysis Process of breaking fibrin apart
fight-or-flight response State wherein the body
G
becomes physiologically ready to defend itself by either
fighting or fleeing from the stressor gastric ulcer Erosion in the stomach
filtration Process of fluids and the substances gastritis Inflammation of the stomach mucosa
dissolved in them being forced through the cell membrane gate control pain theory Theory that proposes
by hydrostatic pressure that the cognitive, sensory, emotional, and physiologic
fine crackle Dry, high-pitched crackling and popping components of the body can act together to block an
lung sounds of short duration individual’s perception of pain
first assistant Physician or RN who assists the general adaptation syndrome Physiologic
surgeon to retract tissue, aids in the removal of blood and response that occurs when a person experiences a stressor
fluids at the operative site, and assists with homeostasis general anesthesia Method of producing
and wound closure unconsciousness; amnesia, motionlessness, muscle
first responders Persons who have been identified as relaxation, and complete insensibility to pain
the first ones to appear at the scene of a disaster or accident; generic name Name assigned by the U.S. Adopted
designated first responders include health care workers, Names Council to the manufacturer who first develops a
emergency medical personnel, police, and firepersons drug
flashback Rushing of blood back into intravenous genogram A way to visualize family members,
tubing when a negative pressure is created on the tubing; their birth and death dates, or ages and specific health
reliving of an original trauma as if the individual were problems
currently experiencing it genuineness Sincerity

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G-12 GLOSSARY

germicide Chemical that can be applied to both hand hygiene Rubbing together of all surfaces and
animate and inanimate objects for the purpose of crevices of the hands using a soap or chemical and water,
eliminating pathogens followed by rinsing in a flowing stream of water
germinal phase Development beginning with handicap The physical or mental inability to
conception and lasting approximately 10 to 14 days complete a role in one or more major ADL (U.S. Office of
gerontological nursing Specialty within nursing Personnel Management, 1987)
that addresses and advocates for the special care needs of healing Process that activates the individual’s recovery
older adults forces from within; to make whole
gerontologist Specialist in gerontology in advanced healing touch Energy therapy using the hands to
practice nursing, geriatric psychiatry, medicine, and social clear, energize, and balance the energy field
services health According to the World Health Organization,
gerontology Study of the effects of normal aging and the state of complete physical, mental, and social well-
age-related diseases on human beings being, not merely the absence of disease or infirmity
gingivitis Inflammation of the gums health care delivery system Method for
Glasgow Coma Scale Neurological screening providing services to meet the health needs of individuals
test that measures a client’s best verbal, motor, and eye health care surrogate law Law enacted by some
response to stimuli states that provides a legal means for decision making in
glucagon Hormone secreted by the alpha cells of the the absence of advance directives
pancreas, which stimulate release of glucose by the liver health continuum Range of an individual’s health,
gluconeogenesis Conversion of amino acids into from highest health potential to death
glucose health history Review of the client’s functional health
glycogenesis Conversion of glucose into glycogen patterns prior to the current contact with a health care agency
glycogenolysis Conversion of glycogen into glucose health maintenance organization Prepaid
glycosuria Presence of excessive glucose in the urine health plan that provides primary health care services for a
goiter Enlargement of the thyroid gland preset fee and focuses on cost-effective treatment methods
Goodell’s sign Softening of the cervix noted about hearing Act or power of receiving sounds
the 8th week of pregnancy heart sound Sound heard by auscultating the heart
Gower’s sign Walking the hands up the legs to Heberden’s nodes Enlargement and characteristic
get from sitting to standing position (as in Duchenne hypertrophic spurs in the terminal interphalangeal finger
muscular dystrophy) joints
granulation tissue Delicate connective tissue Hegar’s sign Softening of the uterine isthmus about
consisting of fibroblasts, collagen, and capillaries the 6th week of pregnancy
graphesthesia Ability to identify letters, numbers, or HELLP syndrome Pregnancy-induced hypertension
shapes drawn on the skin with liver damage characterized by hemolysis, elevated
gravida Pregnancy, regardless of duration, including liver enzymes, and low platelet count
present pregnancy hemarthrosis Bleeding into the joints
grief Series of intense psychological and physical hematemesis Vomiting of blood
responses occuring after a loss; these responses are necessary, hematocrit Percentage of red blood cells in a given
normal, natural, and adaptive responses to the loss volume of blood
growth Measurable changes in the physical size of the hematopoiesis Process of blood cell production and
body and its parts development
gynecomastia Abnormal enlargement of one or both hematuria Blood in the urine
breasts in males hemiparesis Weakness of one side of the body
hemiplegia Paralysis of one side of the body
hemolysis Breakdown of red blood cells and the
H release of hemoglobin
half-life Time it takes the body to eliminate half hemopneumothorax Presence of blood and air
of the blood concentration level of the original dose of within the pleural space
medication hemorrhagic exudate Discharge that has a large
halitosis Bad breath component of red blood cells
hallucination Sensory perception that occurs in the hemorrhoid Swollen vascular tissue in the rectal area
absence of external stimuli and that is not based on reality hemostasis Cessation of bleeding
hallux varus Placement of the great toe farther from hemothorax Condition wherein blood accumulates
the other toes in the pleural space of the lungs

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 GLOSSARY G-13

hepatitis Chronic or acute inflammation of the liver hypersomnia Alteration in sleep pattern
hesitancy Difficulty initiating the urinary stream characterized by excessive sleep, especially in the daytime
hindmilk Follows foremilk, is higher in fat content, hyperthermia Condition in which the core body
leads to weight gain, and is more satisfying temperature rises above 106°F
hirsutism Excessive body hair in a masculine hypertonic solution Solution that has a higher
distribution molecular concentration than the cell; also called a
histamine Substance released during allergic hyperosmolar solution
reactions hypertrophy Increase in muscle mass
holistic Whole; includes physical, intellectual, hyperuricemia Increased uric acid blood level
sociocultural, psychological, and spiritual aspects as an hyperventilation Breathing characterized by deep,
integrated whole rapid respirations
Homans’ sign Test to check for the presence of clots hypervigilant Condition of constantly scanning the
in the leg environment for potentially dangerous situations
homeostasis Balance or equilibrium among the hypervolemia Increased circulating fluid volume
physiologic, psychological, sociocultural, intellectual, hypnosis Altered state of consciousness or awareness
and spiritual needs of the body; maintenance of internal resembling sleep and during which a person is more
environment receptive to suggestion
homonymous hemianopia Loss of vision in half hypoglycemia Condition wherein the blood glucose
of the visual field on the same side of both eyes level is exceedingly low
hope To look forward to with confidence or hypomania Mild form of mania without significant
expectation; a resource clients can use to promote impairment
physical, psychological, and spiritual wellness hypospadias Placement of the urinary meatus on the
hormone Substance that initiates or regulates activity underside of the penis
of another organ, system, or gland in another part of the hypothermia Condition in which the core body
body temperature drops below 95°F
hospice Humane, compassionate care provided to hypotonia Lax muscle tone
clients who can no longer benefit from curative treatment hypotonic solution Solution that has a lower
and have 6 months or less to live; allows individuals to die molecular concentration than the cell; also called
with dignity hypo-osmolar solution
host Organism that can be affected by an agent hypoventilation Breathing characterized by shallow
human immunodeficiency virus (HIV) respirations
Retrovirus that causes AIDS hypovolemia Abnormally low circulatory blood
human leukocyte antigen Antigen present in volume
human blood hypoxemia Decreased oxygen level in the blood
humoral immunity Type of immunity dominated
by antibodies
I
hydatidiform mole Abnormality of the placenta
wherein the chorionic villi become fluid filled, grape-like iatrogenic Caused by treatment or diagnostic
clusters; the trophoblastic tissue proliferates; and there is procedures
no viable fetus ideal self The person whom the individual would like
hydramnios (polyhydramnios) Excess amount of to be
amniotic fluid identity An individual’s conscious description of who
hydrocele Fluid around the testes in the scrotum he or she is
hydrostatic pressure Pressure that a fluid exerts idiopathic Occurring without a known cause
against a membrane; also called filtration force idiosyncratic reaction Very unpredictable response
hygiene Study of health and ways of preserving health that may be an overresponse, an underresponse, or an
hyperbilirubinemia Excess of bilirubin in the blood atypical response
hyperemesis gravidarum Excessive vomiting ileal conduit Implantation of the ureters into a piece
during pregnancy of ileum, which is attached to the abdominal wall as a
hypergylcemia Condition wherein the blood stoma so urine can be removed from the body
glucose level becomes too high as a result of the absence ileostomy Opening created in the small intestine at
of insulin the ileum
hyperopia Farsightedness illness stage Time period when the client is manifesting
hypersensitivity Excessive reaction to a stimulus specific signs and symptoms of an infectious agent

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G-14 GLOSSARY

illusion Inaccurate perception or misinterpretation of informed consent Legal form signed by a

sensory stimuli competent client and witnessed by another person that
imagery Relaxation technique of using the grants permission to the client’s physician to perform
imagination to visualize a pleasant, soothing image the procedure described by the physician and that
immune response Body’s reaction to substances demonstrates the client’s understanding of the benefits,
identified as nonself risks, and possible complications of the procedure, as well
immunity Body’s ability to protect itself from foreign as alternate treatment options
agents or organisms ingestion The taking of food into the digestive tract,
immunization Process of creating immunity or generally through the mouth
resistance to infection in an individual initial planning Development of a preliminary
immunotherapy Treatment to suppress or enhance plan of care by the nurse who performs the admission
immunologic functioning assessment and gathers the comprehensive admission
implantable cardioverter-defibrillator assessment data
(ICD) Implantable device that senses a dysrythmia and insensible water loss Water loss of which the
automatically sends an electrical shock directly to the person is not generally aware
heart to defibrillate it insomnia Difficulty in falling asleep initially or in
implantable port Device made of a radiopaque returning to sleep once awakened
silicone catheter and a plastic or stainless steel injection inspection Physical examination technique that
port with a self-sealing silicone-rubber septum involves thorough visual observation
implantation Embedding of a fertilized egg into the insulin Pancreatic hormone that aids in both the
uterine lining diffusion of glucose into the liver and muscle cells, and the
impotence Inability of an adult male to have an synthesis of glycogen
erection firm enough or to maintain it long enough to intellectual wellness Ability to function as an
complete sexual intercourse independent person capable of making sound decisions
incidence Frequency of disease occurrence intensity Strength of the contraction at the acme
incompetent cervix Descriptor for when the cervix interdependent nursing intervention Nursing
begins to dilate, usually during the second trimester action that is implemented in a collaborative manner with
incomplete protein Protein with one or more of other health care professionals
the essential amino acids missing internal respiration Exchange of oxygen and
increment Increasing intensity of a contraction carbon dioxide at the cellular level
incubation period Time between entry of an interstitial fluid Fluid in tissue spaces around each
infectious agent in the host and the onset of symptoms cell
independent nursing intervention Nursing interval Resting period between two contractions
action initiated by the nurse and do not require direction intoxication Reversible effect on the central nervous
or an order from another health care professional system soon after the use of a substance
induction of labor Stimulation of uterine intracath Plastic tube for insertion into a vein
contractions before contractions begin spontaneously for intracellular fluid Fluid within the cells
the purpose of birthing an infant intradermal Injection into the dermis
infancy Development from the end of the first month intramuscular Injection into the muscle
to the end of the first year of life intraoperative phase Time during the surgical
infection Invasion and multiplication of pathogenic experience that begins when the client is transferred to the
microorganims in body tissue that results in cellular injury operating room table and ends when the client is admitted
infectious agent Microorganism that causes to the postanesthesia care unit
cellular injury intrathecal analgesia Administration of analgesics
infertility Inability or diminished ability to produce into the subarachnoid space
offspring intravascular fluid Fluid consisting of the plasma in
infiltration Seepage of foreign substances into the the blood vessels and the lymph in the lymphatic system
interstitial tissue, causing swelling and discomfort at the intravenous Injection into a vein
IV site intravenous therapy Administration of fluids,
inflammation Nonspecific cellular response to tissue electrolytes, nutrients, or medications by the venous
injury route
informal teaching Teaching that takes place intravesical Within the urinary bladder
anytime, anyplace, and whenever a learning need is intussusception Telescoping of one part of the
identified intestine into another

