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2nd Edition

MedSurg
Notes Nurse’s Clinical Pocket Guide

Tracey Hopkins, BSN, RN

Ehren Myers, RN

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1
Legal Issues in MedSurg Care
Legal issues affect all aspects of nursing care. Urgent care situations, in
which the patient’s life may be lost or potential quality of life compromised,
require even more vigilant attention to nursing standards of care and best
practices.
The nurse practice law of each state defines the scope of nursing
practice for that state.
Advanced practice nurses, such as nurse midwives, nurse anesthetists, and
clinical nurse specialists, function under a broader scope of practice.
■ Know your state’s nurse practice law; contact your state board of nursing
for a copy.
■ Know your state’s requirements for licensure, and maintain your nursing
license as required.
■ Keep informed of local, state, and national nursing issues; get involved as
a lobbyist in your state; contact your state representatives regarding
issues that affect nursing practice.
■ Know if and how a nursing union could affect your practice.
Nurses have a duty of care of careful and continuous monitoring
of the patient’s status.
Nurses assess and directly intervene on patients more than any other health-
care professionals.
■ Monitor each patient’s vital signs, neurological status, intake and output,
status per physician order, nursing care plan, hospital policy and
procedure; increase frequency of vital signs if indicated, and notify the
physician.
■ Evaluate family members’ concerns as soon as possible; the family often
detects subtle changes in a patient’s status.
Nurses have a duty to communicate the patient’s status to the
medical staff, particularly on an immediate/STAT basis when the
patient’s status warrants.
The nurse is usually the first team member to detect an urgent care situation
and has an obligation to report any changes in patient condition to the
medical staff for timely intervention.
■ Notify the physician as soon as you detect any change in the patient’s
condition that indicates deterioration in status. Document assessment,
time of call to physician, and nursing interventions and patient’s response.
■ Use the hospital’s chain of command if the physician fails to respond
within minutes. Notify the nursing supervisor if the physician does not
respond immediately.
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■ The nurse must maintain accurate nursing notes, flow sheets, medical
Kardexes, and nursing care plans that record the patient’s symptoms, time
symptoms were present, time physician was notified, and time physician
arrived. The medical chart should be a factual record of the patient’s
medical treatment, responses thereto, vital signs, and all nursing
interventions.
Nurses have a duty to administer medications safely at all times,
including urgent care situations.
Medication errors are the most common source of nursing negligence.
Procedural safeguards should be followed to prevent medication errors. The
“five rights” of medication administration are minimum practice standards.
■ Give the right drug in the right dose to the right patient by the right route
at the right time.
■ Document the five rights—which medication, to whom, in what dose,
through which route, and at what time.
■ Document fully any suspected adverse drug reaction, time and nature
of the reaction, time physician notified, interventions taken, and patient’s
response.
■ Nurses have a duty to know about all the drugs they administer: drug
names, drug categories, dosage, timing, technique of administration,
expected therapeutic response, duration of drug use, and procedures to
minimize the incidence or severity of adverse drug effects.
Nurses have a duty to maintain safe patient care conditions.
This is akin to the nurse’s duty to advocate for the patient at all times.
■ Report an unsafe staffing condition to the nursing supervisor as soon as
it is apparent. The nurse-patient ratio in intensive care settings should not
exceed 1:2; on general floors, 1:6.
■ Working beyond a 12-hour shift can create a substantial decline in
performance.
■ Know the nurse practice limitations on nurses under your supervision;
licensed practical nurses and student nurses cannot perform all the
actions of the registered nurse.
Nurses have a duty to keep the patient safe from self-harm.
The nurse must be vigilant regarding any changes in the patient’s sensorium/
mental status. Any patient can experience a psychiatric crisis from a myriad
of causes, including hypoxia, drug reaction, drug withdrawal, ICU psychosis,
or underlying organic disease.
■ Assess the patient’s mental status with each nursing intervention; note
subtle changes, and notify the physician.
■ Signs of impending psychiatric crisis include changes in orientation to
person, place, and time; verbal abusiveness; restlessness; increased
anxiety; and agitation.

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■ If a patient is at risk of self-harm and/or of harming others, restraints can
be applied.
■ Most states require a written physician order before restraining the
patient, except in an emergency. The physician must be notified
immediately of the use of restraints.
■ If restraints are applied, the patient must be monitored closely for changes
in medical condition and mental status, for maintenance of adequate circu-
lation, and for prevention of positional asphyxiation. Document all assess-
ments and frequency of checks (no less frequent than every 15 minutes).
■ Know the hospital’s policy and procedure regarding use of restraints, and
follow them at all times.
Nurses have a duty to carry out physician orders as required by
state law, hospital policy and procedure, and nursing practice
standards.
Concurrently, as patient advocate, the nurse must question an order he or
she deems problematic, particularly when an urgent care situation is present
or when one could arise from fulfillment of the order.
■ Contact the physician immediately for any order that is unclear, contrary
to standard drug dosage/route/frequency of administration, or that does
not address the acuity of the patient’s medical condition; e.g., an order for
vital signs every shift for a postoperative patient recently transferred to a
general surgical floor.
■ Question an order for a patient’s discharge from the hospital when the
patient’s medical condition is not stable, when delay in treatment resulting
from discharge could injure the patient, or when the patient is going to a
potentially unsafe environment. Document interaction with the physician
and health-care team.
■ Follow written physician orders; be particularly vigilant in carrying out an
order that changes over time; e.g., tapering of medication or oxygen at
specified time intervals.
Informed consent is the process of informing the patient, not
simply completing the form with the patient’s signature.
■ Informed consent involves providing the patient with adequate medical
information so that he or she can make a reasonable decision as to
treatment based upon that information. In urgent care situations it can
be impossible to obtain a patient’s informed consent for an immediate
intervention.
■ State laws differ regarding the informed consent standards; know your
state’s informed consent law and the hospital’s policy and procedure for
obtaining informed consent.

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■ Exceptions to informed consent include an emergency in which the

patient is incompetent and cannot make an informed choice, there is not
sufficient time to obtain an authorized person’s consent, and the patient’s
medical condition is life-threatening.
■ If a patient is competent and refuses medical care, even when the
condition is life-threatening, the patient’s choice supersedes the opinion
of the health-care provider.
■ Ensure that each patient’s advance directive or living will (patient’s
advance legal permission to the physician to withhold or discontinue
treatment) is complied with and well documented in the medical chart
per state law and hospital policy and procedure. Know if the patient
has a do not resuscitate order, and ensure that it is well documented.
Nurses are held to the standard of care of the profession.
When nursing care falls below the standard of care, the care could be
deemed to be negligent or deficient if that care (or lack of care) causes the
patient some type of injury. This is the basis of a lawsuit against the health-
care professional, called medical malpractice.
■ Each nurse owes every patient the duty of “reasonable care.” This is
implicit in the standard of care defined by what nursing professionals
generally recognize on a national level as correct patient care.
■ Nationally recognized nursing textbooks, nursing journals, and nursing
treatises that nurses generally regard as authoritative define the nursing
standards of care.
■ Whether a nurse’s care of a patient met the applicable standards of
nursing care in a medical malpractice case is determined by a nursing
expert, a nurse who has the requisite experience and knowledge of the
authoritative resources.
As nursing practice, along with medical technology, continues to become
more sophisticated and complex, the standards of nursing care will likewise
increase.

Documentation Guidelines for Urgent Situations

Documentation is critical in urgent situations. It enhances decision making
and helps anyone who reads it understand what happened, how it was
handled, and what the outcomes were. It is crucial in any legal analysis of
care. Keep the following in mind as you document:
■ Always document your assessment findings, your interventions, and what
triggered the situation. Did you observe a problem, did the patient call for
help, or did you find the patient in distress? What were your immediate
interventions?

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■ Document as you go. It establishes a timeline for the incident as well as
conveying the interventions and outcomes accurately. Time, date, and sign
every individual entry.
■ Always note at what time, by what route, and how much medication you
or another member of the team has administered. Always record
response to the medication and the time the response(s) occurred or the
time you observed for a response, whether there was a response or not.
The same applies to any non-drug intervention.
■ Always note the time you called the physician or nurse practitioner and
his or her response.
■ If you do not get the response from the physician or nurse practitioner
you think is required for the patient’s best interests, call your
administrative superior (nurse manager), and report the problems.
Document your call and the supervisor’s response. Do not blame or
complain about someone; just note that you called the supervisor to
report the patient’s condition.
■ If you fail to document something, write another entry called “Addendum”
to the note above, and give the time and date of the first note.

Delegation Guidelines
The National Council of State Boards of Nursing defines delegation as
“transferring to a competent individual the authority to perform a selected
nursing task in a selected situation. The nurse retains accountability for the
delegation.” Check your state’s nurse practice act for details about which
nursing activities cannot be delegated.
Sample of nursing tasks that cannot be delegated:
■ Initial assessment or assessments of change in patient condition
■ Formulating the nursing diagnosis; creating the nursing plan of care
■ Administration of medications by direct IV bolus (IV push)
■ Administration of blood products
■ Programming a PCA pump
■ Changing a tracheotomy tube
Before delegating, determine the following:
■ The complexity of the task and the potential for harm posed by the task
(what psychomotor skills are required? what harm can occur if the proce-
dure is done incorrectly?)
■ The predictability or unpredictability of the outcome (is this procedure
new to the patient, or has the patient tolerated this procedure well
before?)

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■ The problem-solving or critical thinking abilities required (problem-prone

activities such as changing a new colostomy appliance, for example, may
require the more in-depth knowledge and problem-solving skills only the
RN can supply)
Remember the Five Rights of Delegation:
■ Right Task—is the task within the caregiver’s scope of practice?
■ Right Person—does the assigned caregiver have the knowledge and skill
required?
■ Right Circumstances—is the setting appropriate; are the right resources
available? what is the current health status of the patient?
■ Right Direction—clear description of the activity to be performed, relevant
patient conditions, limits, and expectations.
■ Right Supervision—monitoring performance, maintaining your availability
to assist, receiving feedback about the procedure and patient’s tolerance,
providing feedback.
Remember: The RN delegates a task but retains responsibility and account-
ability. Specialized nursing skills and nursing judgment cannot be delegated.

Critical Thinking Guidelines

Identifying
■ The first thing the nurse must do is identify that a problem exists. The
triggering event is something unexpected. It may be as obvious as
crushing chest pain or as subtle as a complaint of thirst. Big red flags are
easy to see; do not ignore tiny red flags.
■ Listen and observe. Know recent trends in the patient’s status; understand
normal and abnormal findings. Recognize differences and similarities.
■ Have you noticed or has the patient complained of something
unexpected?
■ Follow up with questions any new complaint or unusual finding.
■ If you have any doubts, do not ignore them; ask a nurse who is senior
to you, or notify the physician/NP.
Assessing
■ Once a problem is identified, seek information; gather objective,
subjective, historical, and current data.
■ Perform a focused physical examination; obtain relevant laboratory and
diagnostic reports; read recent entries in the chart.
■ Order problems in importance; determine if the problem is urgent; if not,
determine how important it is.

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Analyzing
■ Analysis involves breaking the whole into parts and discovering the
relationships of the part to the whole. Is the problem hypotension? Think
about the factors that influence blood pressure: What is the hemoglobin
level, urinary output, recent blood loss? Can you assess cardiac output?
Is the patient on medications that affect blood pressure?
■ Think about what you have discovered through assessment. Ask if the
laboratory values or tests suggest a cause.
■ Consider if the data fit any of the known complications of the patient’s
condition. Do the data suggest something is worsening? Link the data
to the patient’s physical status. Do the data “fit”?
■ Ask yourself if you are making the data fit and if you have overlooked
another cause.
■ Ask yourself what other information is needed. Do you need to assess
another body system? Have you asked the patient about all recent related
events? Should you check the medication record?
■ Other types of problems may require a different set of information (What
other supplies are needed? Does the patient require referral to a religious
leader? Does the family need to see a social worker?).
■ While you analyze, double-check that you are not making erroneous
assumptions. Ask yourself if the data can be interpreted another way.
Ask yourself what other issues or conditions could cause similar signs
and symptoms.
Diagnosing
■ The end result of analysis is a conclusion. For nurses who are thinking
critically about a problem, this conclusion is a nursing diagnosis or a
definition of the problem.
■ State the problem clearly, what the problem is related to, and what data
support this conclusion. State the desired outcomes as well and in what
time frame you expect them to be achieved.
■ Determine the significance of this problem. Ask yourself again: Is it urgent?
Does it have the potential to cause a sudden and rapid deterioration in the
patient’s health status? Is it imperative that you act immediately? Do you
need help?
Planning
■ Consider which intervention(s) will be most effective; predict the conse-
quences of the intervention and if it will produce the desired outcome.
■ Urgent problems require that you immediately summon a
physician or nurse practitioner.
■ Implement the plan; document all problems and interventions.