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 GLOSSARY G-15

invasive Accessing the body tissues, organs, or cavities kwashiorkor Condition resulting when there is a
through some type of instrumentation procedure sudden or recent lack of protein-containing foods
involution Return of the reproductive organs, kyphosis Increased roundness of the thoracic spinal
especially the uterus, to their pre-pregnancy size and curve
condition
ion Atom bearing an electrical charge L
ischemia Oxygen deprivation, usually due to poor
perfusion lanugo Fine hair covering the fetus’s body
ischemic pain Discomfort resulting when the blood large for gestational age Infant’s weight falls
supply to an area is restricted or cut off completely above the 90th percentile for gestational age
isolation Separation from other persons, especially late deceleration Reduction in fetal heart rate
those with infectious diseases that begins after the uterus has begun contracting and
isotonic solution Solution that has the same increases to the baseline level after the uterine contraction
molecular concentration as does the cell; also called an has ceased
isosmolar solution learning Act or process of acquiring knowledge, skill,
isotopes Atom of the same element that has a or both in a particular subject; process of assimilating
different atomic weight (i.e., different numbers of knowledge resulting in behavior changes
neutrons in the nucleus) learning disability Heterogenous group of
iv push (bolus) The administration of a large dose of disorders manifested by significant difficulties in the
medication in a relatively short time, usually 1–30 minutes acquisition and use of listening, speaking, reading, writing,
reasoning, or mathematical abilities
J learning plateau Peak in the effectiveness of
teaching and depth of learning
jaundice Yellow discoloration of the skin, sclera, learning style Individual preference for receiving,
mucous membranes, and body fluids that occurs when the processing, and assimilating information about a particular
liver is unable to fully remove bilirubin from the blood subject
Johnsonian intervention Confrontational lecithin Major component of surfactant
approach to a client with a substance problem that lessens Leopold’s maneuvers Series of specific palpations
the chance of denial and encourages treatment before the of the pregnant uterus to determine fetal position and
client “hits bottom” presentation
judgment Conclusion based on sound reasoning and let-down reflex Neurohormonal reflex that causes
supported by evidence milk to be expressed from the alveoli into the lactiferous
ducts
K leukocytosis Increased number of white blood cells
Kardex A brief worksheet with basic client care leukopenia Decreased number of white blood cells
information licensure Mandatory system of granting licenses
keloid Abnormal growth of scar tissue that is elevated, according to specified standards
rounded, and firm with irregular, clawlike margins life review Form of reminiscence wherein a client
keratin Tough, fibrous protein produced by cells in attempts to come to terms with conflict or to gain
the epidermis called keratinocytes meaning from life and die peacefully
keratitis Inflammation of the cornea ligation Application of a band or tie around a
kernicterus Severe neurological damage resulting structure
from a high level of bilirubin (jaundice) lightening Descent of the fetus into the pelvis,
Kernig’s sign Diagnostic test for inflammation in the causing the uterus to tip forward, relieving pressure on the
nerve roots; the inability to extend the leg when the thigh diaphragm
is flexed against the abdomen linea nigra Dark line on the abdomen from umbilicus
ketone Acidic by-product of fat metabolism to symphysis during the pregnancy
ketonuria Presence of ketones in the urine lipid Organic compound that is insoluble in water but
ketosis Condition wherein acids called ketones soluble in organic solvents such as ether and alcohol; also
accumulate in the blood and urine, upsetting the acid– known as fats
base balance lipodystrophy Atrophy or hypertrophy of
kilocalorie Equivalent to 1,000 calories subcutaneous fat
kinesthetic learner Person who learns by processing lipoma Benign tumor consisting of mature fat cells
information through touching, feeling, and doing lipoprotein Blood lipid bound to protein

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G-16 GLOSSARY

liquefaction necrosis Death and subsequent M

change of tissue to a liquid or semi-liquid state; often
descriptive of a primary tubercle macrosomia Excessive fetal growth characterized by
listening Interpreting the sounds heard and attaching
a fetus weighing more than 4,000 g (8.8 lb.)
magnetic resonance imaging Imaging technique
meaning to them
that uses radiowaves and a strong magnetic field to make
litholapaxy Procedure involving crushing of
continuous cross-sectional images of the body
a bladder stone and immediate washing out of the
maladaptive measure Measure used to avoid
fragments through a catheter
conflict or stress
lithotripsy Method of crushing a calculus anyplace in
malignant Becoming progessively worse and often
the urinary system with ultrasonic waves
resulting in death
liver mortis Bluish-purple discoloration of the skin
malpractice Negligent acts on the part of a
that is a by-product of red blood cell destruction; it begins
professional; relates to the conduct of a person who is
within 20 minutes of death
acting in a professional capacity
living will Legal document that allows a person to
managed care A cost-saving system where a case
state preferences about the use of life-sustaining measures
management, individual, or team control what specialists
should he or she be unable to make his or her wishes
the client sees, as well as the frequency or duration of that
known
specialty care
local adaptation syndrome Physiologic response
mania Extremely elevated mood with accompanying
to a stressor (e.g., trauma, illness) affecting a specific part
agitated behavior
of the body
marasmus Condition resulting from severe
localized infection Infection limited to a defined
malnutrition; afflicts very young children who lack both
area or single organ
energy and protein foods as well as vitamins and minerals
lochia Uterine/vaginal discharge after childbirth;
Maslow’s hierarchy of needs Theory of
initially bright red, then changing to a pink or pinkish behavioral motivation based on needs; includes
brown, then to a yellowish white physiologic, safety and security, love and belonging, self-
locomotor Pertaining to movement or the ability to
esteem, and self-actualization needs
move mastication Chewing food into fine particles and
long-term care facility Health care facility that mixing the food with enzymes in saliva
provides services to individuals who are not acutely ill, mastitis Inflammation of the breast, generally during
have continuing health care needs, and cannot function breastfeeding
independently at home material principle of justice Rationale for
long-term care managed care Care that refers determining those times when there can be unequal
to a spectrum of services provided to individuals who allocation of scarce resources
have an ongoing need for health care; traditionally a matter Anything that occupies space and possesses
community-based nursing home licensed for skilled or mass
intermediate care maturation Process of becoming fully grown and
long-term goal Statement that profiles the desired developed; involves physiologic and behavioral aspects
resolution of the nursing diagnosis over a long period of maturational loss Loss that occurs as a person
time, usually weeks or months moves from one developmental stage to another
lordosis Exaggeration of the curvature of the lumbar mechanism of labor Series of movements of the
spine fetus as it passes through the pelvis and birth canal
loss Any situation, either potential, actual, or perceived, meconium Fecal material stored in the fetal intestines
wherein a valued object or person is changed or is not meconium ileus Impacted feces in the newborn,
accessible to the individual causing intestinal obstruction
lumbar puncture Aspiration of cerebrospinal fluid Medicaid Government title program (XIX) that
from the subarachnoid space pays for health services for people who are older, poor,
lung stretch receptor Receptor that monitors the or disabled, and for low-income families with dependent
patterns of breathing and prevents overexpansion of the children
lungs medical asepsis Practices that reduce the number,
lymphokine Chemical substance released by growth, and spread of microorganisms
sensitized lymphocytes (T cells) and that assists in antigen medical diagnosis Clinical judgment by the
destruction physician that identifies or determines a specific disease,
lymphoma Tumor of the lymphatic system condition, or pathological state

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 GLOSSARY G-17

medical model Traditional approach to health care minority group Group of people constituting less
wherein the focus is on treatment and cure of disease not than a numerical majority of the population and are often
prevention labeled and treated differently from others in the society
Medicare Amendment (Title XVIII) to the Social miscarriage Spontaneous abortion
Security Act that helps finance the health care of misdemeanor Offense that is less serious than a
persons over 65 years old and younger persons who are felony and may be punished by a fine or by sentence to a
permanently disabled to receive Social Security disability local prison for less than 1 year
benefits misuse Use of a legal substance for which it was not
Medigap insurance Insurance plan for persons with intended, or exceeding the recommended dosage of a
Medicare that pays for health care costs not covered by drug
Medicare mixed agonist-antagonist Compound that
meditation An activity that brings the mind and spirit blocks opioid effects on one receptor type while
in focus on the present and provokes a sense of peace and producing opioid effects on a second receptor type
relaxation mixture Substances combined in no specific way
melanin Pigment that gives skin its color mnemonic Method to aid in association and recall; a
melena Stool containing partially broken down blood memorable sentence created from the first letters of a list
usually black, sticky, and tar-like of items to be used to recall the items later
menarche Onset of the first menstrual period mode of transmission Process of the infectious
meningitis Inflammation of the meninges agent moving from the reservoir or source through the
meningocele Saclike protrusion along the vertebral portal of exit to the portal of entry of the susceptible
column filled with cerebrospinal fluid and meninges “new” host
menopause Cessation of menstruation modulation Central nervous system pathway that
menorrhagia Excessively heavy menstrual flow selectively inhibits pain transmission by sending signals
mental disorder Clinically significant behavior back down to the dorsal horn of the spinal cord
or psychological syndrome or pattern that occurs in molding Shaping of the fetal head to adapt to the
an individual and is associated with present distress or mother’s pelvis during labor
disability or with a significantly increased risk of suffering, molecule Atoms of the same element that unite with
death, pain, disability, or an important loss of freedom each other
(APA, 1994) Mongolian spots Large patches of bluish skin on the
mental illness Condition wherein an individual has buttocks of dark-skinned infants
a distorted view of self, is unable to maintain satisfying monounsaturated fatty acid Forms a glycerol
personal relationships, and is unable to adapt to the ester with a double or triple bond; nuts, fowl, and olive oil
environment mood Subjective report of the way an individual is
mentation Ability to concentrate, remember, or think feeling
abstractly moral maturity Ability to decide for oneself what is
metabolic rate Rate of energy utilization in the body “right”
metabolism Sum total of all the biological and morbidity Illness
chemical processes in the body mortality Death
metastasis Spread of cancer cells to distant areas of morula Mass of cells resembling a mulberry
the body by way of the lymph system or bloodstream mourning Period during which grief is expressed and
metritis Inflammation of the uterus including the integration and resolution of the loss occur
endometrium and parametrium multigravida Condition of being pregnant two or
metrorrhagia Vaginal bleeding between menstrual more times
periods multipara Condition of having delivered twice or
micturition Process of expelling urine from the more after 24 weeks’ gestation
urinary bladder; also called urination or voiding myelomeningocele Saclike protrusion along the
middle adulthood Development from the ages of vertebral column that is filled with spinal fluid, meninges,
40 years to 65 years nerve roots, and spinal cord
milia Pearly white cysts on the face myocardial infarction Necrosis (death) of the
minimum data set An assessment tool for assessing myocardium caused by an obstruction in a coronary
a resident’s physical, psychological, and psychosocial artery; commonly known as heart attack
functioning in a Medicare and Medicaid-certified long- myocarditis Inflammation of the myocardium of the
term care facility heart

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G-18 GLOSSARY

myofascial pain syndrome Group of muscle nevus vascularis Birthmark of enlarged superficial
disorders characterized by pain, muscle spasm, tenderness, blood vessels, elevated and red in color
stiffness, and limited motion nociceptor Receptive neuron for painful sensations
myopia Nearsightedness nocturia Awakening at night to void
myringotomy Surgical incision of the eardrum nocturnal enuresis Incontinence that occurs during
myxedema Severe hypothyroidism in adults sleep
noninvasive Descriptor for procedure wherein the
N body is not entered with any type of instrument
nonmaleficence Ethical principle based on the
narcolepsy Sleep alteration manifested as sudden obligation to cause no harm to others
uncontrollable urges to fall asleep during the daytime nonshivering thermogenesis Metabolism of
narrative charting Chronological account brown fat; process unique to the newborn
written in paragraphs describes the client’s status, the nonverbal communication Body language or a
interventions and treatments, and the client’s response to method of sending a message without words
treatments nosocomial infection Infection acquired in the
necrosis Tissue death as the result of disease or injury hospital or other health care facility that was not
neglect Situation wherein a basic need of the client is present or incubating at the time of the client’s
not being provided admission
negligence General term referring to careless acts on noxious stimulus Underlying pathology that causes
the part of an individual who is not exercising reasonable pain
or prudent judgment nuchal cord Condition of the umbilical cord being
neonatal stage First 28 days of life following birth wrapped around the baby’s neck
neonatal transition First few hours after birth nuchal rigidity Pain and rigidity in the neck
wherein the newborn makes changes to and stabilizes nulligravida Condition of never having been
respiratory and circulatory functions pregnant
neonate Newborn from birth to 28 days of life nullipara Condition of never having delivered an
neoplasm Any abnormal growth of new tissue infant after 24 weeks’ gestation
nephrotoxic Quality of a substance that causes nursing The art and science of assisting individuals in
kidney tissue damage learning to care for themselves whenever possible and of
nerve agents Powerful acetylcholinesterase caring for them when they are unable to meet their own
inhibitors that alter cholinergic synaptic transmission at needs
neuroeffector junctions, at skeletal myoneural junctions nursing audit Method of evaluating the quality of
and autonomic ganglia, and in the central nervous system care provided to clients
nesting Surge of energy late in pregnancy when the nursing care plan Written guide of strategies to
pregnant woman organizes and cleans the house be implemented to help the client achieve optimal
neuralgia Paroxysmal pain that extends along the health
course of one or more nerves nursing diagnosis Second step in the nursing
neurogenic shock Hypotensive situation resulting process; a clinical judgment about individual, family, or
from the loss of sympathetic control of vital functions community (aggregate) responses to actual or potential
from the brain health problems/life processes
neuropeptide Amino acid produced in the brain nursing intervention Action performed by a nurse
and other sites in the body that acts as a chemical that helps the client achieve the results specified by the
communicator goals and expected outcomes
neurotransmitter Chemical substance produced nursing interventions
by the body that facilitates or inhibits nerve-impulse classification Standardized language for nursing
transmission interventions
neutral thermal environment Environment in nursing minimum data set Elements that should
which the newborn can maintain internal body temperature be in clinical records and abstracted for studies on the
with minimal oxygen consumption and metabolism effectiveness and costs of nursing care
nevi Pigmented areas in the skin; commonly known as nursing outcomes classification Standardized
birthmarks or moles language for nursing outcomes
nevus flammeus Large, reddish-purple birthmark nursing practice act Statute that is enacted by the
usually found on the face or neck and does not blanch legislature of a state and that outlines the scope of nursing
with pressure practice in that state

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 GLOSSARY G-19

nursing process Systematic method for providing orthopnea Difficulty breathing while lying down
care to clients, consisting of five steps: assessment, orthostatic hypotension Significant decrease in
diagnosis, outcome identification and planning, blood pressure that results when a person moves from a
implementation, and evaluation lying or sitting (supine) position to a standing position
nutrition All of the processes (ingestion, digestion, osmolality Measurement of the total concentration
absorption, metabolism, and elimination) involved in of dissolved particles (solutes) per kilogram of water
consuming and using food for energy, maintenance, and osmolarity Concentration of solutes per liter of
growth cellular fluid
nystagmus Constant, involuntary movement of the osmosis Movement of a solvent, usually water,
eye in various directions through a semipermeable membrane, from a region of
higher concentration to a region of lower concentration
O osmotic pressure Pressure exerted against the cell
membrane by the water inside a cell
obesity Weight that is 20% or more above the ideal
osteoporosis Increase in the porosity of bone
body weight
Outcomes and Assessment Information Set
objective data Observable and measurable data that
An outcomes measurable tool developed and
are obtained through standard assessment techniques
implemented to determine the care given and
performed during the physical examination and through
reimbursement required; Outcomes and Assessment
laboratory and diagnostic tests
Information Set (OASIS) data is reported to the Centers
occult blood Blood in the stool that can be detected
for Medicare and Medicaid Services (CMS)
only through a microscope or by chemical means
overflow incontinence Leaking of urine when the
occult blood test (guaiac) Test for microscopic
bladder becomes very full and distended
blood done on stool
oxidation Chemical process of combining with oxygen
older adulthood Development occurring from age
oxidized Joined with oxygen
65 years until death
oligomenorrhea Decreased menstrual flow
oliguria Diminished production of urine
P
oncology Study of tumors pain Unpleasant sensory and emotional experience
ongoing assessment Type of assessment that associated with actual or potential tissue damage or
includes systematic monitoring of specific problems described in terms of such
ongoing planning Updates the client’s plan of care pain threshold Level of intensity at which pain
onset of action Time for the body to respond to a becomes appreciable or perceptible
drug after administration pain tolerance Level of intensity or duration of pain
oophoritis Inflammation of the ovary that a person is willing to endure
open reduction Surgical procedure that enables palliative care Care that relieves symptoms, such as
the surgeon to reduce (repair) a fracture under direct pain, but does not alter the course of disease
visualization pallor Abnormal paleness of the skin, seen especially
ophthalmia neonatorum Inflammation of a in the face, conjunctiva, nail beds, and oral mucous
newborn’s eyes that results from passing through the birth membranes
canal when a gonorrheal or chlamydial infection is present palpation Physical examination technique that
opinion Subjective belief uses the sense of touch to assess texture, temperature,
opisthotonos Complete arching of the body with moisture, organ location and size, vibrations and
only the head and feet on the bed pulsations, swelling, masses, and tenderness
opportunistic infection Infection in persons with pancreatitis Acute or chronic inflammation of the
a defective immune system that rarely causes harm in pancreas
healthy individuals Papanicolaou test Smear method of examining
oppression Condition wherein the rules, values, and stained exfoliative cells
ideals of one group are imposed on another group paracentesis Aspiration of fluid from the abdominal
orchiectomy Removal of a testis cavity
orientation Person’s awareness of self in relation to paradoxical reaction Opposite effect of that which
person, place, time, and in some cases, situation would normally be expected
orthopedics (orthopaedics) Branch of medicine paramedic Specialized health care professional
that deals with the prevention or correction of the trained to provide advanced life support to the client
disorders and diseases of the musculoskeletal system requiring emergency interventions

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G-20 GLOSSARY

paraplegia Paralysis of lower extremities peripheral nervous system System of the

parasomnia Disorders that intrude on sleep in very cranial nerves, spinal nerves, and the autonomic nervous
active ways system
parenteral Any route other than the oral- peripheral resistance Pressure within a vessel
gastrointestinal tract that resists the flow of blood such as plaque buildup or
parenteral nutrition Feeding method whereby vasoconstriction
nutrients bypass the small intestine and enter the blood peristalsis Rhythmic, coordinated, serial contraction
directly of the smooth muscles of the gastrointestinal tract
paresthesia Abnormal sensation such as burning, peritonitis Inflammation of the peritoneum, the
prickling, or tingling membranous covering of the abdomen
paroxysmal Descriptor for a symptom that begins permeability Ability of a membrane to permit
and ends abruptly substances to pass through it
paroxysmal nocturnal dyspnea Condition petechiae Pinpoint hemorrhagic spots on the skin
of suddenly awakening, sweating, and having difficulty phantom limb pain Neuropathic pain that occurs
breathing after amputation with pain sensations referred to an area
passive euthanasia Process of working with the in the missing portion of the limb
client’s dying process pharmacokinetics Study of the absorption,
patency Being freely opened distribution, metabolism, and excretion of drugs to
pathogen Microorganism that causes disease determine the relationship between the dose of a drug and
pathogenicity Ability of a microorganism to produce the drug’s concentration in biological fluids
disease phimosis Condition wherein the opening in the
patient-controlled analgesia Device that foreskin is so small that it cannot be pulled back over the
allows the client to control the delivery of intravenous or glans
subcutaneous pain medication in a safe, effective manner phlebitis Inflammation in the wall of a vein without
through a programmable pump clot formation
peak plasma level Highest blood concentration of phlebothrombosis Formation of a clot because
a single dose of a drug until the elimination rate equals the of blood pooling in the vessel, trauma to the vessel’s
rate of absorption endothelial lining, or a coagulation problem with little or
peer assistance program Rehabilitation program no inflammation in the vessel
that provides an impaired nurse with referrals, professional phlebotomist Individual who performs venipuncture
and peer counseling support groups, and assistance and phlebotomy Removal of blood from a vein
monitoring back into nursing phospholipid Lipid composed of glycerol, fatty acids,
peptic ulcer Erosion formed in the esophagus, and phosphorus; the structural component of cells
stomach, or duodenum resulting from acid/pepsin physical agent Factor in the environment capable of
imbalance causing disease in a host
perception Ability to experience, recognize, organize, physical restraint Equipment that reduces the
and interpret sensory stimuli client’s movement
percussion Physical examination technique that uses physical wellness Healthy body that functions at an
short, tapping strokes on the surface of the skin to create optimal level
vibrations of underlying organs physically aggressive Descriptor of an individual
perfectionism Overwhelming expectation of being who threatens or actually harms someone
able to get everything done in a flawless manner physiologic anemia of pregnancy Condition of
perfusion Blood flow through an organ or body part having delivered after 24 weeks’ gestation, whether infant
pericardial friction rub Short, high-pitched squeak is born alive or dead or number of infants born
heard as two inflamed pericardial surfaces rub together phytochemical Physiologically active compound
pericardiocentesis Removal of fluid from the present in plants in very small amounts that gives plants
pericardial sac flavor, odor, and color
pericarditis Inflammation of the membrane sac pica Practice of eating substances not considered
surrounding the heart edible and that have no nutritive value, such as laundry
perineal care Cleansing of the external genitalia, starch, dirt, clay, and freezer frost
perineum, and the surrounding area pie charting Documentation method using the
perioperative Period of time encompassing the problem, intervention, evaluation (PIE) format
preoperative, intraoperative, and postoperative phases of piggyback Addition of an intravenous solution to
surgery infuse concurrently with another infusion