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Evaluating
■ Evaluation is the step that lets you know if the plan is working.
■ Assess the status of the problem at appropriate intervals; evaluate if the
interventions are effective.
■ Determine if further intervention is required.

Enhance Your Clinical Reasoning Abilities

■ The link between a problem and a positive outcome is sound professional

judgment. Pose new questions to yourself every day. Ask yourself why a
certain complication occurs or why a medication helps. Find out the
answers. Ask others; consult the literature.
■ Keep current. Read journals and other literature.
■ Learn about other specialty areas such as oncologic nursing, wound care,
respiratory or physical therapy.
■ Know your real strengths, skills, and weaknesses. Correct weaknesses.
■ Be alert in your observations and assessments. Realize that everybody
makes assumptions and that assumptions can be wrong. Ask yourself
what else might be responsible for the signs and symptoms.
■ Work in other fields to gain experience. Challenge yourself.
■ Ask questions of other experts in medicine, surgery, nursing, and related
fields. All practioners fundamentally are teachers. Learn from them.

Principles of Pain Management

■ Differentiate between acute and chronic pain. Patients in chronic pain may
not exhibit signs of being in pain.
■ Do not assume that the patient’s pain is exaggerated because he or she
asks for pain medicine frequently. Look for ways to better manage pain.
■ Assess each patient’s pain, and create an individualized treatment plan
■ Reassure patients in pain or who expect to have pain that pain can be
relieved.
■ Assess any changes in pain pattern to ensure that new causes are not
overlooked.
■ Try the least invasive route first in patients with cancer or chronic pain.
Keep dosage schedules simple.
■ Monitor side effects. Use prevention strategies, especially for constipation
when opiods are used.

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■ Be careful switching from oral to IV, IM, IT, or other route. Dosages
change, and different drugs may not provide as much pain relief. Use an
equianalgesic dosing table for guidance.
■ Teach or arrange for instruction in biofeedback, relaxation exercises, and
hypnosis.
■ All can reduce pain and stress and give a greater sense of control.
■ Do not avoid opioids because of fear the patient will become addicted.
■ Encourage patients to request pain medication before pain becomes
severe.
■ Suggest administering medication on an around-the-clock schedule to
maintain therapeutic blood levels.
■ Suggest time-released pain medications to avoid peaks and valleys in
pain control.
■ Consult with a pain management clinical specialist, if available.
■ Include family in pain control plan.

Pain Management
Numeric Scale

0 1 2 3 4 5 6 7 8 9 10
No Mild Moderate Severe Very severe Worst
pain pain pain pain pain possible
pain

Visual Analog Scale

Text/image rights not available.

0 2 4 6 8 10
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST

Wong-Baker FACES Pain Rating Scale. Use for children over 3 years. (From Hockenberry
MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis,
2005, p. 1259. Used with permission. Copyright, Mosby.)

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Using Pain Scales

■ Most patients can use the numerical scale.

■ Say: “On a scale of zero to ten, with zero meaning no pain and ten
meaning the worst pain possible, tell me what level of pain you are
feeling now.”
■ Ask how distressing the pain is, using a scale of 0–10.
■ Some patients report a moderate to high numerical score (5 or above)
but are not distressed and do not want medication.
■ Some patients report a lower numerical value but are very distressed
by the pain and may need medication or other intervention.
■ Always ask the patient directly if he or she would like medication.
■ Contact a pain care nurse, if available.
■ For patients who cannot use the numerical scale, use the Wong-Baker
FACES Pain Rating Scale. Tailor questions accordingly.
Mnemonics for Thorough Pain Assessment (PQRST and COLDERRA)
Perform pain assessment quickly but thoroughly prior to medicating. Always
find out if the pain is new and different; if it is consistent with the patient’s
diagnosis, procedure, or surgery; or if it is typical and expected. New onset
pain, or pain that is unusual for the diagnosis, procedure, or surgery, needs
to be evaluated by the physician or nurse practitioner as soon as possible.
Chest pain requires immediate assessment (see Chest Pain in CV tab).

PQRST
P (provokes/point) ............What provokes the pain (exertion, spontaneous
onset, stress, postprandial, etc.)
Point to where the pain is.
Q (quality) .........................Is it dull, achy, sharp, stabbing, pressing, deep,
surface, etc.? Is it similar to pain you have had
before?
R (radiation/relief) ............Does it travel anywhere (to the jaw, back, arms,
etc.)? What makes it better (position, being still)?
What makes it worse (deep inspiration,
movement)?
S (severity/s/s) ..................Explain the 10/10 pain scale and have patient rate
pain. Are there any signs or symptoms associated
with this pain (n/v, dizziness, diaphoresis, pallor,
SOB, dyspnea, abnormal vital signs, etc.)?
T (time/onset) ...................When did it start? Is it constant or intermittent?
How long does it last? Sudden or gradual onset?
Does it start after you have eaten? Frequency?

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COLDERRA
Characteristics..........................................Dull, achy, sharp, stabbing, pressure?
Onset ..........................................................................................When did it start?
Location ..................................................................................Where does it hurt?
Duration .........................................................How long does it last? Frequency?
Exacerbation ......................................................................What makes it worse?
Radiation...........................................Does it travel to another part of the body?
Relief.....................................................................................What provides relief?
Associated s/s ......................................Nausea, anxiety, autonomic responses?

Nursing Interventions for Pain Management

Provide comfort ..................................................positioning, rest and relaxation
Validate patient’s response to pain .....................................offering reassurance
Relieve anxiety and fears ....................................setting aside time with patient
Teach relaxation techniques ......................rhythmic breathing, guided imagery
Provide cutaneous stimulation ........................massage, heat and cold therapy
Decrease irritating stimulation ....................................bright lights, noise, temp

Comparison of Routes of Analgesic Administration

Route Advantages Disadvantages

Oral Easiest, least invasive; Metabolized in the liver before
consider oral first reaching bloodstream—less
while taking into drug available (40% to 60%)
account patient status than with other routes; takes
longer to act. Cannot be used
if patient has difficulty taking
oral medications.

IM Quicker onset of action Painful, potential nerve injury;

than oral route difficulty finding sites in
undernourished patients

Subcutaneous No need for IV access; Only small volumes of fluid can

changing sites usually be injected each hour. Must
easy; 80% of drug use concentrated medica-
available tions, which increases risk for
drug error.
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Comparison of Routes of Analgesic Administration (continued)

Route Advantages Disadvantages

IV PCA Immediate effect; can have IV sites are portal for
a continuous rate and a infection.
bolus May not be appropriate
for confused patient.
NOTE: Never admin-
ister a dose for the
patient—can lead to
respiratory depres-
sion and death.
Inform family also.

IT Epidural Much lower doses, fewer Potential for infection or

side effects other complication

Transdermal Easy to use. Slow buildup Not suitable for acute

of drug, fewer side pain. Drug remains
effects. active for 14–25 hours
Usually used for patients after removal, which
with cancer pain. presents problems if
patient overdosed.

Sublingual Better absorption, quicker Used primarily for

onset than oral route. break-through pain
Good for patients who for cancer patients.
cannot tolerate PO
medications

Cultural Sensitivity
It is not possible for nurses to know intimately all other cultures different
from his or her own. It is possible, however, to acknowledge that significant
cultural variations exist and to adopt an attitude of sensitivity that includes
a desire to learn about and respect the culture of the patients for whom you
care.
Potential for Stereotyping
Books that list cultural characteristics of various groups have some value but
can lead to stereotyping. Too often people make assumptions based on the

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color of someone’s skin or other overt characteristics. The challenge for
nurses is to learn whether a person considers himself or herself to be a
member of a group and to recognize that significant variation exists within
groups.

Cultural Assessment
Cultural assessment covers many factors, too numerous for this book. Keep
in mind that cultural variation is frequently expressed within domains
applicable to any culture. Maintain a respectful and open attitude as you
learn about each patient. Common domains of importance related to health
care include:
■ Communication styles—eye contact, personal space, tone of voice, and
more. Observe each patient, and follow his or her lead. If you are not sure,
ask politely and respectfully.
■ Religion—you may ask how important religion is to the patient in daily life
and if he or she consults with another member of that religion in health-
care matters.
■ Language—it is very important to use competent interpreters when
obtaining and receiving health information. Do not automatically use
a family member. Sensitive information may be embarrassing for the
two people to discuss. Try to get someone of about the same age and
gender as the patient. Always ask if the patient is willing to use the
interpreter. In an emergency, communicate through the oldest family
member present.
■ Family relationships—families may have a hierarchy that includes a
spokesperson, so to speak. Show respect for that person’s role. As always,
do not reveal confidential information about a person’s health without the
express consent of the patient.
■ Food preferences—providing the patient’s preferred food can be
instrumental in rate of recovery. Ask about any natural remedies the
patient has or is using.
■ Health beliefs—What causes illness, how care is provided, how the patient
handles being ill or in pain are powerful cultural beliefs. Ask the patient or
family members about these issues and integrate the information into
your plan of care.
■ Birth and death rituals—End-of-life beliefs can vary significantly within
any culture. Suggest meeting with the family if the patient approves of
you sharing or receiving information about personal preferences. Discuss
issues such as organ donation, autopsy if applicable to the case, special
care of the body, and what the family will want to do in the immediate
time after death.

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Spiritual Care
Providing spiritual care means different things to different people. Some
nurses may be too intimidated to address this issue. Many do not feel
competent to do so or that it is none of their business. You can always ask
the patient how he or she feels spiritually. The answer will be very revealing
in terms of willingness to discuss the topic. Follow the patient’s lead, and
never impose your own beliefs. Often, the best spiritual intervention is to
ask open-ended questions and then listen.

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Focused Assessment of the CV System
■ A focused assessment of CV status includes:
■ The core cardiovascular system—the heart, its rate and rhythm, the
carotid arteries, blood pressure, and other hemodynamic measures.
■ The peripheral vascular system—the extremities, particularly the
lower extremities.
■ The lungs—adventitious sounds, cough, and oxygenation status.
■ Mental status—level of alertness, restlessness, confusion, irritability,
or stupor.
■ Vital signs:
■ Blood pressure, heart rate, respiratory rate, O2 saturation.
■ Mental status, head and neck:
■ Look for restlessness, ↓ LOC, circumoral cyanosis, color of conjunctiva,
jugular venous distention.
■ Inspect the anterior chest:
■ Look for visible pulsations of the chest wall.
■ Palpate the anterior chest:
■ Locate apical beat, which is the point of maximum impulse (PMI).
■ Assess for heaves—a very forceful PMI.
■ Assess for thrills—a palpable murmur; feels like a cat purring.
■ Auscultate the heart and lungs:
■ Obtain rate and rhythm; assess for rhythm abnormalities.
■ Listen for normal heart sounds and possible murmurs.
■ Use the diaphragm of stethoscope first, then the bell.
■ Listen for carotid abdominal and femoral bruits.
■ Assess extremities: Check for:
■ Cyanosis, temperature, color, and amount of moisture.
■ Capillary refill time in hands and feet.
■ Changes in foot color, ulcers, varicose veins.
■ Edema of lower extremities (check sacrum if client is bedridden).
■ Presence and equality of pedal pulses. If pulses are not palpable,
use a Doppler sonogram.
■ Assess current symptoms:
■ RED FLAG symptoms require immediate attention and intervention.
Shortness of breath.
Chest pain, possibly with neck, jaw, or left arm pain.
Syncope possibly with palpitations and shortness of breath.
Palpitations possibly with chest pain and dizziness.
Cyanosis of lips, fingers, or nailbeds.
Pain, coolness, pallor, or pulse changes in extremities.
Sweating, nausea, vomiting, fatigue (especially in women).

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Assessment Guides
Circulation Scale Pulse Scale

Capillary Refill Pulse Strength

Normal ! #3 sec Absent ! 0
Delayed ! $3 sec Weak ! "1
Normal ! "2
Full ! "3
Bounding ! "4

Edema Scale
Press thumb carefully into edematous area, usually on the shin
(pretibial edema) or dorsum of foot (pedal edema):
0–1/4 inch; disappears in #5 sec ! "1
1/4–1/2 inch; disappears in 10–15 sec ! "2
1/2–1 inch; disappears in 1–2 min ! "3
$1 inch; disappears $2 min ! "4

Possible Causes of Shortness of Breath

Source Potential Causes

Cardiac Coronary artery disease, angina, MI, heart failure,
cardiomyopathy, valve disease, left ventricular
hypertrophy, pericarditis, dysrhythmias
Pulmonary COPD, asthma, pneumothorax, pulmonary embolus
(PE), pulmonary edema
Combined car- COPD with comorbid cardiac disorder, deconditioning,
diopulmonary chronic pulmonary emboli, trauma
Other Metabolic acidosis, pain, neuromuscular disorders,
upper airway disorders, anxiety, panic,
hyperventilation

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Cardiac auscultation sites.