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 GLOSSARY G-21

placenta Membranous vascular organ connecting the portal of entry Route by which an infectious agent
fetus to the mother, which produces hormones to sustain enters the host
a pregnancy, supplies the fetus with oxygena and food, portal of exit Route by which an infectious agent
and transports waste products out of the fetal system leaves the reservoir
placenta previa Condition in which the placenta postictal After a seizure
forms over or very near the internal cervical os post-mortem care Care given immediately after
plague An infectious disease transmitted by a bite of death before the body is moved to the mortuary
a flea from a rodent (usually a rat) infected with the postoperative phase Time during the surgical
bacillus Yersinia pestis; plague is a potential agent of experience that begins at the end of the surgical procedure
bioterrorism and ends when the client is discharged, not just from
planning Third step of the nursing process; includes the hospital or institution, but from medical care by the
both the establishing of guidelines for the proposed course surgeon
of nursing action to resolve the nursing diagnoses and postpartum blues Mild transient condition of
developing the client’s plan of care emotional lability and crying for no apparent reason,
plateau Level at which a drug’s blood concentration is which affects up to 80% of women who have just given
maintained birth, and lasts about 2 weeks
pleural effusion Collection of fluid within the postpartum depression Condition similar
pleural cavity to postpartum blues but is more serious, intense, and
pleural friction rub Abnormal breath sound that persistent
is creaky and grating in nature and is heard on inspiration postpartum hemorrhage Blood loss of more
and expiration than 500 mL after the third stage of labor or 1,000 mL
pleurisy Condition arising from inflammation of the following a cesarean birth
pleura, or sac, that encases the lung postpartum psychosis Condition more severe
pneumonia Inflammation of the bronchioles and than postpartum depression and characterized by
alveoli accompanied by consolidation, or solidification of delusions and thoughts of self-harm or infant harm
exudate, in the lungs postprandial After eating
pneumothorax Condition wherein air or gas postterm Delivery after 42 weeks’ gestation
accumulates in the pleural space of the lungs, causing the post-void residual Urine that remains in the
lungs to collapse bladder after urination
point-of-care charting Documentation system that prayer A type of communication between an
allows health care providers to gain immediate access to individual and spiritual entities
client information at the bedside preadolescence Development from the ages of
poison Any substance that when taken into the body approximately 10 years to 12 years
interferes with normal physiologic functioning; may be precipitate birth Birth occurring suddenly and
inhaled, injected, ingested, or absorbed by the body unexpectantly without a CNM/physician present to
polydipsia Excessive thirst assist
polymenorrhea Menstrual periods that are precipitate labor Labor lasting less than 3 hours
abnormally frequent, generally less than every 21 days from the onset of contractions to the birth of the infant
polyp Abnormal growth of tissue preeclampsia Phase of pregnancy-induced
polyphagia Increased hunger hypertension prior to convulsions
polypharmacy Problem of clients taking numerous preferred provider organization Type of
prescription and over-the-counter medications for managed care model wherein member choice is limited
the same or various disease processes, with unknown to providers within the system for full reimbursement and
consequences from the resulting combinations of other providers for less reimbursement
chemical compounds and cumulative side-effects prenatal care Care of a woman during pregnancy,
polyunsaturated fatty acid Forms a glycerol before labor
ester with many carbons unbonded to hydrogen atoms; prenatal stage Development beginning with
fish, corn, sunflower seeds, soybeans, cotton seeds, and conception and ending with birth
safflower oil preoperative phase Time during the surgical
polyuria Increased urination experience that begins when the client decides to have
Port-a-Cath Port that has been implanted under the surgery and ends when the client is transferred to the
skin with a catheter inserted into the superior vena cava operating table
or right atrium through the subclavian or internal jugular presbycusis Sensorineural hearing loss associated
vein with aging

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G-22 GLOSSARY

presbyopia Inability of the lens of the eye to change professional boundaries Limits of the
curvature to focus near objects professional relationship that allow for a safe, therapeutic
preschool stage Development from the ages of connection between the professional and the client
3 years to 6 years progressive muscle relaxation Stress-
prescriptive authority Legal recognition of the management strategy in which muscles are alternately
ability to prescribe medications tensed and relaxed
presenting part Part of the fetus in contact with the projectile vomiting Forceful ejection (up to 3 feet)
cervix of the contents of the stomach
pressured speech Rapid, intense style of speech prolapsed cord Condition in which the umbilical
preterm Delivery after 24 weeks’ gestation but before cord lies below the presenting part of the fetus
38 weeks (full term) prolapsed uterus Downward displacement of the
preterm birth Birth that takes place before the end uterus into the vagina
of the 37th week of gestation prospective payment Predetermined rate paid for
preterm labor Onset of regular contractions of each episode of hospitalization based on the client’s age
the uterus that cause cervical changes between 20 and and principal diagnosis and the presence or absence of
37 weeks’ gestation surgery or comorbidity
prevention Obstructing, thwarting, or hindering a protocol Series of standing orders or procedures
disease or illness that should be followed under certain specific
priapism Prolonged erection that does not occur in conditions
response to sexual stimulation proxemics Study of the space between people and its
primary care provider Health care provider effect on interpersonal behavior
whom a client sees first for health care, typically a family pruritus Severe itching
practitioner (physician/nurse), internist, or pediatrician pseudocyesis False pregnancy
primary health care Client’s point of entry into pseudomenstruation Blood-tinged mucus
the health care system; includes assessment, diagnosis, discharge from the vagina of a newborn caused by the
treatment, coordination of care, education, prevention withdrawal of maternal hormones
services, and surveillance psychoanalysis Therapy focused on uncovering
primary hypertension High blood pressure, unconscious memories and processes
the cause of which is unknown; also known as essential psychological wellness Enjoyment of creativity,
hypertension satisfaction of the basic need to love and be loved,
primary prevention All practices designed to keep understanding of emotions, and ability to maintain
health problems from developing control over emotions
primary source Major provider of information about psychomotor domain Area of learning that
a client involves performance of motor skills
primary tubercle Nodule that contains tubercle psychoneuroimmunology Study of the complex
bacilli and forms within lung tissue relationship among the physical, cognitive, and affective
primigravida Condition of being pregnant for the aspects of humans
first time psychoprophylaxis Mental and physical
primipara Condition of having delivered once after preparation for childbirth; synonymous with Lamaze
24 weeks’ gestation psychosis State wherein an individual has lost the
privacy The right to be left alone, to choose care ability to recognize reality
based on personal beliefs, to govern body integrity, and psychotherapy Treatment of mental and emotional
to choose when and how sensitive information is shared disorders through psychological rather than physical
(Badzek & Gross, 1999) methods
problem-oriented medical record ptosis Drooping upper eyelid
Documentation method employs a structured, logical puberty Emergence of secondary sex characteristics
format and focuses on the client’s problem that signal the beginning of adolescence
process Series of steps or acts that leads to public law Law that deals with an individual’s
accomplishing some goal or purpose relationship to the state
procrastination Intentionally putting off or delaying public self What the client thinks others think of him
something that should be done or her
prodromal stage Time interval from the onset of pudendal block Injection of a local anesthetic into
nonspecific symptoms until specific symptoms of the the pudendal nerve to provide perineal, external genitalia,
infectious process begin to manifest and lower vaginal anesthesia

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 GLOSSARY G-23

puerperal (postpartum) infection Infection referred pain Discomfort from the internal organs
following childbirth occurring between the birth and that is felt in another area of the body
6 weeks postpartum reframing Technique of monitoring negative
puerperium Term for the first 6 weeks after the birth thoughts and replacing them with positive ones
of an infant regional anesthesia Method of temporarily
pulse amplitude Measurement of the strength or rendering a region of the body insensible to pain
force exerted by the ejected blood against the arterial wall rehabilitation Process or therapy designed to assist
with each heart contraction individuals to reach their optimal level of physical, mental,
pulse deficit Condition in which the apical pulse and psychosocial functioning
rate is greater than the radial pulse rate relapse Return to a previous behavior or condition
pulse rate Indirect measurement of cardiac output relaxation technique Method used to decrease
obtained by counting the number of peripheral pulse anxiety and muscle tension
waves over a pulse point religion A system of organized beliefs, rituals, and
pulse rhythm Regularity of the heartbeat practices with which a person identifies and wishes to be
purpura Reddish-purple patches on the skin indicative associated
of hemorrhage religious support system Group of ministers,
purulent exudate Discharge resulting from priests, nuns, rabbis, shamans, mullahs, or laypersons who
infection; also called pus are able to meet clients’ spiritual needs
pyelonephritis Bacteral infection of the renal pelvis, REM movement disorder Condition wherein the
tubules, and interstitial tissue of one or both kidneys normal paralysis of REM sleep is absent or incomplete
pyorrhea Periodontal disease and the sleeper acts out the dream
pyuria Pus in the urine remission Decrease or absence of symptoms of a
disease
Q renal colic Severe pain in the kidney that radiates to
the groin
quadriplegia Dysfunction or paralysis of both arms,
repolarization Recovery phase of the cardiac
both legs, and bowel and bladder
muscle
quickening Descriptor for when the mother first feels
reportable conditions Diseases or injuries that
the fetus move, about 16 to 20 weeks’ gestation
the government requires be reported to the appropriate
authority or agency; include suspected abuse and/or
R neglect, sexually transmitted diseases (STDs), and certain
race A group of people with biological similarities other contagious illnesses that could threaten the health of
radiation Loss of heat by transfer to cooler near the general public
objects, but not through direct contact reservoir Place where the agent can survive
radiation sickness An abnormal condition resulting resident flora Microorganisms that are always
from exposure to ionizing radiation, either purposefully or present, usually without altering the client’s health
by accident residual urine Urine remaining in the bladder after
radiography Study of x-rays or gamma-ray-exposed the individual has urinated
film through the action of ionizing radiation respect Acceptance of an individual as is and in a
radiotherapy Treatment of cancer with high-energy nonjudgmental manner
radiation respiration Process of exchanging oxygen and carbon
rapport Mutual trust established between two people dioxide
readiness for learning Evidence of willingness to respite care Care and service that provides a break
learn to caregivers and is used for a few hours a week, for an
real self How the individual really thinks about him- occasional weekend, or for longer periods of time
or herself rest State of mental and physical relaxation and
reasoning Use of the elements of thought to solve a calmness
problem or settle a question restitution Rotation of the fetal head back to normal
reconstructive To rebuild or reestablish alignment with the shoulders after delivery of the fetal
rectocele Anterior displacement of the rectum into head
the posterior vaginal wall restless leg syndrome Condition characterized
recurrent acute pain Identified by repetitive by uncomfortable sensations of tingling or crawling in the
painful episodes that recur over a prolonged period or muscles, and twitching, burning, prickling, or deep aching
throughout a client’s lifetime in the foot, calf, or upper leg when at rest

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G-24 GLOSSARY

restraint Protective device used to limit the physical circulating nurse and who is qualified by training or
activity of a client or to immobilize a client or extremity experience to prepare and maintain the integrity, safety,
resuscitation Support measures implemented to and efficiency of the sterile field throughout an operation
restore consciousness and life sebaceous cyst Sebaceous gland filled with sebum
reticulocyte Immature red blood cell sebum Oily substance secreted by the sebaceous
retroperitoneal Behind the peritoneum outside the glands of the skin
peritoneal cavity secondary care Care focused on diagnosis and
reverse isolation Barrier protection designed to treatment after the client exhibits symptoms of illness
prevent infection in clients who are severely compromised secondary hypertension High blood pressure
and highly susceptible to infection; also known as occurring as a sequel to a pre-existing disease or injury
protective isolation secondary prevention Early detection, screening,
reverse tolerance Phenomenon whereby a smaller diagnosis, and intervention, to reduce the consequences of
amount of substance will elicit the desired psychic effects a health problem
review of systems Brief account of any recent sedation Reduction of stress, excitement, or
signs or symptoms related to any body system irritability via some central nervous system depression
rhinorrhea Watery nasal discharge self-awareness Consciously knowing how the self
Ricin A poison made from the waste products of castor thinks, feels, believes, and behaves at any specific time
bean processing; a potential agent of bioterrorism because self-care deficit State wherein an individual is not
of its ease of dissemination able to perform one or more activities of daily living
rigor mortis Natural stiffening of muscles after self-concept Individual’s perception of self; includes
death; begins about 4 hours after death self-esteem, body image, and ideal self
risk nursing diagnosis Nursing diagnosis self-efficacy Belief in one’s ability to succeed in
indicating that a problem does not yet exist but that attempts to change behavior
specific risk factors are present; composed of “Risk for” self-esteem A personal opinion of oneself
followed by the diagnostic label and a list of the risk semipermeable membrane Membrane that
factors allows passage of only certain substances
role An ascribed or assumed expected behavior in a sensation Ability to receive and process stimuli
social position or group received through the sensory organs
role performance Specific behaviors a person sensible water loss Water loss of which the person
exhibits within each role is aware
rooming-in Practice of staying with the client sensitivity Susceptibility of a pathogen to an
24 hours a day to provide care and comfort antibiotic
sensorineural hearing loss Condition in which
S the inner ear or cochlear portion of cranial nerve VIII is
abnormal or diseased
salpingitis Inflammation of the fallopian tube sensory deficit Change in the perception of sensory
salt Product formed when an acid and a base react with stimuli; can affect any of the senses
each other sensory deprivation State of reduced sensory input
sanguineous Bloody drainage from a wound or from the internal or external environment, manifested by
surgical drain alterations in sensory perception
sarcoma Cancer occurring in connective tissue sensory overload State of excessive and sustained
Sarin A dangerous man-made nerve agent, first multisensory stimulation manifested by behavior change
developed as an insecticide that is a potential agent for and perceptual distortion
bioterrorism sensory perception Ability to receive sensory
satiety Feeling of adequate fullness from food impressions and, through cortical association, relate the
school-age stage Development from the ages of stimuli to past experiences and form an impression of the
6 years to 10 years nature of the stimulus
sclerotherapy Treatment that involves injecting seroconversion Evidence of antibody formation in
a chemical into the vein, causing the vein to become response to disease or vaccine
sclerosed (hardened) so blood no longer flows through it serosanguineous exudate Discharge that is clear
sclerotic Hardened tissue with some blood tinge; seen with surgical incisions
scoliosis Lateral curvature of the spine serous exudate Discharge composed primarily
scrub nurse RN, LP/VN, or surgical technologist of serum; is watery in appearance and has a low protein
who provides services under the direction of the level.

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 GLOSSARY G-25

serum lithium level Laboratory test done to somatic pain Nonlocalized discomfort originating in
determine whether the client’s lithium level is within a tendons, ligaments, and nerves
therapeutic range somnambulism Sleepwalking
shaman Folk healer-priest who uses natural and Somogyi phenomenon In response to
supernatural forces to help others hypoglycemia, the release of glucose-elevating hormones
shearing Force exerted against the skin by movement (epinephrine, cortisol, glucose), which produces a
or repositioning hyperglycemic state
shift report Report about each client between shifts sonorous wheeze Abnormal breath sound that
shock Condition of profound hemodynamic and is low pitched and snoring in nature and is louder on
metabolic disturbance characterized by inadequate tissue expiration
perfusion and inadequate circulation to the vital organs spermatogenesis Production of sperm
shroud Covering for the body after death spina bifida occulta Failure of the vertebral arch
sibilant wheeze Abnormal breath sound that is high to close
pitched and musical in nature and is heard on inhalation spinal shock Cessation of motor, sensory,
and exhalation autonomic, and reflex impulses below the level of injury;
sickle When red blood cells become crescent-shaped characterized by flaccid paralysis of all skeletal muscles,
and elongated loss of spinal reflexes, loss of sensation, and absence of
single point of entry Common feature of HMOs autonomic function below the level of injury
wherein the client is required to enter the health care spiritual care Recognition of and assistance toward
system through a point designated by the plan meeting spiritual needs
single-payer system Health care delivery model spiritual distress A client in this situation may have
wherein the government is the only entity to reimburse a troubled, fragmented, or possibly disintegrating spirit
health care costs spiritual needs Individual’s desire to find purpose
situational loss Loss that takes place in response to and meaning in life, pain, and death
external events generally beyond the individual’s control spiritual wellness Inner strength and peace
slander Words that are communicated verbally to spirituality The core of a person’s being, a higher
a third party and that harm or injure the personal or experience or transcendence of oneself
professional reputation of another spore Bacteria in a resistant stage that can withstand
sleep State of altered consciousness during which a unfavorable environments
person has minimal physical activity, changes in levels of sprain Injury to ligaments surrounding a joint caused
consciousness, and a slowing of physiologic processes by a sudden twist, wrench, or fall
sleep apnea A period during sleep of not breathing; stable Alert with vital signs within the client’s normal
often associated with heavy snoring range
sleep cycle Sequence of sleep beginning with the staff development Delivery of instruction to assist
four stages of NREM sleep, a return to stage 3 and then nurses achieve the goals of the employer
stage 2 (first phase), followed by the first REM sleep standard Level or degree of quality
(second phase) Standard Precautions Preventive practices to be
sleep deprivation Prolonged inadequate quality used in the care of all clients in hospitals regardless of their
and quantity of sleep diagnosis or presumed infection status
small for gestational age Infant’s weight falls standards of practice Guidelines established to
below the 10th percentile for gestational age direct nursing care
smallpox (variola) A highly contagious and startle response Overreaction to minor sounds or
frequently fatal viral disease, which is a potential agent for noises
a bioterroristic attack; there are two varieties, known as stasis dermatitis Inflammation of the skin due to
variola major and variola minor decreased circulation
Snellen Chart Chart containing various-sized letters station Relationship of the fetal presenting part to the
with standardized numbers at the end of each line of ischial spines
letters status asthmaticus Persistent, intractable asthma
sociocultural wellness Ability to appreciate the attack
needs of others and to care about one’s environment and status epilepticus Acute, prolonged episode of
the inhabitants of it seizure activity that lasts at least 30 minutes and may or
somatic nervous system Nerves that connect the may not involve loss of consciousness
central nervous system to the skin and skeletal muscles statutory law Law enacted by legislative bodies
and control conscious activities steatorrhea Fatty stool

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G-26 GLOSSARY

stent Tiny metal tube with holes in it that prevents subinvolution Incomplete return of the uterus to its
a vessel from collapsing and keeps the atherosclerotic prepregnant size and consistency
plaque pressed against the vessel wall; any material used subluxation Partial separation of an articular surface
to hold tissue in place or provide support substance A drug, legal or illegal, that may cause
stereognosis Ability to recognize an object by feel physical or mental impairment
stereotyping Belief that all people within the same suicidal ideations Thoughts of hurting or killing
ethnic, racial, or cultural group act the same way, sharing oneself
the same beliefs and attitudes supine hypotensive syndrome Lowering of
sterile Without microorganisms blood pressure in a pregnant woman when lying supine
sterile conscience Individual’s personal sense due to compression of the vena cava by the enlarged,
of honesty and integrity with regard to adherence to heavy uterus
the principles of aseptic technique, including prompt surfactant Phospholipids that are present in the
admission and correction of any errors and omissions lungs and lower surface tension to prevent collapse of the
sterile field Area surrounding the client and the airways
surgical site that is free from all microorganisms; created surgery Treatment of injury, disease, or deformity
by draping of the work area and the client with sterile through invasive operative methods
drape suture Thin, fibrous, membrane-covered space
sterilization Destroying all microorganisms, between skull bones
including spores synarthrosis Immovable joint
stock supply Medications dispensed and labeled syndactyly Fusion of two or more fingers or toes
in large quantities for storage in the medication room or synergism Result of two or more agents working
nursing unit together to achieve a greater effect than either could
stoma Surgical opening between a cavity and the produce alone
surface of the body synthesiasis Hearing colors and seeing sounds
stomatitis Inflammation of the oral mucosa synthesis Chemical reaction when two or more
strabismus Inability of the eyes to focus in the same atoms, called reactants, bond and form a more complex
direction molecular product; putting data together in a new way
strain Injury to a muscle or tendon due to overuse or
overstretching
T
stress Nonspecific response to any demand made on
the body (Selye, 1974) tachycardia Heart rate in excess of 100 beats per
stress incontinence Leakage of urine when a person minute in an adult
does anything that strains the abdomen, such as coughing, tachypnea Respiratory rate greater than 24 beats per
laughing, jogging, dancing, sneezing, lifting, making a minute
quick movement, or even walking talipes equinovarus A congenital deformity in
stress test Measure of a client’s cardiovascular which the foot and ankle are twisted inward and cannot be
response to exercise moved to a midline position; also known as clubfoot
stressor Any situation, event, or agent that produces teaching Active process wherein one individual shares
stress information with another as a means to facilitate learning
striae gravidarum Reddish streaks frequently found and thereby promote behavioral changes
on the abdomen, thighs, buttocks, and breasts; also called teaching strategy Technique to promote learning
“stretch marks” teaching–learning process Planned interaction
stridor High-pitched, harsh sound heard on that promotes a behavioral change that is not a result of
inspiration when the trachea or larynx is obstructed maturation or coincidence
stroke volume Volume of blood pumped by the telangiectasic nevi Birthmarks of dilated
ventricle with each contraction capillaries that blanch with pressure; also called
stye Pustular inflammation of an eyelash follicle or stork-bites
sebaceous gland on the eyelid margin telangiestasia Permanent dilation of groups of
subacute care Short-term, aggressive care for superficial capillaries and venules; commonly known as
clients who are out of the acute stage of illness but who “spider veins”
still require skilled nursing, monitoring, and ongoing telehealth An electronic information services
treatment that offer increased client and family participation; for
subcutaneous Injection into the subcutaneous tissue example, nurse and client use interactive videos, telephone

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 GLOSSARY G-27

cardiac rate monitoring with EKG readout, digital thrombus Formed clot that remains at the site where
subscriber lines, and Internet transmission of data it formed
telemedicine An element of telehealth permitting time management System to help meet goals
physicians to provide care through a telecommunication through problem solving
system tinnitus Ringing sound in the ear
teleology Ethical theory that states that the value of a tocolysis Process of stopping labor with medications
situation is determined by its consequences tocolytic agent Medication that inhibits uterine
tenesmus Spasmodic contradiction of the anal or contractions
bladder sphincter, causing pain and a persistent urge to toddler stage Development begins at approximately
empty the bowel or bladder 12 to 18 months of age, when a child begins to walk, and
teratogen Agent such as radiation, drugs, viruses, and ends at approximately 3 years of age
other microorganisms capable of causing abnormal fetal tolerance Decreased sensitivity to subsequent doses
development of the same substance; an increased dose of the substance
teratogenic Causing abnormal development of the is needed to produce the same desired effect
embryo tophi Subcutaneous nodules of sodium urate
teratogenic substance Substance that crosses the crystals
placenta and impairs normal growth and development tort Civil wrong committed by a person against
term Descriptor for a pregnancy between 38 and another person or property
42 weeks’ gestation tort law Enforcement of duties and rights among
terrorism Instilling fear in large groups of persons individuals and independent of contractual agreements
by using any product, weapon, or the threat of using a touch Means of perceiving or experiencing through
harmful act or substance to kill or injure people tactile sensation
tertiary care Care focused on restoring the client to toxic effect Reaction that occurs when the body
the state of health that existed before the development of cannot metabolize a drug and the drug accumulates in the
an illness; if unattainable, then care is directed to attaining blood
the optimal level of health possible trade (brand) name Name assigned to a drug by
tertiary prevention Treatment of an illness or the pharmaceutical company; always capitalized
disease after symptoms have appeared, so as to prevent transcendence A state of being or existence above
further progression and beyond the limits of material experience
tetany Sharp flexion of the wrist and ankle joints, transcutaneous electrical nerve
involving muscle twitching or cramps stimulation Process of applying a low-voltage
therapeutic communication Communication electrical current to the skin through cutaneous electrodes
that is purposeful and goal directed, creating a beneficial transducer Instrument that converts electrical energy
outcome for the client to sound waves
therapeutic massage Application of hand pressure transduction Noxious stimulus that triggers
and motion to improve the recipient’s well-being electrical activity in the endings of afferent nerve fibers
therapeutic procedure accident Accident (nociceptors)
that occurs during the delivery of medical or nursing transmission Process whereby the pain impulse
interventions travels from the receiving nociceptors to the spinal cord
therapeutic touch Technique of assessing Transmission-based Precautions Practices
alterations in a person’s energy fields and using the hands designed for clients documented as, or suspected of, being
to direct energy to achieve a balanced state infected with highly transmissible or epidemiologically
thermogenesis Production of heat important pathogens for which additional precautions
thermoregulation Maintenance of body beyond Standard Precautions are required to interrupt
temperature transmission in hospitals
thoracentesis Aspiration of fluid from the pleural trauma Wound or injury
cavity traumatic imagery Imagining the feelings of
thrombocytopenia Decrease in the number of horror felt by the victim or reliving the horror of the
platelets in the blood incident
thrombophlebitis Formation of a clot due to an triage Classification of clients to determine priority of
inflammation in the wall of the vessel need and proper place of treatment
thrombosis Formation of a clot due to an triglyceride Lipid compound consisting of three fatty
inflammation in the wall of the vessel acids and a glycerol molecule