Arterial Hematoma

CLINICAL PICTURE
The patient may have:
■ Pressure dressing to radial/brachial/femoral artery insertion site that is
saturated with blood.
■ Cannulated artery that has been inadvertently decannulated and is
hemorrhaging.
■ Hematoma, possibly pulsatile, around arterial puncture site.

IMMEDIATE INTERVENTIONS
■ Notify physician or NP.
■ Place patient in a supine position with affected limb extended.
■ Don sterile gloves and, using folded sterile gauze dressings, apply
firm pressure 2 cm above puncture site, using the first three fingers
of one hand.
■ Continue to apply pressure for 10 minutes or more, until bleeding has
been controlled.

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■ Once bleeding is controlled, apply sterile gauze dressing overlayed with

a pressure dressing (Elastoplast). Depending on institution protocol, use
a sandbag or other pressure device over the pressure dressing for added
pressure.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Monitor distal pulses, skin color, temperature, and sensation of affected
limb.
■ Assess VS, noting decrease in BP or increase in HR.
■ Assess LOC and patient’s ability to maintain extremity in immobile,
neutral position.
■ Assess for pain.

STABILIZING AND MONITORING

■ Instruct patient to maintain supine position a minimum of 6 hours.
■ Frequently assess site for rebleeding.
■ Monitor circulation, mobility, and sensation in affected extremity.
■ Frequently monitor VS for changes in BP and HR.
■ Reassess for pain.
■ Assess for history of preexisting conditions such as clotting abnormalities
or blood dyscrasias or for recent/current administration of antiplatelet or
anticoagulant medications.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Assist physician or NP with cannulation of an alternate arterial site.
■ Obtain IV access for the administration of blood, clotting factors, or
anticoagulant reversal agents such as protamine sulfate.

POSSIBLE ETIOLOGIES
■ Hemophilia, von Willebrand’s disease, thrombocytopenia, DIC, vascular
trauma or iatrogenic arterial injury, anticoagulant therapy, antiplatelet
therapy, thrombolytic therapy.

Arterial Occlusion
CLINICAL PICTURE
The patient may have:
■ Numbness, tingling, severe burning pain, or coolness in affected extremity.
■ Loss of sensation in the extremity.

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■ Pale, mottled, cyanotic, or ashen extremity.
■ Edematous, tight, shiny skin over affected extremity.
■ Capillary refill !3 sec or absent.

IMMEDIATE INTERVENTIONS
■ Check all arterial pulses in the affected extremity. Compare with those in
contralateral extremity.
■ Assess any sites of arterial puncture (e.g., arteriogram puncture site or
A-line insertion site) for swelling or hematoma.
■ Assess mobility of affected extremity; compare with that of contralateral
extremity.
■ Assess VS.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess for pallor, pain, paresthesias, paralysis, and pulselessness (5 Ps)
by assessing circulation (skin color, capillary refill, pulses), movement
(flexion, extension, rotation), and sensation (response to pinprick or light
touch; pain level) of affected extremity.
■ Assess pulses with Doppler amplification.
■ Assess bandages or cast proximal to diminished pulses.

STABILIZING AND MONITORING

■ Continue to monitor condition of extremity.
■ Keep extremity at heart level to promote arterial flow without diminishing
venous return.
■ Remove or do not use ice on the extremity.
■ Control and manage pain.

BE PREPARED TO
■ Remove any external fixtures (casts) on the extremity, or assist the
physician or NP with fasciotomy for immediate relief of pressure.
■ Prepare the patient for surgery.
■ Initiate large-bore IV access.

POSSIBLE ETIOLOGIES
■ Compartment syndrome, major vascular injury, thrombus, ruptured aortic
aneurysm, local or regional block anesthesia, cord injury, lymphedema,
fracture, hypotension, hypothermia, dehydration, shock.

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Bradycardia
CLINICAL PICTURE
The patient may have:
■ HR "60 bpm.
■ Nausea and vomiting, dizziness or lightheadedness.
■ Signs of unstable bradycardia:
■ Altered LOC.
■ Chest pain, shortness of breath (SOB).
■ Hypotension, pulmonary congestion, and/or cyanosis.

IMMEDIATE INTERVENTIONS
■ Have patient sit or lie down in bed.
■ Administer supplemental O2.
■ Assess BP.
■ Notify physician or NP.
■ Obtain a 12-lead ECG.
■ Check for patent IV access.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess LOC and orientation.
■ Assess BP and HR.
■ Assess respirations for rate and effort; assess SaO2 if readily available.
■ Assess skin for color, moistness, and temperature. Assess for associated
symptoms (chest pain, SOB, hypotension).
■ If patient on telemetry or cardiac monitor, assess ECG.

STABILIZING AND MONITORING

■ Monitor VS.
■ Set up cardiac monitoring, and monitor rate and rhythm.
■ Assess recent laboratory results.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Administer oral or IV medications as ordered.
■ Obtain or order laboratory tests.
■ Titrate O2 to SaO2 !90%.
■ Obtain IV access if none available.
■ Assist with external pacing.
■ Transfer patient to ICU or telemetry unit.

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POSSIBLE ETIOLOGIES
■ Medication toxicity, vasovagal response, hyperkalemia, hypothermia,
hypothyroidism, sepsis, severe infection, hypoglycemia, hypothermia,
excellent physical condition (athletes), myocardial infarction, shock.

Chest Pain
CLINICAL PICTURE
The patient may have (see table below on Possible Causes of Chest Pain):
■ Substernal or epigastric sensations of fullness, pressure, or tightness; pain
may radiate to left neck, jaw, back, and/or arm.
■ Cool, pale, and/or diaphoretic skin.
■ Nausea, vomiting.
■ SOB, tachypnea.
■ Dizziness, fatigue, fainting.
■ Marked anxiety, expression of “impending doom.”

IMMEDIATE INTERVENTIONS
■ Elevate head of bed (HOB) to facilitate breathing.
■ Administer high-flow O2 by nonrebreather mask (10–15 L/min) or by nasal
cannula (4–6 L/min).
■ Assess VS, character and quality of pain (PQRST), skin color.
■ Check for standing orders of nitrogylcerine (NTG) sublingual 0.4 mg q
5 min # 3 doses maximum (hold for BP "90 mm Hg) and one 325 mg
nonenteric-coated aspirin. Administer STAT.
■ Check for IV access. Prepare to initiate saline lock IV access.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess HR, rhythm, BP, respiratory rate (RR), and effort.
■ Inspect skin for color, temperature, and moistness.
■ Assess SaO2 with pulse oximetry.
■ Assess rhythm strip.
■ Auscultate lung fields.

STABILIZING AND MONITORING

■ Administer medications STAT for cardiac symptoms, if ordered: NTG 0.4
mg SL (hold for BP "90 mm Hg); morphine (MS) 2 mg IV (hold for RR "8,
BP "90 mm Hg); aspirin (ASA) 162–325 mg PO.

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■ Assess response to medications.

■ Identify underlying rhythm.
■ Obtain cardiac enzymes/troponin levels.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Assess need and eligibility for thrombolytic therapy.
■ Set up cardiac monitoring.
■ Set up or change the O2 delivery system.
■ Administer oral or IV medications.
■ Call for a STAT 12-lead ECG.
■ Obtain laboratory tests (electrolytes, PT, PTT, cardiac markers).
■ Transfer patient to ICU.
■ Call a code; perform CPR.

POSSIBLE ETIOLOGIES
■ Angina, anxiety, MI, pulmonary embolism, pulmonary edema, chest
trauma, endocarditis, pericarditis, indigestion, gastroesophageal reflux
disorder, pleurisy, bronchitis.

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Possible Causes of Chest Pain

Provocation Quality Location and Severity and

Etiology and Onset and Relief Radiation Time (Duration)

MI No provocation; Pressure, Substernal Severe, lasting

large, heavy meal; squeezing. anterior chest or longer than
extreme exertion, No relief. epigastrium, → 20 min.
stress, or fright. to left neck, jaw,
Sudden onset. arm, back

Angina Provoked by exertion. Pressure, Same as MI Mild to moderate,

Sudden onset. tightness. lasting "2 min.
Rest or sl NTG
provides relief
23

Pneumonia No provocation or Ache with sharp, Anterior chest, Moderate, lasting

coughing. stabbing pain. shoulder, neck. hours.
Gradual or sudden No relief.
onset.

PE No provocation. Dull, aching but Variable. None, mild, or

Sudden. may also have moderate of

CARDIAC
sharp pain. variable
No relief. duration.

(Continued on the following page)

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Possible Causes of Chest Pain (continued)

Provocation Quality Location and Severity and

Etiology and Onset and Relief Radiation Time (Duration)

Pericarditis No provocation; Sharp. Substernal Moderate to

deep breathing, anterior chest. severe, endures
coughing. for hours to
Gradual or sudden days.
onset.

Epigastric Gradual or sudden. Sharp, burning Chest, throat, Moderate, last-

disorders when patient RUQ, LUQ, back. ing minutes or
in upright hours.

24
position,
antacids
provide relief.

Musculoskeletal Gradual or sudden. Dull ache; Arm, shoulder, Mild to moderate,

disorders possible sharp neck, back, lasting minutes
pain. sternum, ribs, to hours.
Rest and mild abdomen.
analgesics or
CARDIAC

NSAIDs
provide relief.

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Heart Failure
CLINICAL PICTURE
The patient may have:
■ Fatigue, weakness, anxiety.
■ SOB, orthopnea, dyspnea, adventitious breath sounds (rales or crackles),
cyanosis.
■ Change in mental status anxiety, restlessness, confusion.
■ Edema, jugular vein distention, increased CVP, positive fluid balance.

IMMEDIATE INTERVENTIONS
■ Assess VS; note if hypotensive.
■ Elevate HOB, and lower legs if possible.
■ Administer supplemental O2 (100% nonrebreather mask).
■ Restrict fluids.
■ Assess for patent IV.
■ Notify physician or NP.

FOCUSED ASSESSMENT
■ Assess airway, RR and effort, BP, and HR.
■ Auscultate lung fields for pulmonary congestion (crackles, wheezes).
■ Assess SaO2 via pulse oximetry.
■ Assess LOC and orientation.
■ Assess cardiac rhythm.

STABILIZING AND MONITORING

■ Restrict fluids, and administer diuretics as ordered.
■ Closely monitor I&O.
■ Assess for improvement of LOC and oxygenation status.

BE PREPARED TO
■ Titrate O2 to keep SaO2 !90%.
■ Obtain IV access.
■ Set up cardiac monitoring.
■ Administer oral or IV diuretics, NTG, morphine, and electrolytes as
ordered.
■ Order a chest x-ray and ECG.
■ Order or obtain laboratory tests (BUN, creatinine, CBC, electrolytes).
■ Transfer patient to ICU or telemetry unit.

POSSIBLE ETIOLOGIES
■ Atrial fibrillation, marked bradycardia, systemic infection, septic shock,
pulmonary embolism; physical, environmental, and emotional excesses;

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stress; cardiac infection and inflammation; excessive intake of water

and/or sodium administration of cardiac depressants or drugs cause
salt retention; cardiomyopathy, hypertension, severe aortic stenosis,
ischemic myocardial disease, coronary artery disease, acute mitral
or aortic regurgitation, infective endocarditis with acute valve incom-
petence, MI, anemia, hyperthyroidism, pregnancy, glomerulonephritis,
cor pulmonale, polycythemia vera, carcinoid syndrome, obesity.

Hemorrhage/Wound Hemorrhage
CLINICAL PICTURE
The patient may have:
■ Saturated postoperative dressings.
■ Excessive amounts of blood in wound drainage system.
■ Peri-incisional swelling and hematoma.
■ Subtle changes in LOC, anxiety, irritability, restlessness, decreased
alertness (early CNS signs of blood loss).
■ Confusion, combativeness, lethargy, coma (later CNS signs).
■ Increased HR to severe tachycardia.
■ Delayed capillary refill (!3 sec), diminished peripheral pulses ("$l2),
cool extremities and pale, mottled, or cyanotic skin.
■ Slightly elevated RR to severe tachypnea.
■ Hypotension.
■ Narrowing of pulse pressure.
■ Thirst.
■ Bruising around umbilicus or retroperitoneally in flank areas (internal
bleeding).