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G-28 GLOSSARY

trocar Sharply pointed surgical instrument contained V

in a cannula
Trousseau’s sign Carpal spasm caused by inflating a value system Individual’s collection of inner beliefs
blood pressure cuff above the client’s systolic pressure and that guides the way the person acts and helps determine
leaving it in place for 3 minutes the choices the person makes
trust Ability to rely on an individual’s character and values Influences on the development of beliefs and
ability attitudes rather than behaviors; a principle, standard, or
tumor marker Substance found in the serum that quality considered worthwhile or desirable
indicates the possible presence of malignancy values clarification Process of analyzing one’s own
turgor Normal resiliency of the skin values to better understand those things that are truly
type and cross-match Laboratory test that important
identifies the client’s blood type (e.g., A or B) and variable deceleration Reduction in fetal heart rate
determines the compatibility of the blood between that has no relationship to contractions of the uterus
potential donor and recipient vasectomy Surgical resection of the vas deferens
venipuncture Puncturing of a vein with a needle to
U aspirate blood
ventilation Movement of gases into and out of the
ultrasound Use of high-frequency sound waves to lungs
visualize deep body structures; also called an echogram or veracity Ethical principle based on truthfulness
sonogram (neither lying nor deceiving others)
umbilical cord Structure that connects the fetus to verbal communication Using words, either
the placenta spoken or written, to send a message
uncomplicated grief Grief reaction normally verbally aggressive Descriptor of an individual
following a significant loss who says things in a loud and/or intimidating manner
unilateral neglect Failure to recognize or care for vernix caseosa White, creamy substance covering a
one side of the body fetus’s body
unit dose form System of packaging and labeling vertigo Dizziness
each dose of medication by the pharmacy, usually for a vesicant Agent that may produce blisters and tissue
24-hour period necrosis
urethrocele Downward displacement of the urethra vesicular sound Soft, breezy, low-pitched sound
into the vagina heard longer on inspiration than expiration resulting from
urethrostomy Formation of a permanent fistula air moving through the smaller airways over the lung
opening into the urethra periphery, with the exception of the scapular area
urge incontinence Inability to suppress the sudden villi Finger-like projections that line the small intestine
urge or need to urinate viral load test Test that measures copies of HIV RNA
urgent care center A facility designed for the visceral pain Discomfort felt in the internal organs
effective and efficient treatment of acute illnesses and visual hallucination Perception by an individual
injuries; clients do not require an appointment, do not see that something is present when nothing in fact is
the same provider consistently, and are usually seen in the visual learner Person who learns by processing
order of arrival or the order of acuity information through seeing
urobilinogen Colorless derivative of bilirubin formed vitamin Organic compounds essential to life and
by the normal bacterial action of intestinal flora on health
bilirubin vitiligo Depigmentation of the skin caused by
urticaria Allergic reaction causing raised pruritic, red, destruction of melanocytes; appears as milk-white patches
nontender wheals on the skin; also called hives on the skin
uterine retraction Unique ability of the muscle void Process of urine elimination
fibers of the uterus to remain shortened to a small degree volvulus Twisting of a bowel on itself
after each contraction
uterine souffle Sound of blood pulsating through
the uterus and placenta
W
utility Ethical principle that states that an act must water-soluble vitamin Vitamin that must be
result in the greatest positive benefit for the greatest ingested daily in normal quantities because it is not stored
number of people involved in the body: vitamins C and B-complex

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 GLOSSARY G-29

wellness State of optimal health wherein an individual word salad Nonsensical combination of words that
maximizes human potential, moves toward integration of is meaningless to others
human functioning, has greater self-awareness and self- wound Disruption in the integrity of body tissue
satisfaction, and takes responsibility for health
Western blot test Confirmatory test used to detect
HIV infection Y
Wharton’s jelly Thick substance surrounding and
yin and yang Opposing forces that yield health
protecting the vessels of the umbilical cord
when in balance
whistleblowing Calling public attention to
young adulthood Development from the ages of
unethical, illegal, or incompetent actions of others
21 years through approximately 40 years
windowing Cutting a hole in a plaster cast to
relieve pressure on the skin or a bony area and to permit
visualization of the underlying body part
witch’s milk A whitish fluid secreted by a newborn’s
Z
nipples zoonotic disease A disease of animals that is
withdrawal Symptoms produced when a substance directly transmissible to humans from the primary animal
on which an individual has dependence is no longer used host
by that individual zygote Fertilized ovum

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Copyright 2010 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
 INDEX
Page numbers followed by “f” denote figures, “t” denote tables, and “b” denote boxes.

A acquired cystic kidney disease (ACKD), 259

acquired hemolytic anemia, 171
Acute Pain (nursing diagnosis)
angina, 140b
AA (Alcoholics Anonymous), 624, 625t acquired immunodeficiency syndrome (AIDS) appendicitis, 208b
ABCs (Airway, Breathing, and Circulation), 700 See also human immunodeficiency virus (HIV) breast cancer, 455b
abdominal aortic aneurysms, 147 defined, 564 burns, 518b
abdominal binders, 35, 37f demographics of in United States, 565–566 carpal tunnel syndrome, 301b
abdominal distention, postoperative, 32 management of, 566–567 cholecystitis/cholelithiasis, 229b
abdominal emergencies, 706–707 modes of transmission, 565–566 diverticulitis, 212b
abdominal hernias, 218 overview, 489–490, 564–565 diverticulosis/diverticulitis, 211b
abducens (VI) nerve, 310t race/ethnicity, 565, 566f endometriosis, 438
ABGs (arterial blood gases), 78t, 80 acrocyanosis, 74t fibroid tumors, 445b
abnormal posturing, 314t acromegaly, 405–406, 406b gastritis, 205b
abortion, spontaneous, 473 ACS (American Cancer Society), 45 glaucoma, 376–377b
abortive therapy, for migraines, 351 ACTH (adrenocorticotrophic hormone), 390t hemophilia, 184b
absolute fracture risk, 290 Activase (alteplase recombinant), 95 hemorrhoids, 220b
abstinence, 474t, 482 activated partial thromboplastin time (APTT), 153 hernia, 218b
abuse active drainage devices, 28t hyperparathyroidism, 420b
caring for the abused client, 611b actively suicidal, 595–596 intestinal obstruction, 217b
defined, 610 activities of daily living (ADLs) lung cancer, 63b
domestic violence, 611 bathing, 650 male inflammatory disorders, 441b
elder, 610–611, 611f defined, 650 menstrual disorders, 466
interviewing survivors of, 612b dressing, 651 musculoskeletal emergencies, 710b
nursing diagnoses, 613b eating, 651 musculoskeletal trauma, 288b
physical, possible signs of, 508b grooming, 651 myocardial infarction, 142b
rape, 612–613 hygiene, 651 osteomyelitis, 290b
substance, 618 mobility, 650 otitis media, 373b
teen dating violence, 610b safety measures, 650b pancreatitis, 228b
AC (hydrogen cyanide), 719 toileting, 651–652 pelvic inflammatory disease, 435b
acceleration/deceleration injuries, 333f Activity Intolerance (nursing diagnosis) peritonitis, 220b
accessory organs See also Risk for Activity Intolerance pleural effusion, 92b
anatomy and physiology of, 198 abdominal emergency, 707b pneumothorax, 110b
disorders of decreased erythrocytes and hemoglobin, pulmonary embolism, 96b
cholecystitis, 228–229 173b Raynaud’s disease, 157b
cholelithiasis, 228–229 hyperparathyroidism, 420b sickle cell anemia, 174b
cirrhosis, 221–224 Ménière’s disease, 369b skin infection, 524b
hepatitis, 224–227 myxedema, 417b skin wounds, 510
pancreatitis, 227–228 pneumonia, 82b stomatitis, 200b
ACE (angiotensin converting enzymes) inhibitors, postoperative nursing care, 31 thrombocytopenia, 185b
143 acute glomerulonephritis, 248–250, 249–250b transurethral resection of prostate,
acid-fast bacilli (AFB), 83 acute hemolytic reactions, 551 447b
ACKD (acquired cystic kidney disease), 259 acute leukemia, 177–178 ulcers, 207b
acoustic (VIII) nerve, 310t acute lymphocytic leukemia (ALL), 177, 178b urolithiasis, 254b
acoustic neuroma, 371–372, 371–372b acute myelogenous leukemia (AML), 177, 178b venous thrombosis, 154b
acquired (adaptive) immunity, 546, 546t acute myocarditis, 133 acute radiation syndrome (ARS), 719
I-1

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I-2 INDEX

acute renal failure (ARF) AIDS. See acquired immunodeficiency syndrome amphetamine sulfate (Adderall), 608t
intrarenal, 259–260 (AIDS); human immunodeficiency virus amphetamines, 628–629
management of, 260–261 (HIV) amphiarthrosis, 278
nursing process, 261 AIDS dementia complex (ADC), 573 amputations, 295–299
postrenal, 259 air-filled mattresses, 537 amylase, 198
prerenal, 259 airway amyotrophic lateral sclerosis (ALS, Lou Gehrig’s
acute respiratory distress syndrome (ARDS), 98–99, See also Ineffective Airway Clearance disease), 344–345
99b anatomy and physiology of, 71–73 anabolic steroids, 635–636
acute respiratory failure, 99 general anesthesia, 8 anagrelide (Agrylin), 176
acute respiratory tract disorders Airway, Breathing, and Circulation (ABCs), 700 analgesia
acute respiratory distress syndrome, 98–99 alanine aminotransferase (ALT), 19 defined, 3
acute respiratory failure, 99 alcohol patient-controlled, 10
atelectasis, 92–94 associated problems/disorders, 622–623 regional, 10–11
pulmonary edema, 96–98 incidence of, 621–622 anaphylactic reactions, 550–552
pulmonary embolism, 94–96 interaction with other drugs, 624–625t anaphylactic shock, 701, 702t
acute tubular necrosis (ATN), 259 level of in beverages, 622f, 622t anaphylaxis, 550, 552b
AD. See Alzheimer’s disease (AD) potential for addiction, 622 androgen (sex hormones), 390t
adaptive (acquired) immunity, 546, 546t signs and symptoms of, 622 anemia
ADC (AIDS dementia complex), 573 surgery and, 19 acquired hemolytic, 171
Adderall (amphetamine sulfate), 608t treatment/rehabilitation, 623–624 aplastic, 169–170
Addison’s disease (adrenal hypofunction), 423–425, withdrawal from, 623, 623f iron deficiency, 168–169
424b alcohol withdrawal syndrome (AWS), 623 pernicious, 170–171
adenocarcinoma, 110f alcoholic hepatitis, 622 sickle cell, 171–175
ADH (antidiuretic hormone), 390t Alcoholics Anonymous (AA), 624, 625t anesthesia, 2–14
ADHD. See Attention-Deficit/Hyperactivity Aldactone (spironolactone), 222 general
Disorder (ADHD) Aldrete Score (Postanesthetic Recovery Score), 27 airway management, 8
adhesions, 216 alemtuxumab (Campath), 179 emergence from, 9
adjuncts to anesthesia, 6t alimentary system. See gastrointestinal system induction of, 8
ADLs. See activities of daily living (ADLs) alkylating agents, 53t, 179 maintenance of, 8–9
adrenal (suprarenal) glands, 389, 392t ALL (acute lymphocytic leukemia), 177, 178b recovery from, 9–10
adrenal cortex, hormones of, 390t alleged sexual assault, 707 overview, 3
adrenal disorders allergens, 547 postoperative pain management, 10–11
Addison’s disease, 423–425 allergic response, 547f preparation for, 3–4
Cushing’s disease syndrome, 422–423 allergic urticarial reactions, 551 regional
pheochromocytoma, 425–426 allergies residual effects of, 7–8
adrenal hyperfunction (Cushing’s disease colds versus, 549f types of, 5–7
syndrome), 422–423, 422–423b to foods, 548b sedation, 5
adrenal hypofunction (Addison’s disease), 423–425, to iodine, 22b anesthesiologists, 3
424b to latex, 22b, 554, 554b anesthetists, 3
adrenal medulla, hormones of, 391t nursing diagnosis, 549–550f aneurysms
adrenaline (epinephrine), 391t overview, 547–550 aortoiliac, 147f
adrenocorticotrophic hormone (ACTH), 390t preparation for surgery, 22 defined, 146
adult day care, 688 severe, 550b microaneurysms, 403f
advance directives, 344 allogeneic blood products, 551 nursing diagnoses, 148b
adventitious breath sounds, 75, 77t allopurinol (Zyloprim), 176 overview, 146–148
AFB (acid-fast bacilli), 83 alopecia, 57, 539 anger-control assistance, 594
affect, 312, 361, 604 alpha blockers, 157 angina, 132b, 140b
afferent nerve pathways, 360 alpha globulins, 164 angina pectoris, 137–140
afterload, 122 alpha-glucosidase inhibitors, 398t angioedema, 547
age ALS (amyotrophic lateral sclerosis, Lou Gehrig’s angiogenesis, 508
See also older adults disease), 344–345 angiomas, 521
Attention-Deficit/Hyperactivity Disorder, 608b ALT (alanine aminotransferase), 19 angiotensin, 148
exfoliative dermatitis, 530b alteplase recombinant (Activase), 95 angiotensin converting enzymes (ACE) inhibitors,
HIV/AIDS, 565, 565b alveolar capillary membrane, 72 143
nicotine, 631b alveoli, 72 animal bites, 711b
preoperative assessment, 17–18 Alzheimer’s disease (AD) Ann Arbor Staging System, 186–187t
age-appropriate care, 680 older adults, 662–663 annulus, 135
ageism, 648 overview, 345–348 anorexia, 55
Agency for Health Care Policy and Research sample nursing care plan, 665–667b anosognosia, 324
(AHCPR), 56 stages of, 346b anoxia, 74t
agglutinogens, 165 “A.M. admit” clients, 38 ANS. See autonomic nervous system (ANS)
aging. See age; older adults amantadine hydrochloride (Symmetrel), 337 Antabuse (disulfiram), 624, 626
agnosia, 324 ambulatory care, 679, 679–680, 680f antacids, 205t
agonist-antagonists, 633t ambulatory surgery, 37–39, 37b anthrax, 719–720
agranulocytes (nongranular leukocytes), 164f, 165, amenorrhea, 437, 465 antianxiety agents, 586, 587t, 625t
544, 545f American Cancer Society (ACS), 45 antibiotics
agranulocytosis, 180–181, 412 aminophylline (Aminophyllin), 99 chemotherapy, 53t
Agrylin (anagrelide), 176 amitriptyline hydrochloride (Elavil), 591t ulcers and gastritis, 205t
AHCPR (Agency for Health Care Policy and AML (acute myelogenous leukemia), 177, 178b antibodies (immunoglobulins), 545
Research), 56 amnesia, 5 anticancer agents, 52

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 INDEX I-3

anticholinergics male inflammatory disorders, 441b atrophy, skin, 506f

asthma, 100 otosclerosis, 370b atropine, 4
Parkinson’s disease, 337 penile cancer, 464b Attention-Deficit/Hyperactivity Disorder (ADHD)
Anticipatory Grieving (nursing diagnosis) pressure ulcers, 539b age, 608b
acoustic neuroma, 371–372b pyelonephritis, 247b combined type, 608
cancer, 60t refractive errors, 380b management of, 608–610
lung cancer, 112b retinal detachment, 378b nursing diagnoses, 610b
renal tumors, 258b sexually transmitted infections, 492b overview, 607
shock, 703b venous thrombosis, 154b predominantly hyperactive-impulsive type, 608
anticoagulants anxiolytics, 586 predominantly inattentive type, 608
anesthesia and, 4 aortic insufficiency, 135t audiologists, 366b
interaction with alcohol, 624t aortic stenosis, 135t auditory hallucinations, 601
overview, 95b aortoiliac aneurysm, 147f auras, 327
thrombus/phlebitis, 153 aphasia, 312 auricle (pinna), 362
anticonvulsants, 327, 605t, 606b apheresis, 185 auscultation, 74–75
antidepressants, 590, 590t, 592b, 625t aplastic anemia, 169–170 autograft, 514–515
antidiarrheal medications, 58 apnea, 74t autoimmune disorders/diseases
antidiuretic hormone (ADH), 390t appendectomies, 207 defined, 545
antiembolism stockings, 31–32 appendicitis, 207–208 myasthenia gravis, 560–564
antiemetics, 55t, 187 appliances, for ostomy management, 210 rheumatoid arthritis, 554–558
antigens, 545 alprazolam (Xanax), 587t systemic lupus erythematosus, 558–560
antihistamines, interaction with alcohol, 625t APTT (activated partial thromboplastin time), 153 autologous blood transfusions, 166, 551
antihormonal agents, 53t aqueous humor, 363 automatisms, 327
antihypertensives arachnoid mater, 306 autonomic dysreflexia, 331
acute renal failure, 260t ARDS (acute respiratory distress syndrome), 98–99, Autonomic Dysreflexia (nursing diagnosis), 335b
chronic renal failure, 265 99b autonomic hyperreflexia, 331
interaction with alcohol, 624t areflexia, 331 autonomic nervous system (ANS)
antimanics, 605t ARF. See acute renal failure (ARF) anatomy and physiology of, 308
antimetabolites, 53t arousal, 360–361 defined, 306
antimicrobial soap, 25 ARS (acute radiation syndrome), 719 autonomic neuropathy, 402
antimicrobials, interaction with alcohol, 624t arterial blood gases (ABGs), 78t, 80 autosomal, 407
antineoplastics, 52, 189 arteries, 121–123 AV blocks. See atrioventricular (AV) blocks
antioxidants, foods high in, 338b arteriolar sclerosis, 137 awareness, 309, 361
antipsychotics, 601, 602b, 602t, 603b, 625t arterioles, 122–123 AWS (alcohol withdrawal syndrome), 623
antitachycardia pacing (ATP), 130 arteriosclerosis, 137, 148 axial loading, 333f
anuria, 241t arthroplasty, 293 azotemia, 222, 259
anus, 198 ascending colostomy, 209f
anvil (incus), 362 ascites
anxiety clients with cancer, 58 B
defined, 585 defined, 124, 218
depression, 588–589 asepsis, 24–25 Babinski reflex, 315f
Generalized Anxiety Disorder, 585 aseptic technique, 23 Bacillus anthracis, 719
management of, 586–588 aspartate aminotransferase (AST), 19 bacillus Calmette-Guerin (BCG), 86, 255
mild, 585 aspiration. See Risk for Aspiration bacterial pneumonia, 80
moderate, 585 assisted living, 688 balance, 313
nursing diagnoses, 588b assistive devices, for dressing, 651f Balanced Budget Act (BBA) (1997), 672
Obsessive-Compulsive Disorder, 586 AST (aspartate aminotransferase), 19 balloon tamponade, 202
panic, 585 asthma balloon-tipped catheters, 138f
Panic Disorder, 585–586 nursing diagnoses, 101b bandages, 35, 36f
Post-Traumatic Stress Disorder, 586 overview, 100–101 bands, 165
reducing preoperatively, 20–21 signs and symptoms of, 107t bariatric surgery, 233f
severe, 585 astigmatism, 379 barriers, 476
Anxiety (nursing diagnosis) asymptomatic, 482 Barthel Index, 685
acute renal failure, 262b asystole, 130f basal-cell carcinoma, 519, 519f
acute respiratory distress syndrome, 99b atelectasis baseline level, 153
angina, 132b, 140b defined, 90 basilar fractures, 317
anxiety, 588b nursing diagnoses, 94b basophils, 164f, 544, 545f
asthma, 101b overview, 92–94, 93f bathing older adults, 650
brain tumor, 322b atherosclerosis, 137 Bathing Self-care Deficit (nursing diagnosis). See
cardiac valvular disorders, 136b Ativan (lorazepam), 587t Self-care Deficit (nursing diagnoses)
cervical cancer, 457b ATN (acute tubular necrosis), 259 BBA (Balanced Budget Act) (1997), 672
chronic glomerulonephritis, 251b atomoxetine hydrochloride (Strattera), 608t B-cells (B-lymphocytes), 545, 545f
diverticulosis/diverticulitis, 211b atonic impotence, 471 BCG (bacillus Calmette-Guerin), 86, 255
endometriosis, 438 ATP (antitachycardia pacing), 130 Beau’s lines, 507f
esophageal varices, 204b atrial dysrhythmias, 128–129 behavioral tolerance, 622
fibrocystic breast changes, 444b atrial fibrillation, 128–129, 141 Bellevue Bridge, 440f
genital herpes, 493b atrial flutter, 128, 128t benign papillomas, 254
Hodgkin’s disease/non-Hodgkin’s lymphoma, atrial tachycardia, 128 benign prostatic hyperplasia (BPH), 445–448
188b atrioventricular (AV) blocks, 130–131 benign prostatic hypertrophy (BPH), 242
hypertension, 152b atrioventricular (AV) node, 121–122 benzodiazepines, 626