IMMEDIATE INTERVENTIONS
■ Get help, and notify surgeon.
■ Discontinue thrombolytics or anticoagulants.
■ Control external bleeding with direct pressure.
■ Do not remove saturated dressings, as this may also remove any clot
formation.
■ Instead, reinforce with additional dressing and pressure.
■ Administer supplemental O2; maintain patent airway.
■ If IV not in place, obtain large gauge (#18) IV access, and have IVF ready
to hang.
■ Monitor VS frequently.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

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FOCUSED ASSESSMENT
■ Assess LOC, orientation, and VS (HR, RR, BP).
■ Assess for orthostatic hypotension if possible.
■ Assess SaO2 via pulse oximetry if available (Note: may be unreliable due
to decreased peripheral perfusion).
■ Assess skin for color, temperature, moistness, turgor, capillary refill.

STABILIZING AND MONITORING

■ Monitor VS and oxygenation status.
■ If patient previously typed and cross-matched, call blood bank to see if
any blood available.
■ Monitor output from Hemovac, JP drains, NGT, and urinary catheter.
■ Check laboratory values.
■ Provide emotional support to patient/family.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Assist with insertion of a central line.
■ Obtain laboratory tests STAT (Hgb/Hct, ABGs, electrolytes, blood type and
crossmatch).
■ Prepare the patient for surgery.
■ Administer colloidal infusions.
■ Insert Foley catheter.
■ Administer blood.
■ Mechanically ventilate.

POSSIBLE ETIOLOGIES
■ External bleeding: wounds (postsurgical and traumatic); internal bleeding:
blunt trauma, cancer, ruptured aneurysm, postsurgical, GI perforation,
thrombolytic therapy.

Hypertensive Urgency/Emergency
Hypertensive urgency: systolic BP !200 mm Hg or a diastolic BP !120 mm
Hg. Hypertensive emergency: diastolic BP !140 mm Hg with evidence of
acute end-organ damage.

CLINICAL PICTURE
The patient may have:
■ Fatigue, headache, restlessness, confusion, visual disturbances, seizure.
■ Dyspnea, tachycardia, bradycardia, pedal edema, chest pain.
■ Lightheadedness, dizziness.
■ Nausea, vomiting.

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CARDIAC

IMMEDIATE INTERVENTIONS
■ Assess BP in both arms.
■ Elevate HOB to 30%–45%.
■ Administer supplemental O2.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess LOC and orientation.
■ Assess respiratory status.
■ Assess for neurological deficits (hemiparesis, slurred speech).
■ Assess baseline VS (temperature, HR, RR, BP).
■ Assess SaO2 via pulse oximetry, if available.
■ Assess for associated symptoms: visual disturbances, chest pain,
peripheral edema, hematuria.

STABILIZING AND MONITORING

■ Maintain continuous monitoring of BP and HR.
■ Assess for changes in cardiac rhythm if patient is on a monitor.
■ Monitor I&O.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Titrate O2 to SaO2 !90%.
■ Obtain a saline lock IV access.
■ Administer ordered antihypertensive medications (oral or IV).
■ Obtain or order laboratory tests (BUN, creatinine, electrolytes, UA).
■ Assist with arterial line placement.
■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES
■ Atherosclerosis, primary hypertension, stress, anxiety, anger, medication,
stroke, toxemia of pregnancy, diabetes, cardiac or renal disease, drugs
(amphetamine, cocaine, corticosteroids, oral contraceptives).

Hypotension
CLINICAL PICTURE
The patient may have:
■ A systolic BP of "90 mm Hg or systolic BP 40 mm Hg less than baseline.
■ Altered LOC or orientation.
■ Cool, pale, ashen, cyanotic, diaphoretic skin.

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■ SOB, dyspnea.
■ Nausea and vomiting.
■ Tachycardia or bradycardia.
■ Decreased urine output ("30 mL/hr).

IMMEDIATE INTERVENTIONS
■ Place patient in a supine position with legs elevated above heart level to
increase circulation to vital organs. Note: This position is contraindicated
if the airway is compromised; to maintain airway patency, place patient
in supine or low Fowler’s position (HOB slightly elevated).
■ If respiratory effort inadequate (RR "8, cyanosis, SaO2 "90%), administer
high-flow O2 via mask (10–15 L/min), or manually assist ventilations with
an Ambu bag (mask-valve device).
■ Control bleeding, if any, with direct pressure.
■ Check for patent IV access. Note: IVF is not routinely administered until
reason for hypotension is determined. Hypotension could be due to
cardiac compromise, in which case fluids might be contraindicated.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess LOC, orientation, baseline VS (temperature, HR, RR, BP), and pulse
quality and rhythm.
■ Assess respiratory effort and airway patency.
■ Assess skin for color, temperature, moistness, turgor, and capillary refill.
■ Assess for associated symptoms (chest pain, dyspnea, nausea).
■ Assess I&O; ask patient about recent history of vomiting, diarrhea, or
urinary symptoms (burning, frequency, flank pain, hematuria).
■ Assess MAR for medications that can affect blood pressure.

STABILIZING AND MONITORING

■ Assess for cause.
■ Continue to monitor VS.
■ Review laboratory data (Hgb/Hct; BUN; urine specific gravity, electrolytes).
■ Evaluate previous 24-hr I&O.
■ Check MAR for possible medication-induced hypotension.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Titrate O2 to SaO2 of 90%.
■ Obtain IV access, and administer ordered IVF.
■ Administer ordered vasoactive medications.
■ Order specific laboratory tests to be drawn STAT.
■ Transfer patient to a critical care unit.

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POSSIBLE ETIOLOGIES
■ Medication; dehydration; hemorrhage; vasovagal response to anxiety;
sepsis; shock; GI bleed or other internal bleeding; aneurysm; congestive
heart failure; cardiac dyrsrhythmias; myxedema; adrenal crisis;
hypoglycemia; completed stroke.

Palpitations
CLINICAL PICTURE
The patient may have or be:
■ Sensation of fluttering in chest, heart racing, or dizziness.
■ Tachycardia, bradycardia, irregular rate.
■ Cold and clammy skin, hypotensive (drop in BP &20 mm Hg from
baseline).
■ SOB, dyspnea, nausea.

IMMEDIATE INTERVENTIONS
■ Place patient supine in bed. Apply O2 if available at bedside.
■ Stay with patient, and provide reassurance.
■ Take BP, and assess apical HR and rhythm. Compare apical rate to radial
rate as one measure of perfusion.
■ Check for patent IV access.
■ Quickly assess perfusion by assessing mental status, peripheral pulses.
■ Observe cardiac monitor if patient is being monitored. Obtain rhythm strip
to document event.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess LOC, VS, and pulse quality and rhythm.
■ Assess precipitating event, pain level, anxiety, hyperventilation.
■ Assess breath sounds, O2 saturation
■ Assess peripheral pulses, skin temperature and color, edema.
■ Assess trends in pertinent laboratory data, e.g., Hg, Hct, electrolytes.
■ Obtain and assess laboratory data such as ABG, cardiac enzymes,
if appropriate.
■ Document assessment thoroughly.

STABILIZING AND MONITORING

■ Continue to monitor rhythm; obtain and analyze rhythm strip every
4 hours and when rate or rhythm changes.
■ Continue to monitor VS and O2 saturation.

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■ Keep IV line patent, and infuse IVF.
■ Review laboratory data such as Hgb/Hct; BUN and creatinine; electrolytes,
other chemistries, blood glucose, liver and cardiac enzymes.
■ Check MAR for possible drug side effect or interactions.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Obtain a 12- or 15-lead ECG
■ Administer antiarrhythmic medication (e.g.: procainamide, quinidine,
amiodarone).
■ Obtain IV access, administer ordered IVF and medications.
■ Transfer patient to a unit with cardiac monitoring.
■ Assist with placement of temporary transvenous or external pacemaker
or cardioversion.

POSSIBLE ETIOLOGIES
■ Premature atrial or ventricular contractions (PACs or PVCs) or other
cardiac dyrsrhythmia, mitral valve prolapse; stress, anxiety; medications;
hyperthyroidism; dehydration; hemorrhage; heart failure; adrenal crisis;
hypoglycemia.

Possible Causes of Palpitations

Source Conditions
Cardiac Sinus tachycardia or bradycardia.
PAC, PVC, PJC, SVT, VT.
Bradycardia/tachycardia syndrome (sick sinus syndrome).
Atrial fibrillation or flutter.
Wolff-Parkinson-White syndrome.
Heart failure, cardiomyopathy, pericarditis.
Congenital heart disease.
Pacemaker malfunction.

Drugs Theophylline, digoxin, phenothiazine.

Vasodilators, antiarrhythmics.
Beta2 agonists (e.g., albuterol, terbutaline, salmeterol).
Cocaine, alcohol, tobacco, caffeine.
Vascular Vasovagal or postural hypotension.
Transient ischemic attack, stroke.
Other Hyperventilation, hypoxia, fever, hypoglycemia, thyrotoxicosis,
anemia.

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Syncope
CLINICAL PICTURE
The patient may have or be:
■ Lightheadedness, feeling faint.
■ Palpitations.
■ Tachypnea, hyperventilation.
■ Nausea, vomiting.
■ Cool, pale, diaphoretic skin.

IMMEDIATE INTERVENTIONS
■ Assist patient to chair or bed, or floor (if necessary).
■ Administer supplemental O2 via nasal cannula.
■ Assess rate, ease of breathing.
■ Assess BP.
■ Assess HR, rhythm, and quality.
■ If patient is hypotensive, keep supine, and elevate lower legs above heart
level, using pillows.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess patency of airway and patient’s breathing.
■ Assess LOC and mental status; determine if patient had a sensation
of spinning or movement.
■ Assess for associated neurological signs (slurred speech, numbness,
weakness).
■ Assess skin for color, temperature, turgor, and moistness.
■ Ask if patient feels nauseated or is experiencing chest pain.
■ Check recent chemistry and hematology laboratory results.
■ Check if new medications have been administered.
■ Review I&O records from preceding days.

STABILIZING AND MONITORING

■ Assess orthostatic VS: take HR and BP in supine, sitting, and standing
positions, each 2 min apart. Note if pulse increases by 20 or more bpm
and the systolic BP drops by 20 mm Hg or more, which suggests
hypovolemia or dehydration.
■ Assess mucous membranes and skin turgor for signs of dehydration.
■ Continue to assess VS as frequently as indicated.
■ Review history and all current medications.

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■ Test stool for occult blood.
■ Chart patient status and convey to physician or NP.

BE PREPARED TO
■ Obtain IV access.
■ Administer IVF or a fluid challenge.
■ Obtain a chemstick blood sugar level.
■ Administer 50% dextrose IV.
■ Order specific laboratory tests to be drawn STAT.

POSSIBLE ETIOLOGIES
■ Dysrhythmias, cardiac insufficiency, anemia, hypoxia, orthostatic/postural
hypotension, hypovolemia/dehydration, hypertension, medication reaction,
electrolyte imbalance, hypoglycemia, hyperglycemia, concussion,
vasovagal response, stress/anxiety/fear.

Possible Causes of Syncope

Source Conditions
Cardiac Bradycardia (HR "60 bpm).
Tachycardia (HR !100 bpm).
Decreased cardiac output, hemorrhage.
Aortic or pulmonic stenosis.
Pulmonary hypertension.

Neurological Seizure, head trauma.

Vascular Vasovagal or postural hypotension.
Transient ischemic attack, stroke.
Other Hyperventilation, hypoxia.

Tachycardia
CLINICAL PICTURE
The patient may have:
■ HR 100–150 bpm (sinus tachycardia—may be asymptomatic);
HR !150 bpm (supraventricular tachycardia).
■ Palpitations, dizziness or lightheadedness.
■ Chest discomfort, SOB.
■ Anxiety, restlessness.

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CARDIAC

■ Signs of unstable tachycardia:

■ Altered LOC.
■ Chest pain.
■ Hypotension.
■ Pulmonary congestion and/or cyanosis.

IMMEDIATE INTERVENTIONS
■ Have patient sit or lie in bed.
■ Assess blood pressure and respirations.
■ Administer supplemental O2.
■ Reduce or eliminate environmental stressors.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and
physician or NP response.