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I-4 INDEX

beta agonists, 100 bradypnea, 74t calcitonin (Fortical, Miacalcin), 291, 390t
beta blockers, 143 brain calcium channel blockers, 156–157
beta globulins, 164 anatomy and physiology of, 306, 307f calculi, 228, 242
beta-adrenergic blocking agents, 149 injuries to callus ossification, 284
bifurcated synthetic graft, 147f closed injury, 317–319 Campath (alemtuxumab), 179
biguanides, 398t management of, 319–320 cancellous bone, 278
bile, 198f open injury, 317 cancer
bilirubin, 19 overview, 318f See also oncology
binaural hearing aids, 366 brain tumor, 321–322, 322b breast
binders, 35, 37f breast cancer nursing diagnoses, 452–453b
biologic response modifiers (BRMs), 54 nursing diagnoses, 452–453b overview, 448–455
biological agents, isolation guidelines for, 721t overview, 448–455 risk factors for, 47t
biological replacement valves, 136 risk factors for, 47t sample nursing care plan, 453–455b
bioterrorism, 719–720 sample nursing care plan, 453–455b screening guidelines, 49t
biotherapy, for cancer, 54 screening guidelines, 49t staging of, 450f
Biot’s respirations, 74t staging of, 450f cervical
Bipolar Disorder, 604–607, 607b breast self-examination (BSE), 442, 443f nursing diagnoses, 457b
birthmarks (nevi), 501 breasts overview, 455–457
bismuth compounds, 205t anatomy of, 431 risk factors for, 47t
bladder characteristics of common breast masses, 442f screening guidelines, 49t
anatomy of, 240f cross section of, 431f staging of, 456f
management, 659f, 660t quadrants of, 449f colorectal
blanching, 533 breath sounds overview, 231–232
blanket continuous skin closure method, 35f adventitious, 75 risk factors for, 47t
blastic phase, 178 location of, 76f screening guidelines, 49t
blindness, defined, 381 normal, 74–75 defined, 45
blood breathing. See Ineffective Breathing Pattern diet, 46b
anatomy and physiology of brief dynamic therapy, 590 endometrial
blood transfusions, 166 BRMs (biologic response modifiers), 54 overview, 457–458
blood types, 165–166 bronchi, 72 screening guidelines, 49t
plasma, 164 bronchial circulation, 71 esophageal, 47t
platelets, 165 bronchial sounds, 74 laryngeal, 112–113
red blood cells, 164–165 bronchial tree, 72 liver, 232–234
Rh factor, 166 bronchiectasis, 106–108, 107t lung
white blood cells, 165 bronchioles, 72 nursing diagnoses, 111–112b
circulation of, 121 bronchitis, 102 overview, 110–112
effects of chronic renal failure on, 264t bronchodilators, 93, 100, 102 risk factors for, 47t
transfusion reactions, 551 bronchovesicular sounds, 75 sample nursing care plan, 61–63b
blood pressure (BP) bruises (ecchymosis), 504t, 507f nicotine, 631
classification of, 149t bruxism, 299 nursing diagnoses, 60–61t
recovery from general anesthesia, 9 BSE (breast self-examination), 442, 443f oral, 230–231
blood transfusions Buck’s traction, 286f ovarian
autologous, 166, 551 Buerger-Allen exercises, 156 nursing diagnoses, 459–460b
overview, 166 Buerger’s disease (thromboangiitis obliterans), overview, 458–460
transfusion reactions, 551, 552b 155–156 penile
blood urea nitrogen (BUN), 19 bullae, 505f nursing diagnoses, 464–465b
B-lymphocytes (B-cells), 545, 545f BUN (blood urea nitrogen), 19 overview, 464–465
BMD (bone mineral density), 290 Burn Wheel, 513–514, 513f prostate
BMT (bone marrow transplantation), 54, 170 burns nursing diagnoses, 462b
body images. See Disturbed Body Image causes of, 512 overview, 461–462
body mass index (BMI), 232 complications of, 514 risk factors for, 47t, 461b
bone marrow dysfunction, 55 elderly, 516 screening guidelines, 49t
bone marrow transplantation (BMT), 54, 170 management of, 514–516, 711 skin
bone mineral density (BMD), 290 nursing diagnoses, 517–519b older adults, 671
bone repair, 284f self-image, 515 risk factors for, 47t
Boniva (ibandronate), 291 severity of, 512–513 stomach, 47t
Borrelia burgdorferi, 301 skin layers involved in, 512f testicular
botulism, 720 bursitis, 289 nursing diagnoses, 463–464b
bowel dysfunctions, in clients with cancer, 57–58 buspirone hydrochloride (BuSpar), 587t overview, 462–464
Bowel Incontinence (nursing diagnosis) butterfly rash, 559, 559f risk factors for, 47t
ovarian cancer, 460b thyroid, 418
prostate cancer, 462b Candida albicans, 244
BP. See blood pressure (BP) C candidiasis (monilia), 438
BPH (benign prostatic hyperplasia), 445–448 canes, 286–287
BPH (benign prostatic hypertrophy), 242 CABG (coronary artery bypass graft) surgery, 138, cannabis. See marijuana (cannabis)
brachytherapy, 451, 452f 139f Capastat Sulfate (capreomycin sulfate), 85
Braden Scale for Predicting Pressure Sore Risk, 534, cachectic, 258 CAPD (continuous ambulatory peritoneal dialysis),
535–536t cachexia, 55 269
bradycardias, 127, 141 caffeine, 629, 630t capillaries, 123
bradykinesia, 336 caged-ball valve, 136 capnography, 5

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 INDEX I-5

capreomycin sulfate (Capastat Sulfate), 85 peripheral vascular disease, 657 level of consciousness, 309, 311
carbamazepine (Tegretol), 605t physiologic changes, 39t mental status, 311
carbon monoxide poisoning, 514 overview, 120 overview, 308
carbuncles, 522t peripheral vascular disorders pupil reaction, 312
carcinogens, 46 aneurysm, 146–148 cerebrospinal fluid (CSF), 306–307
carcinomas Buerger’s disease, 155–156 cerebrovascular accident (CVA), 322–326
breast, 442f hypertension, 148–152 certified registered nurse anesthetists (CRNAs), 3
defined, 46 Raynaud’s disease/phenomenon, 156–158 cerumen, 362
cardiac biomarkers, 126t varicose veins, 155 cervical cancer
cardiac cycle, 122 venous thrombosis/thrombophlebitis, nursing diagnoses, 457b
cardiac output (CO), 121 152–154 overview, 455–457
cardiac resynchronization therapy (CRT), sympathetic and parasympathetic systems, 311t risk factors for, 47t
130–131 cardioversion, 129 screening guidelines, 49t
cardiac sphincter, 197 carpal tunnel syndrome, 300–301 staging of, 456f
cardiac tamponade cartilage, 292b cervical caps, 475t
clients with cancer, 59 caseation, 83 cervical intraepithelial neoplasia (CIN), 572–573
defined, 133 casts, 285 cervix, anatomy of, 432
cardiac transplantation, 146 cataracts, 374–375, 374f, 375b, 663, 663f CF (cystic fibrosis), 108b
cardiac troponin I, 141 CAUTION acronym, 48b CG (phosgene), 719
cardiac valvular disorders, 136b cavitation, 83 chain of custody, 708b
cardiogenic shock, 701, 702t CCNS (cell-cycle nonspecific), 52 chalazion, 378–379, 379f
cardiotonics, 260t CCS (cell-cycle specific), 52 chancre, 486
cardiovascular system, 119–162 CDC (Centers for Disease Control), 489, 489f chemical burns, of eye, 380
alcohol and, 622 cecum, 198 chemical pneumonia, 80
anatomy and physiology of cell-cycle nonspecific (CCNS), 52 chemical terrorism, 719
arterioles and arteries, 122–123 cell-cycle specific (CCS), 52 chemoreceptors, 72–73
capillaries, 123 Centers for Disease Control (CDC), 489, 489f chemotherapy
cardiac output, 121 Centers for Medicare and Medicaid Services cancer, 52–54
circulation of blood, 121 (CMS), 3 defined, 49
conduction system, 121–122 central nervous system (CNS) drugs commonly used in, 53t
coronary arteries, 121 anatomy of, 307f Hodgkin’s Disease, 187
heart, 120–121 brain, 306 home care following, 52b
stroke volume, 121 cerebrospinal fluid, 306–307 non-Hodgkin’s lymphoma, 188
venules and veins, 123 deficits and illness of, 360b oral cancer, 230
assessment of defined, 306 chest cage, 71
health history, 123 opportunistic infections, 573–574 chest trauma, 108–110
overview, 123–125 overview, 360 chest tube, 91b
preoperative, 18 sedation and, 5 Cheyne-Stokes respirations, 74t
cardiac rhythm/dysrhythmia spinal cord, 306 chlamydia, 482–484, 483t, 485b
atrial dysrhythmias, 128–129 central nervous system (CNS) depressants chlorine (CL), 719
atrioventricular blocks, 130 alcohol chloropicrin (PS), 719
bradycardia, 127 associated problems/disorders, 622–623 chlorpromazine (Thorazine), 602t
dysrhythmias, 127 incidence of, 621–622 Cholac (lactulose), 222
normal sinus rhythm, 125–127 potential for addiction, 622 cholecystitis, 228–229
tachycardia, 127–128 signs and symptoms of, 622 cholelithiasis, 228–229
ventricular dysrhythmias, 129–130 treatment/rehabilitation, 623 chordae tendineae, 120
cardiac transplantation, 146 withdrawal from, 623 chorea, 353
cor pulmonale, 146 marijuana, 626–627 choroid, 363
diabetes mellitus, 403 sedative-hypnotics, 626 chromaffin cell tumor (pheochromocytoma),
diagnostic tests, 125 central nervous system (CNS) stimulates 425–426, 425b
effects of chronic renal failure on, 264t amphetamines, 628–629 chronic bronchitis
emergency response, 703–704 Attention-Deficit/Hyperactivity Disorder, nursing diagnoses, 103b
inflammatory disorders 608–609, 608t, 609b overview, 102–103
infective endocarditis, 132–133 caffeine, 629 signs and symptoms of, 107t
mitral valve prolapse, 134–137 cocaine, 627–628 chronic congestive heart failure, 657
myocarditis, 133 interaction with alcohol, 624t chronic glomerulonephritis, 250–251, 251b
pericarditis, 133–134 methylphenidate hydrochloride, 631 chronic leukemia, 178–179
rheumatic heart disease, 132 nicotine chronic lymphocytic leukemia (CLL), 177,
stenosis and insufficiency, 134 associated problems/disorders, 631 178b
valvular heart diseases, 134 incidence of, 629 chronic myelogenous leukemia (CML), 177, 178b
nicotine, 631 potential for addiction, 631 chronic obstructive lung disease (COLD), 102
occlusive disorders signs and symptoms of, 629, 631 chronic obstructive pulmonary disease (COPD),
angina pectoris, 137–140 treatment/rehabilitation, 631 102, 655–656, 656b
arteriosclerosis, 137 withdrawal from, 631 Chronic Pain (nursing diagnosis)
heart failure, 143–146 cephalalgia, 350 herniated intervertebral disk, 331b
myocardial infarction, 140–142 cerebral edema, 319 lung cancer, 112b
older adults cerebral function multiple myeloma, 190b
chronic congestive heart failure, 657 communication, 312–313 osteoarthritis, 293
hypertension, 657 emotional status, 312 osteoporosis, 291b
overview, 656–657 intellectual function, 311–312 ovarian cancer, 459b

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I-6 INDEX

Chronic Pain (Continued) overview, 231–232 cortisol, 390t

rheumatoid arthritis, 557b risk factors for, 47t cosmetic surgery, 16t
venous ulcers, 533b screening guidelines, 49t Coumadin. See warfarin sodium (Coumadin)
chronic renal failure colostomy, 209 coup/contrecoup, 318f
case study, 727–728 combined type ADHD, 608 C-Port Flex-A System, 138
diabetes, 402–403 command hallucinations, 601 CR (cyanogen chloride), 719
dialysis comminuted fractures, 283, 317 cranial nerves, 307, 310–311t, 313
hemodialysis, 267–268 communication, 312–313 cranium, 306
overview, 266 compartment syndrome, 288 creatinine, 19
peritoneal dialysis, 268 compound fracture, 283 crepitus, 279
kidney transplantation, 269–270 Comprehensive Drug Abuse Prevention and cretinism, 416
overview, 263–266 Control Act (1970), 618 cricoid cartilage, 72
chronic respiratory tract disorders compression fractures, 283 crisis, 584, 584–585
asthma, 100–101 concussion, 318f CRNAs (certified registered nurse anesthetists), 3
bronchiectasis, 106–108 condoms, 475t, 485b Crohn’s disease, 213t
chronic bronchitis, 102–103 conduction system, 121–122 cross-tolerance, 626
chronic obstructive pulmonary disease, 102 conductive hearing loss, 366 CRRT (continuous renal replacement therapy), 268
emphysema, 104–106 confabulation, 622 CRT (cardiac resynchronization therapy), 130–131
overview, 99