FOCUSED ASSESSMENT
■ Assess LOC, orientation, and VS (temperature, HR, RR, BP).
■ Assess SaO2 via pulse oximetry, if available.
■ Assess heart rhythm.
■ Assess skin for color, turgor, moistness, and temperature.
■ Assess for associated symptoms (body pain, chest pain, SOB,
hypotension, fever, dehydration).
■ If patient on telemetry or cardiac monitor, assess rhythm strip.

STABILIZING AND MONITORING

■ Assess HR, BP, and SaO2.
■ Assess 12-lead ECG (see ECG in Tools tab).
■ Assess recent history of emotional upset, medication use, infectious
disease, diarrhea, vomiting, blood loss from menses, GI pain or nausea,
melanotic stool.
■ Assess MAR for medications with potential to cause tachycardia.
■ Assess blood glucose level.
■ Assess recent I&O.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Set up cardiac monitoring; order 12-lead ECG.
■ Titrate O2 to keep SaO2 !90%.
■ Obtain IV access.

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■ Administer oral or IV medications as ordered.
■ Order laboratory tests to be drawn STAT.
■ Assist with cardioversion.
■ Transfer patient to the cardiac care or telemetry unit.

POSSIBLE ETIOLOGIES
■ Hypoxia, exercise, caffeine, fever, medications, pain, anxiety, stress, atrial
fibrillation, infection, hypoglycemia, hemorrhage, hypovolemia,
dehydration, electrolyte imbalance.

A & P Snapshot

Left common carotid artery

Brachiocephalic artery
Left subclavian artery
Superior vena cava Aortic arch
Left pulmonary
Right pulmonary artery
artery Left atrium
Left pulmonary
Right pulmonary veins
veins Mitral valve
Pulmonary
Left ventricle
semilunar valve
Aortic
Right atrium semilunar
Tricuspid valve
valve Interventricular
septum
Inferior vena
cava
Chordae Apex
tendinea Right Papillary
ventricle muscles

Cardiac structure and blood flow.

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CARDIAC

Maxillary
Occipital
Facial
Internal carotid External carotid
Vertebral Common carotid
Subclavian
Brachiocephalic
Axillary
Aortic arch
Pulmonary

Celiac Intercostal
Left gastric Brachial
Hepatic Renal
Splenic Gonadal
Superior Inferior
mesenteric mesenteric
Radial
Abdominal aorta
Right Ulnar
common iliac
Internal iliac
Deep
External iliac palmar
arch

Deep femoral Superficial

Femoral palmar arch

Popliteal

Anterior tibial

Posterior tibial

Arterial circulation.

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Focused Respiratory System Assessment
■ A focused assessment of respiratory status includes:
■ Ease of breathing and respiratory rate
■ Lung sounds
■ Use of O2 and oxygenation
■ ABGs
■ Ventilator assessment, if applicable
■ Mental status level of alertness, restlessness, confusion, irritability,
or stupor
■ Ease of breathing and respiratory rate:
■ Ask the patient how his breathing is; use his subjective terminology
when documenting. Ask if SOB is triggered by activity and if rest
relieves the feeling. Ask about energy levels and if the patient can eat
and talk comfortably.
■ Assess rate—normal rate is 12–20; however, most adults have a
respiratory rate in the lower end of the range. Rates !20
respirations/min should be investigated. A rate !26 is cause for alarm,
unless it’s the patient’s baseline.
■ Assess use of accessory muscles or nasal flaring, both of which indicate
respiratory distress.
■ Lung sounds:
■ Listen to lung sounds in all fields. Ask the patient to breathe deeply with
his mouth open.
■ Note adventitious sounds, areas where air movement is not heard,
or areas where breath sounds are diminished.
■ Use of O2 and oxygenation:
■ Note the amount of O2 ordered and the method of delivery (e.g., 3
L/min via nasal cannula).
■ Note if the patient is wearing the O2 all the time and if the device is
correctly applied.
■ Check pulse oximetry to assess percentage of oxygen saturation (SaO2):
97% to 99% is normal, although 93% to 97% may be normal for some
patients. Always look at the whole picture, not just a single reading.
Also, pulse oximetry can be inaccurate in the presence of peripheral
vascular disease. Reading of 90% or less indicates possible need for
ventilation support. Compare trends in O2 saturation to determine if
oxygen therapy is effective.
■ Analyze ABG results:
■ ABG allows for assessment of acid-base balance, ventilation, and
oxygenation. It also tells how well the lungs and kidneys are
compensating or responding to treatments.

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■ pH, PaCO2, and HCO3 tell about acid-base balance.

■ PaO2 and SaO2 indicate oxygenation status.
■ Normal values (memorize):
pH: 7.35–7.45
PaO2: 80–100 mm Hg
PaCO2: 35–45 mm Hg
O2 saturation: 95%–100%
HCO3: 21–28 mEq/L
Base excess: "2 to #2 mEq/L
See detailed explanation of how to interpret ABGs on page 51 in
this tab.

Aspiration
CLINICAL PICTURE
The patient may have:
■ Sudden onset of coughing and shortness of breath (SOB) associated with
eating, drinking, or regurgitation.
■ Tachypnea, dyspnea, cyanosis, decreased breath sounds.
■ Tachycardia, bradycardia.
■ Crackles and rhonchi (usually on the right, but may be on the left or
bilaterally).
■ Altered mental status.
■ Fever.
■ Chest pain (pleuritic).

IMMEDIATE INTERVENTIONS
■ Elevate head of bed (HOB) to upright position; help patient to expectorate.
■ Provide supplemental oxygen.
■ Suction oropharynx.
■ Encourage coughing.
■ If there is evidence of foreign body obstruction see Choking in the
Emergency tab.
■ Notify physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess patient’s ability to clear airway and effort to breathe.
■ Assess airway for secretions or foreign objects.

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■ Assess effectiveness of measures taken to clear airway.
■ Assess oxygenation status: level of consciousness (LOC), SaO2, presence
of circumoral and nailbed cyanosis.
■ Assess HR, BP, respirations (rate, rhythm, and effort), and work of
breathing.
■ Auscultate lung fields.

STABILIZING AND MONITORING

■ Continue to monitor airway and respiratory function.
■ Consider a speech pathology consultation to assess patient’s level of
airway control and/or gag reflexes.
■ Monitor patient during oral intake, and assess patient for evidence of
dysphagia.

BE PREPARED TO
■ Set up and assist with intubation, cricothyrotomy, tracheotomy, or
bronchoscopy, if indicated.
■ Call a code.

POSSIBLE ETIOLOGIES
■ Emesis; disorders that affect normal swallowing and gag reflex (depres-
sion of the laryngeal reflexes, stroke); disorders of the esophagus
(esophageal stricture, gastroesophageal reflux); use of sedative drugs;
anesthesia; coma; excessive alcohol consumption; tracheitis; epiglottitis;
foreign body aspiration.

Chest Tube Dislodgement

CLINICAL PICTURE
The patient may have:
■ Signs of respiratory distress: rapid, shallow, or increased work of
breathing; cyanosis; decreased LOC; and SaO2, restlessness, or anxiety.
■ Partially or completely dislodged chest tube.
■ Visible chest tube drain pores.
■ Whistling sound as air enters or exits wound site or chest tube.

IMMEDIATE INTERVENTIONS
■ Immediately cover chest tube insertion site with sterile petroleum gauze
(occlusive dressing) covered with several 4 $ 4 pads.
■ Maintain constant pressure, but do not tape dressing in order to allow air
to escape from chest cavity.

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■ Administer supplemental O2.

■ Notify physician or NP and respiratory therapist STAT.
■ Document patient status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess respirations and quality of oxygenation including LOC, SaO2, skin
color, and work of breathing.
■ Auscultate lung fields, and compare ventilation left to right.
■ Assess vital signs (VS) and pain level.

STABILIZING AND MONITORING

■ Assure chest x-ray (CXR) is obtained after reinsertion.
■ Continue to evaluate lung sounds and quality of oxygenation.
■ Make sure all chest tube connections are secure and that tubing is not
tangled or encumbered.
■ Maintain drainage system in upright position below heart.
■ Place emergency equipment in patient’s room (sterile NS, 4 $ 4 pads,
petroleum gauze, tape and nontoothed padded clamps).
■ Assess drainage system for proper functioning.
■ Assure that extra drainage collection system is readily available on the
unit.
■ Assist patient with movement and repositioning.

BE PREPARED TO
■ Set up and assist with reinsertion of chest tube.
■ Order portable CXR.
■ Administer supplemental O2.

POSSIBLE ETIOLOGIES
■ Excessive torque or tension on chest tube due to multiple possible causes
(chest tubes not hanging freely during movement, improper transfer
technique, patient confused).

Dyspnea/SOB
CLINICAL PICTURE
The patient may have or be:
■ Mild sensation of discomfort to feeling of suffocation.
■ Difficulty breathing; inability to take a deep breath.
■ Cyanotic, ashen or pale, and diaphoretic.

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■ Tachypneic, wheezing, poor air movement, use of accessory muscles.
■ Restless, confused, anxious, fearful, agitated.
■ Maintaining an upright position to facilitate breathing.

IMMEDIATE INTERVENTIONS
■ Place patient in a position that facilitates breathing.
■ Administer supplemental O2 if no history of COPD.
■ Assess VS.
■ Auscultate lung fields for adventitious sounds and quality of air
movement.
■ Place on pulse oximetry and cardiac monitor if readily available; assess
O2 saturation and cardiac rhythm.
■ If patient is hyperventilating, encourage slower, deeper breathing or, if
indicated, have the patient perform pursed-lipped breathing.
■ Notify physician or NP and respiratory therapy.
■ Stay with patient; maintain calm, reassuring demeanor.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess VS and respiratory status.
■ Assess for chest pain, nausea, leg vein tenderness, other cardiovascular
symptoms.
■ Assess for underlying respiratory conditions.
■ Assess oxygenation status by evaluating for changes in mental status,
noting evidence of chest pain or tightness, measuring SaO2, and
evaluating cardiac rhythm.
■ Ask patient about previous episodes of SOB, what provoked it, if onset
was sudden or gradual, if SOB is made worse by lying flat. Assess cough.
■ Assess work of breathing as evidenced by flared nostrils, retraction of
subclavicular and intercostal spaces, use of accessory muscles, and
orthopnea.
■ Note tracheal alignment, symmetry of chest expansion, bulging
interspaces, and presence of JVD.
■ Assess skin for color, circumoral and nailbed cyanosis, and moistness.
■ Auscultate lung fields, noting diminished breath sounds, crackles,
wheezing, friction rubs or stridor.
■ Assess medication administration record for possible
medication/anaphylactic reactions.

STABILIZING AND MONITORING

■ Continue to monitor respiratory status as detailed in Assessment, and
support effort to breathe.

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■ Continue to assess patient for contributing factors and underlying cause.

■ Administer medications as ordered.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Obtain IV access.
■ Change or set up an O2 delivery system.
■ Assist with diagnostic testing.
■ Obtain ABGs.
■ Place a nasal or oral airway.
■ Suction the oropharynx/trachea.
■ Administer medication.
■ Assist with intubation or chest tube placement.
■ Transfer to ICU.

POSSIBLE ETIOLOGIES
■ Allergic reaction, airway obstruction, anxiety/panic attack, aspiration,
asthma, cardiac dysrhythmias or tamponade, emphysema, heart failure,
cardiac ischemia, pleural effusion/pleuritis, pneumonia, pneumothorax,
pulmonary edema, pulmonary embolism.

Possible Causes of Shortness of Breath

Source Potential Causes

Cardiac Coronary artery disease, angina, MI, heart failure,
cardiomyopathy, valve disease, left ventricular
hypertrophy, pericarditis, dysrhythmias

Pulmonary COPD, asthma, pneumothorax, pulmonary embolus

(PE), pulmonary edema

Combined COPD with comorbid cardiac disorder, deconditioning,

cardiopul- chronic pulmonary emboli, trauma
monary

Other Metabolic acidosis, pain, neuromuscular disorders,

upper airway disorders, anxiety, panic,
hyperventilation

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Hypoventilation/Ineffective Breathing Pattern
CLINICAL PICTURE
The patient may have or be:
■ Dyspnea at rest or on exertion.
■ Hypoxic and appear cyanotic, ashen, or pale.
■ Lethargic, stuporous, obtunded, or unconscious.
■ Rapid and shallow breathing pattern, periods of apnea as in Cheyne-
Stokes (neurological), or notably slow (narcotic) breathing.
■ Signs of right-sided heart failure (JVD, peripheral edema, and
hepatomegaly).
IMMEDIATE INTERVENTIONS
■ Attempt to arouse patient with physical stimulation to enhance breathing.
■ Assess airway for obstruction.
■ Perform orotracheal suctioning to clear secretions.
■ Administer supplemental O2.
■ Manually ventilate patient with a BVM device if RR %8 or O2 saturation
%90%.
■ Get help, notify RT, and call physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess LOC and orientation.
■ Assess VS, noting RR, depth, and quality.
■ Assess skin color and moistness.
■ Auscultate lung fields for adventitious sounds and equality of breath
sounds.
STABILIZING AND MONITORING
■ Insert oral or nasal airway, if necessary.
■ Administer bronchodilators.
■ For narcotic/opioid OD, administer Narcan 0.4 mg IV.
■ For IM benzodiazepine OD, administer Romazicon 0.2 mg IV.
■ Continue to monitor breathing and oxygenation closely.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Assist with setup and application of various O2 delivery systems (mask,
CPAP, BiPAP, intubation/ventilator).
■ Obtain IV access.
■ Obtain CXR, ABGs, other laboratory tests.
■ Administer medication as ordered.
■ Transfer to ICU.

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POSSIBLE ETIOLOGIES
■ COPD, emphysema, chronic bronchitis, neuromuscular disorders,
amyotrophic lateral sclerosis, muscular dystrophy, diaphragm paralysis,
Guillain-Barré syndrome, myasthenia gravis, chest wall deformities,
kyphoscoliosis, fibrothorax, thoracoplasty, central respiratory drive
depression, drugs: narcotics, benzodiazepines, barbiturates; neurological
disorders: encephalitis, brainstem disease, trauma; primary alveolar
hypoventilation, obesity hypoventilation syndrome.

Pulmonary Embolism
CLINICAL PICTURE
The patient may have or be:
■ Dyspnea, pleuritic chest pain, tachycardia.
■ Anxiety, diaphoresis.
■ Syncope, hypotension.
■ Wheezing.
■ Lower extremity edema.
■ Signs and symptoms of thrombophlebitis.

IMMEDIATE INTERVENTIONS
■ Administer supplemental O2.
■ Assess VS.
■ Assess respiratory rate and work of breathing.
■ Notify physician or NP.
■ Place on pulse oximetry and cardiac monitor, if available.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Auscultate lung fields for adventitious sounds and quality of air
movement.
■ Assess O2 saturation, cardiac rhythm, VS.
■ Assess for chest pain, leg vein tenderness.
■ Assess for history of recent surgery, immobilization, recent DVT,
malignancy.
STABILIZING AND MONITORING
■ Continue to assess VS, LOC, respiratory status.
■ Initiate anticoagulant therapy (heparin) as ordered. Have second
practitioner independently calculate dilutions and infusion pump
programming.
■ Chart patient status, and convey to physician or NP.

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BE PREPARED TO
■ Obtain IV access.
■ Change or set up an O2 delivery system.
■ Administer medications or fluids to maintain blood pressure.
■ Assist with obtaining diagnostic studies (CXR, V/Q scan, spiral CT scan,
pulmonary angiogram).
■ Obtain ABGs.
■ Obtain serial PTTs, and titrate heparin infusion.
■ Transfer to ICU for high acuity care or thrombolytic therapy.

POSSIBLE ETIOLOGIES
■ Embolization of thrombi from deep veins of the femur, pelvis, and lower
extremities from multiple causes including venous stasis, hypercoagulable
states, surgery and trauma, oral contraceptive and estrogen replacement
therapy, pregnancy, malignancy.

Respiratory Distress/Failure
CLINICAL PICTURE
The patient may have:
■ Dyspnea, excessive work of breathing.
■ Cyanosis of skin and mucous membranes.
■ Anxiety, confusion, restlessness, or somnolence.
■ Tachycardia and dysrhythmias (due to hypoxemia and acidosis).
■ Decreased O2 saturation (SaO2 %90% is considered abnormal, and
levels below this can represent unstable respiratory status that re-
quires immediate intervention; however, evaluate in context of patient
baseline—some patients with COPD may never have SaO2 greater than
88% but are stable.
■ Abnormal ABG results: Hypoxemic respiratory failure, characterized by
a PaO2 %60 mm Hg and a normal or low PaCO2, is most common and
is caused by any acute disease of the lung (pulmonary edema, pneumo-
nia). Hypercapnic respiratory failure, characterized by a PaCO2 !50 mm Hg,
is associated with drug overdose, neuromuscular disease, chest wall
abnormalities, and severe airway disorders such as asthma or
emphysema.
■ Seizures (may occur with severe hypoxemia).

IMMEDIATE INTERVENTIONS
■ Notify physician or NP and respiratory therapist of decline in respiratory
function.
■ Elevate HOB; position patient to facilitate breathing.

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■ Assess if the airway is patent and if patient is alert enough to manage

secretions and to protect airway.
■ Insert nasal or oral airway, and suction if patient unable to clear
secretions.
■ Apply supplemental oxygen via nasal prongs or face mask to correct
hypoxemia and keep oxygen saturation above 90%. (Use O2 cautiously
in patients with severe COPD and chronic CO2 retention.)
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess oxygenation, lung sounds, respiratory rate, and work of breathing;
assess for circumoral or nailbed cyanosis.
■ Assess VS, LOC, orientation.
■ Assess for underlying cause of respiratory distress.

STABILIZING AND MONITORING

■ Assess cardiac monitor, BP, pulse oximetry, and ABG results.
■ Continue to assess temperature, LOC, orientation.
■ Administer medications to treat underlying cause.
■ If hypoxemia is severe, intubation and mechanical ventilation to increase
PaO2, lower PaCO2, and rest respiratory muscles may be required.
■ Assist with diagnostic and laboratory studies (portable CXR, ABGs, ECG,
other diagnostic tests, sputum culture, bronchoscopy).
■ Insert IV access.

BE PREPARED TO
■ Call a code.
■ Assist with intubation.
■ Transfer to ICU.

POSSIBLE ETIOLOGIES
■ Hypoxemic respiratory failure: chronic bronchitis and emphysema (COPD),
pneumonia, pulmonary edema, pulmonary fibrosis, asthma, pneumoth-
orax, pulmonary embolism, pulmonary arterial hypertension, pneumo-
coniosis, granulomatous lung diseases, bronchiectasis, adult respiratory
distress syndrome, fat embolism syndrome.
■ Hypercapnic respiratory failure: COPD, severe asthma, drug overdose,
poisonings, myasthenia gravis, polyneuropathy, poliomyelitis, primary
muscle disorders, head and cervical cord injury, primary alveolar
hypoventilation, obesity hypoventilation syndrome, pulmonary edema,
adult respiratory distress syndrome, myxedema.

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Ventilators/Mechanical Ventilation
Indications
■ Airway obstruction.
■ Inadequate oxygenation—O2 saturation (90% on hi-flow oxygen via
nonrebreather mask).
■ Inadequate ventilation—hypoventilation (high pCO2, pH acidosis).
■ Increased work of breathing, ineffective breathing pattern.
■ Airway protection.
Common Settings
■ AC (assist control)—patient triggers ventilator to deliver a breath. If apnea
occurs, a minimum rate and volume will be delivered to the patient.
■ CPAP (continuous positive airway pressure)—continuous, nonstop
positive pressure is applied throughout entire respiratory cycle.
■ BiPAP (bilevel positive airway pressure)—same as CPAP but with two
preset pressure settings: one for inspiration and one for expiration.
■ CMV (continuous mandatory ventilation)—ventilator delivers a set tidal
volume at a set rate regardless of patient’s own attempts to breathe.
Expect patient to require sedation.
■ IMV (intermittent mandatory ventilation)—ventilator delivers a set tidal
volume at a set rate, yet also allows the patient to initiate breaths.
■ PSV (pressure support ventilation)—for patients with spontaneous
breathing. Ventilator delivers a preset positive pressure for the duration
of inspiration when the patient initiates a breath.
■ SIMV (synchronized intermittent mandatory ventilation)—ventilator
is triggered only by a patient-activated demand valve and, therefore,
synchronizes with the patient’s own respiratory efforts.
■ PEEP (positive end-expiratory pressure)—maintains a preset positive
airway pressure at the end of each expiration. PEEP is used to treat a
PaO2 of 60 mm Hg on FiO2 of 50%.

Troubleshooting Ventilator Problems

Patient in sudden, severe repiratory distress
■ Unhook the ventilator from the endotracheal (ET) tube, and manually
ventilate patient with 100% oxygen using an Ambu bag. Get help after
unhooking patient from ventilator.
■ If patient is easy to ventilate manually and is no longer in distress,
the ventilator is the probable source of the problem. Notify respiratory
therapy (RT). While you manually ventilate the patient, the respiratory
therapist should assess the ventilator per manufacturer’s guidelines. The
ventilator may need to be changed if the problem cannot be found.

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■ If patient is difficult to ventilate manually: suction the ET tube

to clear secretions. Notify RT. If unable to clear obstruction or pass
suction catheter, extubate and manually ventilate with 100% oxygen
using an Ambu bag and face mask. Suction the oropharynx to clear
secretions. Notify RT/physician STAT, and assist with reintubation.
■ Assess for air leak. Listen for air around the cuff, and check cuff pressure
with a manometer, if available. Notify RT for possible reintubation if air
leak cannot be fixed.
■ Assess for dislodgement. If tube is dislodged, remove and manually
ventilate patient with 100% oxygen using Ambu bag and face mask.
Suction oropharynx to clear secretions. Notify RT/physician STAT, and
assist with reintubation.
■ Assist with reintubation if needed or replacement of ventilator or
ventilator components.
■ If ineffective ventilation continues, inspect and auscultate the patient’s
chest for equal and adequate air entry. If there is unequal chest wall
movement and/or decreased air entry on one side, it may be related to
a malpositioned tube, atelectasis, or a tension pneumothorax. Notify
physician and RT.
■ If ineffective ventilation continues and no physical or mechanical cause
can be found, consider sedating the patient.

Ventilator Alarms: Implications and Interventions

When the ventilator alarms, check the patient first. If patient is in no apparent
distress, check vent to determine source of problem. If patient is showing
signs of distress (“fighting the vent”), try to calm the patient. If unsuc-
cessful, immediately disconnect patient from vent, and manually ventilate
with 100% oxygen using an Ambu bag and call for help.

Alarm Interventions
Low-Pressure ■ Reconnect patient to ventilator.
Alarm ■ Evaluate cuff, and reinflate if needed (if
Usually caused by ruptured, ET tube will need to be
system disconnec- replaced).
tions or leaks. ■ Evaluate connections, and tighten or
replace as needed.
■ Check ET tube placement (auscultate lung
fields, and assess for equal, bilateral
breath sounds).

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Alarm Interventions
High-Pressure ■ Suction patient if secretions are suspected.
Alarm ■ Insert bite block to prevent patient from
Usually caused by biting ET tube.
resistance within ■ Reposition patient’s head and neck, or
the system. Can reposition tube.
be kink or water ■ Sedation may be required to prevent a
in ET tubing, patient from fighting the vent, but only
patient biting the after careful assessment excludes a
tube, copious physical or mechanical cause.
secretions, or
plugged tube.

High Respiratory ■ Suction patient.

Rate ■ Look for source of anxiety (e.g., pain).
Can be caused by ■ Evaluate oxygenation.
anxiety or pain,
secretions in ET
tube/airway,
hypoxia

Low Exhaled ■ Evaluate/reinflate cuff; if ruptured, ET tube

Volume must be replaced.
Usually caused ■ Evaluate connections; tighten or replace as
by ET tubing needed; check ET tube placement;
disconnection, reconnect
inadequate seal to ventilator.

Tracheostomy Dislodgement
CLINICAL PICTURE
The patient:
■ Coughs out tracheostomy tube.
■ If on a ventilator, low pressure alarms may sound.

IMMEDIATE INTERVENTIONS
■ If the tracheostomy is less than 4 days old, STAT intervention is required
as the tract can collapse suddenly. Page respiratory therapist and
physician or NP STAT. Only trained personnel should replace a new
tracheostomy tube.

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■ Open the tracheostomy with a sterile hemostat, suction catheter, or

sterile gloved finger to maintain airway patency, and prevent the edges
of the tracheostomy from collapsing.
■ If patient cannot breathe, ventilate with bag-valve mask.
■ If you cannot be sure that someone clinically prepared to rein-
sert the tracheostomy tube will arrive within 1 minute, call a code.
■ If the tracheostomy is older than 4 days, the tract will be well formed and
will not close quickly.
■ Notify physician or NP and respiratory therapist that tube needs to be
replaced.
■ Obtain replacement tube, if not already at the bedside.
■ Stay with patient, and prepare for insertion of new tube.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess patient’s ability to breathe through stoma. Look, listen, and feel for
signs of air movement through stoma.
■ Assess tracheostomy site for secretions (blood, mucus, etc.), swelling, or
trauma.
■ Auscultate lungs, and assess patient’s ability to cough effectively and clear
airway.

STABILIZING AND MONITORING

■ After tube is reinserted and tracheostomy dressing is in place, check that
ties are secure but not excessively tight. You should be able to easily
insert 1 finger under the ties.
■ Administer humidified supplemental O2.
■ Assess oxygenation status by monitoring LOC and SaO2.
■ For future tracheostomy care, have another nurse hold tube in place while
ties are changed.
■ Obtain sterile hemostat, sterile obturator, and replacement tracheostomy
tube to be kept at bedside.
■ Chart patient status, and report to physician or NP.

BE PREPARED TO
■ Call a code.
■ Assist with the insertion of a new tracheostomy tube.
■ Perform tracheostomy care.

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POSSIBLE ETIOLOGIES
■ Coughing, patient movement, poorly secured tracheostomy tube,
accidental self-extubation, excessive torque or tension on a tracheostomy
tube attached to a ventilator or other O2 administration device, deflated
tracheostomy cuff.

Basic ABG Interpretation

Commonly Used Terms

■ SaO2 is the oxygen saturation, frequently called O-2-”sats”
■ PaO2 is the partial pressure of oxygen in the blood and is referred to
as P-O-2
■ PaCO2 is the partial pressure of carbon dioxide. It can be called carbon
dioxide or carbonic acid, but people generally call it C-O-2
■ HCO3 is bicarbonate, usually called “bicarb”
Step-by-Step Interpretation
Determine the acid base balance: is it acidic, alkaline, or normal?
■ Evaluate pH. The range of 7.35–7.45 is very precise.
■ If the pH is between 7.35 and 7.40 it is considered normal, trending to
acidic; a pH between 7.41 and 7.45 is considered normal, trending to
alkalotic.
1. Determine the source of the imbalance. Is the problem primarily
respiratory or metabolic?
■ Evaluate Paco2. This is the respiratory component. Carbon dioxide is
an acid; therefore, an elevated CO2 & respiratory acidosis. A decreased
CO2 & respiratory alkalosis.
■ Evaluate HCO3. This is the metabolic component. Bicarbonate is a base;
therefore, if it is too low, it means metabolic acidosis. High bicarbonate
& metabolic alkalosis.
■ Putting it together: to determine if the imbalance is primarily respir
tory or metabolic, compare the pH with both the respiratory and the
metabolic components. Whichever of the two is consistent with the
pH result (acidosis or alkalosis) is the system that is dominating. For
example: if the ABG results are pH & 7.50, PaCO2 & 28, and HCO3 & 23,
the pH level is high: alkalosis. PaCO2, which is a respiratory acid, is low.
Low acidity is another way of saying alkalosis, so they are consistent.
HCO3, a metabolic buffer, is normal, neither acidosis or alkalosis. This
means the respiratory system is causing the alkalosis, which is called
respiratory alkalosis.

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2. Determine the body’s response. Is it compensated or not?

■ The kidneys attempt to compensate for respiratory abnormalities,
whereas the lungs try to correct metabolic disturbances. The extent
of correction is referred to as compensation.
■ Compensated: Look at the pH. If it is normal, but the carbon dioxide
or bicarbonate level is off, then the body has fully compensated.
■ If pH is not normal, determine if problem is partially compensated or
uncompensated.
■ Partially compensated: Abnormal pH with either the PaCO2 or the
HCO3 abnormal indicates partial compensation.
■ Abnormal pH with both the PaCO2 and the HCO3 abnormal indicates
no compensation.
3. Determine how well the lungs are oygenating.
■ The two basic measures of oxygen in the blood are SaO2 and PaO2,
although there may be others (hemoglobin and O2CT).
■ PaO2 is a measure of the amount of oxygen dissolved in the blood. It
reflects how well the lungs are getting oxygen into the bloodstream
from the atmosphere. Normal PaO2 & !80 mm Hg.
■ PaO2 60–80 mm Hg & mild hypoxemia
■ PaO2 40–60 mm Hg & moderate hypoxemia
■ PaO2 %40 mm Hg & severe hypoxemia
■ Decreased PaO2 levels are associated with
■ anemia
■ hypoventilation
■ heart failure
■ COPD and other restrictive pulmonary diseases.
■ SaO2 reflects to what degree oxygen is carried by hemoglobin. Hemo-
globin has four oxygen-carrying sites. When all four sites have a
molecule of oxygen attached, the hemoglobin is “saturated.” Normal
SaO2 is 95%–100%. Some patients may have lower levels and not be
in distress; the nurse must look at the whole picture and not just an
isolated number. SaO2 less than 90% requires rapid intervention, unless
it is within the patient’s baseline range.
■ You will sometimes see a PaO2 and a PaO2. These are different
measures. PaO2 is the partial pressure of oxygen in the arteries. PaO2 is
the partial pressure of oxygen in the alveoli. Both are used to calculate
the A-a gradient, which indicates how well the lungs are getting oxygen
from the air into the pulmonary circulation. If the A-a gradient is
elevated, it means the lungs are not performing well.

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Oxygen Delivery Systems
Cannula (nasal prongs)
■ Indicated when low-flow, small-
percentage oxygen therapy is desired.
■ Flow rate of 1–6 L/min delivers
24%–44% oxygen.
■ Allows patient to eat, drink, and talk.
■ Extended use can dry the nose and
nasopharynx; use with humidifier.

Cannula (nasal prongs).

Simple Mask
Exhalation
■ Indicated when desired FiO2 to be ports
delivered is 40%–60%.
■ Flow rate of 6–10 L/min delivers Elastic
strap
35%–60% oxygen.
■ Lateral perforations permit exhalation
of CO2.
■ Permits humidification.
To oxygen
source

Simple mask.
Bag-Mask (nonrebreather) (one-way valves)

■ Indicated when high concentrations of O2

are desired. Exhalation
■ Flow rate of up to 15 L/min delivers up to port
100% oxygen.
■ One-way flaps open and close with respira-
tion, resulting in a high concentration of
delivered oxygen and minimal to no CO2
Inhalation
rebreathed by the patient. port

Bag-mask (nonrebreather).

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Venturi Mask (Ventimask)

■ Indicated for precision titration of oxygen.
■ Accurate delivery of O2 is accomplished with
a graduated dial that is set to the desired
percentage of oxygen to be delivered.
■ Flow rate of 4–8 L/min delivers 24%–40%
oxygen.

Venturi mask (Ventimask).

Ambu Bag, Bag-Valve-Mask
One-way
■ Indicated for resuscitation or to valve
Reservoir
manually ventilate a patient Mask
during transport or ventilator Bag
failure or interruption.
■ Can deliver up to 100% oxygen. O2 supply
■ Appropriate size and fit are essen-
tial, both to create a good seal
and to prevent injury.
■ To create seal, hold mask with
thumb and pointer finger (thumb
toward nose), and grasp under-
neath the ridge of the jaw with
remaining three fingers Ambu bag, bag-valve-mask.
(see picture).

Humidified Systems
■ Indicated for patients requiring long- To oxygen
source
term oxygen therapy to prevent
drying of mucous membranes.
■ Setup may vary among brands.
Fill canister with sterile water to
To patient Maximum
recommended level, attach to fill line
oxygen source, and attach mask
or cannula to humidifier.
■ Adjust flow rate. Minimum
Sterile water water level
in reservoir line

Humidified systems.

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Transtracheal Oxygenation
■ Indicated for patients with a
tracheostomy who require long-
term oxygen therapy and/or
intermittent, transtracheal
aerosol treatment.
■ Ensure proper placement (over Chain necklace
stoma, tracheal tube). Tract
■ Assess for and clear secretions Transtracheal catheter
(connect to oxygen)
as needed.
■ Assess skin for signs of irritation. Trachea
Transtracheal oxygenation.

Artificial Airways
Oropharyngeal Airway OROPHARYNGEAL AIRWAY

■ Indicated for unconscious TRACHEA

TONGUE
patients who do not have a ESOPHAGUS
OROPHARYNGEAL
gag reflex. AIRWAY
■ Measure either from the cor- PHARYNX
ner of the mouth to the earlobe
or from the center of the mouth
to the angle of the jaw.
■ Rotate airway 180' while insert-
ing into oropharynx.

Oropharyngeal airway.

Nasopharyngeal Airway
PHARYNX NASOPHARYNGEAL
■ Indicated for patients with a gag AIRWAY
reflex, comatose with spontaneous TRACHEA

respirations, lockjaw.
■ Measure from the tip of the
patient’s nose to the earlobe.
■ The diameter should match that
ESOPHAGUS
of the patient’s pinkie.
■ NEVER insert in the presence
of facial trauma.
Nasopharyngeal airway.

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Endotracheal Tube
■ Indicated for apnea, airway obstruction, respiratory failure, risk of
aspiration, combative patient (protect from further injury), or when goal of
therapy is hyperventilation.
■ Can be inserted through the mouth or nose.
■ Inflated cuff protects patient from aspiration.

Endotracheal tube.

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A & P Snapshot

Arteriole Pulmonary
Frontal sinuses capillaries
Alveolar
Sphenoidal duct
sinuses
Nasal cavity
Nasopharynx

Soft palate
Epiglottis
Larynx and Alveolus
vocal folds
Trachea Venule
B
Superior lobe
Left lung
Right lung
Left
primary
Right bronchus
primary Superior
bronchus lobe

Middle
lobe
Bronchioles
Inferior lobe

Inferior Mediastinum Pleural

lobe membranes
Diaphragm Cardiac notch
Pleural space
A
Respiratory system.

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Pulmonary

e
ac
capillary

sp
ir
ra
e ola O2
Alv pickup
O2

Hb

Hb O2

O2 O2

Systemic
capillary O2
delivery

Plasma
Hb O2

Red blood
cells Hb O2

O2

O2
s

e
in su
lls tis
Ce ral
e
iph
per

Oxygen pickup and delivery.

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59

Pulmonary

e
ac
capillary

sp
ir
ra
e ola CO2
Alv delivery
CO2

CO2

H2CO3
H 2O
CO2
Systemic
Hb capillary CO2
Hb CO2 pickup

CO 2 H2CO3
Hb

H 2O
Hb
s

e
in su
lls tis
CO2 Ce ral
e
iph
per

B CO2

CO2 delivery and pickup.

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NEURO

Neurological Assessment
Mental Status
■ See Mini Mental Status Examination.
■ Assess affect, mood, appearance, grooming.
■ Assess speech for clarity and coherence.
■ Assess LOC—alert, lethargic, stuporous, obtunded.
■ Assess orientation—person, place, time.
Cranial Nerves
■ See Cranial Nerve Assessment in this tab.
Balance and Coordination
■ Gait/balance
■ Observe gait patterns while instructing patient to walk away from you
and then back again.
■ Have patient hop in place on each foot.
■ Have patient stand from a sitting position.
■ Coordination
■ Instruct patient to tap the tip of the thumb with the tip of the index
finger as fast as possible.
■ Instruct patient to touch nose and your index finger alternately several
times. Continually change the position of your finger during the test.
Sensation, Strength, Motion, Reflexes
■ Ask about altered sensations such as numbness and tingling.
■ Using your finger and a toothpick, instruct patient to distinguish between
sharp and dull sensations. Compare left side of body with right, with
patient’s eyes closed.
■ Assess motor strength of all four extremities.
Muscle Strength Grading Scale
0 No muscle movement
1 Visible muscle movement, but no movement at the joint
2 Movement at the joint, but not against gravity
3 Movement against gravity, but not against added resistance
4 Movement against resistance, but less than normal
5 Normal strength
■ Assess reflexes using a reflex hammer
Tendon Reflex Grading Scale
0 Absent
1$ Hypoactive
2$ Normal
3$ Hyperactive without clonus
4$ Hyperactive with clonus

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■ Assess plantar (Babinski’s) reflex by stroking the lateral aspect of the
sole of each foot with the reflex hammer. Normal response is flexion
(withdrawal) of the toes.

Glasgow Coma Scale (GCS)

The GCS is an LOC assessment tool.

Best Eye Response (E)
Spontaneously 4
On command 3
To pain 2
No response 1
Score:_______
Best Verbal Response (V)
Alert and oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
No response 1
Score:_________
Best Motor Response (M)
Follows direction 6
Localizes pain 5
Withdraws from pain 4
Abnormal flexion 3
Abnormal extension 2
No response 1
Score:________
Score may range from 3 (lowest neurological function) to 15 (highest
function). However, a number of combinations of eye opening, verbal
response, and motor response will give the same score. To provide a clearer
picture of the patient’s neurological functioning, record the score in the
following manner:
GCS ! 9/15 (E ! 2, V ! 3, M ! 4)
This is read as “Glasgow Coma Score ! 9 out of a possible 15, eye opening
score 2, verbal response score 3, motor response score 4.”

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Cranial Nerve Assessment

Nerve Name Function Test

I Olfactory Smell Identify familiar odors (e.g., coffee,
peppermint).

II Optic Visual acuity Assess visual acuity using eye chart.

Visual field Assess peripheral vision.
III Oculomotor Pupillary Assess pupils for equality and
reaction reactivity to light.
IV Trochlear Eye Patient follows finger without
movement moving head.

V Trigeminal Facial Touch face, and assess for sharp

sensation and dull sensation.
Motor Have patient hold mouth open.
function

VI Abducens Motor Patient follows finger without

function moving head.

VII Facial Motor Have patient smile, wrinkle face,

function puff cheeks.
Sensory Patient differentiates between sweet
and salty taste.

VIII Acoustic Hearing Snap fingers close to patient’s ears.

Balance Feet together, arms at side, eyes
closed for 5 sec.

IX Glossopha- Swallowing Have patient swallow and then say

ryngeal and voice “Ah.”

X Vagus Gag reflex Use tongue depressor or swab to

elicit gag reflex.

XI Spinal Neck motion Patient shrugs or turns head against

accessory resistance.

XII Hypoglossal Tongue Patient sticks out tongue and moves

movement it from side to side.

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Mini Mental Status Examination

Task Instructions Scoring Score

Date orientation “Tell me the date.” 1 point each for
Ask for omitted year, season,
items. date, day of
week, and month.
Place “Where are you?” 1 point each for
orientation Ask for omitted state, county,
items. town, building,
and floor or
room.
Register Name three 1 point for each
three objects objects slowly item repeated
and clearly. Ask correctly.
patient to repeat
them.
Serial 7s Ask patient to 1 point for each
count backward correct answer
from 100 by 7. (or letter).
Stop after five
answers (or ask
patient to spell
“world”
backwards).
Recall three Ask patient to 1 point for each
objects recall the objects item remembered
mentioned correctly.
above.
Naming Point to your watch 1 point for each
and ask patient correct answer.
“What is this?”
Repeat with a
pencil.
Repeating Ask patient to say 1 point if successful
a phrase “No ifs, ands, or on first try.
buts.”

(Continued on the following page)

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NEURO

Mini Mental Status Examination (continued)

Task Instructions Scoring Score

Verbal commands Give patient a plain 1 point for each

piece of paper and correct action.
say “Take this
paper in your right
hand, fold it in
half, and put it on
the floor.”
Written commands Show patient a piece 1 point if patient
of paper with closes eyes.
“Close your eyes”
printed on it.
Writing Ask patient to write 1 point if
a sentence. sentence has
a subject and
a verb and
makes sense.
Drawing Ask patient to copy a 1 point if the
pair of intersecting figure has
pentagons onto a 10 corners and
piece of paper. 2 intersecting
lines.
Scoring
Total possible score: 30. Score of 24 or above is considered normal.

Altered Level of Consciousness

CLINICAL PICTURE
The patient may have or be:
■ Change in usual state of full consciousness.
■ Difficulty or inability to respond to verbal stimuli.
■ Inability to speak, obey commands, or open eyes in response to verbal
or painful stimuli.
■ Confused, lethargic, obtunded, stuporous, or comatose (see following
table for definitions).

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IMMEDIATE INTERVENTIONS
■ Assess and protect airway.
■ Administer supplemental O2, or ventilate if patient is not breathing
adequately (RR "8 and/or cyanosis).
■ Suction the oropharynx, and clear secretions as needed.
■ Assess VS, O2 saturation, and pupillary reaction.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess airway for patency and secretions/obstructions.
■ Assess breathing and oxygenation.
■ Assess HR for rate and regularity.
■ Assess LOC (see GCS in this tab), pupil reactivity and size, best motor
response, and orientation.
■ Assess responsiveness to verbal or painful stimuli. Note: Does patient
respond to verbal stimuli? If not, does patient respond to gentle stimuli
(shaking the arm) or only to painful stimuli (e.g., grasping the pectoralis
muscle)? Is the motor response to stimuli purposeful (removing or
withdrawing from stimuli or posturing)?
■ Assess for associated neurological deficits such as weakness or numbness
on one side of the body.
■ Assess medication administration record (MAR) for drugs capable of
causing altered LOC.

STABILIZING AND MONITORING

■ Collaborate with health-care team to treat underlying causes (such as
drug overdose), if applicable.
■ Continue to monitor VS, breathing, and oxygenation closely.
■ Continue to monitor neurological status.

BE PREPARED TO
■ Assist with airway management or intubation if needed.
■ Start an IV.
■ Give medications.
■ Order laboratory tests.
■ Transfer patient to ICU.

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POSSIBLE ETIOLOGIES
■ Brain lesions/interruptions in blood flow, metabolic disorders (hypo-
glycemia, hypoxia), psychiatric disorder, toxic medication levels/drug
overdose, increasing intracranial pressure (ICP), dysrhythmia.

Levels of Consciousness

LOC Characteristics

Full consciousness Awake, alert, and oriented. Understands written

and spoken language, and responds reliably.

Confusion Disoriented first to time, then place, then person.

Memory deficits, difficulty following commands,
restless, agitated.

Lethargy Oriented to time, person, and place, but

demonstrates slow mental processes, sluggish
speech. Sleeps frequently, but wakens to spoken
word or gentle shake. Maintains wakefulness
with sufficient stimulation.

Obtundation Extreme drowsiness, responds with one or two

words, follows very simple commands, requires
more vigorous stimulation to waken, and stays
awake for only a few minutes at a time.

Stupor Minimal movement, responds unintelligibly, and

wakens briefly only to repeated vigorous
stimulation.

Coma Does not respond to verbal stimuli, does not speak.

May have appropriate motor response (e.g.,
withdraws from noxious stimuli), nonpurposeful
response, or no response.

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Change in Mental Status/Delirium
CLINICAL PICTURE
The patient may have or be:
■ Confused, restless, agitated, disoriented to time and place.
■ Easily distracted, delusional, hallucinating.
■ Disturbed general appearance, motor activity, dress, and facial expression.
■ Agitated or obtunded with fluctuating LOC.
■ Rambling, disorganized speech.
■ Impaired cognitive function.
■ Reversal of sleep-wake cycle.

IMMEDIATE INTERVENTIONS
■ Assist patient to safe area or back to bed.
■ If LOC is diminished, position to maintain patent airway.
■ Provide supplemental O2 if saturation in room air is 93%.
■ Check MAR for recently given medications.
■ Stay with patient, and notify physician or NP.
■ Document patient status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess VS, oxygenation, and neurological status.
■ Assess mental status with Mini Mental Status Examination (see table in
this tab).
■ Assess for associated neurological deficits, such as weakness or
numbness on one side of the body or changes in consciousness.
■ Assess for history of alcohol abuse, medication use, psychiatric illness.
■ Assess for possible source of infection.

STABILIZING AND MONITORING

■ Assess neurological status, motor function, and respiratory function.
■ Auscultate lungs for adventitious sounds.
■ Reorient as needed. Place calendar, clock, and family photos in room.
■ Provide stable, quiet, and well-lighted environment.
■ Keep staff consistent, if possible.
■ Explain procedures before beginning care.
■ Have patient wear eyeglasses and hearing aids, if applicable.
■ Enhance safety of environment.
■ Stay with patient, and offer support and reassurance.
■ Avoid use of restraints.

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■ Assess nutritional status and ability to take foods and fluids.

■ Monitor I&O/fluid status.
■ Monitor laboratory results.
■ Provide support.
■ Collaborate with health-care team to treat identified cause(s).
■ Document patient status, and communicate to physician.

BE PREPARED TO
■ Start a peripheral IV.
■ Obtain laboratory work; prepare patient for diagnostic studies.
■ Obtain blood, sputum, and urine cultures.
■ Administer appropriate medications as ordered.
■ Arrange for one-on-one care.

POSSIBLE ETIOLOGIES
■ Hypoglycemia, hypoxia, low blood pressure, compromise of cerebral
blood supply (stroke), elevated ammonia levels (end-stage liver failure),
toxic medication levels, drug-induced psychosis, urosepsis (especially in
the elderly), structural lesions, metabolic disorders, psychiatric disorders,
renal disease, compromise of cerebral blood flow.

Dizziness
CLINICAL PICTURE
The patient may have or be:
■ Sensation of spinning (vertigo), disequilibrium, or faintness.
■ Weakness, nausea.
■ Chest pain, tightness, squeezing, or pressure.
■ Shortness of breath, palpitations.
■ Tingling, pins-and-needles, weakness of extremities.

IMMEDIATE INTERVENTIONS
■ Assist patient to safe place to sit or lie down.
■ Administer supplemental O2.
■ Assess VS.
■ Encourage slow deep breaths.
■ Stay with patient, and provide reassurance.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

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FOCUSED ASSESSMENT
■ Assess VS and respiratory status.
■ Assess cardiac rhythm and rate; assess for orthostasis (take blood
pressure supine, sitting, and standing; note changes in systolic BP
and HR).
■ Assess for circumoral cyanosis, skin temperature, and moistness.
■ Assess MAR for recently taken medications that can cause dizziness.
■ Assess history of similar episodes.
■ Assess for history of inner ear disease or migraine.
■ Assess recent laboratory values for electrolyte abnormality.
■ If patient is diabetic, obtain blood glucose level by fingerstick.

STABILIZING AND MONITORING

■ Administer medications for dizziness as ordered.
■ Assess VS and subjective feeling of dizziness.
■ Help patient with ambulation and self-care until dizziness resolves.
■ Monitor I&O.
■ Monitor laboratory values.

BE PREPARED TO
■ Start an IV.
■ Assist with diagnostic testing.

POSSIBLE ETIOLOGIES
■ Hypertension, hypotension, stroke, hypoglycemia, cardiac dysrhythmias,
myocardial infarction, neuropathy, deconditioning, dehydration,
arteriosclerosis, Ménière’s disease, medications, migraine,
hyperventilation.

Head Trauma
CLINICAL PICTURE
The patient may have:
■ Scalp lacerations, hematoma, bilateral orbital ecchymosis.
■ Battle’s sign (bruising behind the ear at the mastoid process).
■ Altered mental status of LOC: agitated, semiconscious, consciousness
or unconscious; may have seizures.
■ CSF leakage from ear or nose.
■ Signs of ICP:
■ Decreasing LOC, deterioration in GCS.
■ Cushing’s response (bradycardia, hypertension, bradypnea).

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IMMEDIATE INTERVENTIONS
■ Assess airway, breathing, circulation; assess VS.
■ Call for assistance, and notify physician or NP.
■ If patient conscious, open airway, and inspect. Clear blood, vomitus, or
secretions.
■ Immobilize cervical spine with collar or by holding head and neck in
neutral alignment with body.
■ With proper assistance and C-spine aligned or in collar, transfer patient to
bed or stretcher.
■ Treat bleeding lacerations.
■ Document patient status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Examine for lacerations, depressions, swelling, Battle’s sign.
■ Inspect mouth for blood, foreign bodies, and vomitus.
■ Inspect pupils for equality and reactivity.
■ Inspect ears and nose for leakage of clear fluid (CSF) suggestive of skull
fracture.
■ Assess for distal deficits such as numbness or paralysis in the arms or
legs.
■ Assess cause and underlying conditions.
■ Assess for history of seizures.
■ Assess recent laboratory values, if available.

STABILIZING AND MONITORING

■ Continue to assess for impaired consciousness, deterioration in LOC,
unequal pupils/decrease in reactivity, severe tachycardia or bradycardia—
report changes in condition immediately.
■ Assess for severe and persistent headache, nausea and vomiting,
irritability or altered behavior.
■ Assist with diagnostic procedures (x-ray or CT scan).

BE PREPARED TO
■ Set up and assist with intubation.
■ Administer O2, and monitor oxygen saturation.
■ Monitor cardiac rhythm and VS.
■ Assist with diagnostic testing.
■ Insert an indwelling urinary catheter.
■ Start an IV; administer IVF and medications as ordered.
■ Assist with immobilization of neck and back.
■ Insert a nasogastric tube once skull fracture has been ruled out.

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POSSIBLE ETIOLOGIES
■ Patient fall, trauma.

Increasing Intracranial Pressure (ICP)

CLINICAL PICTURE
The patient may have or be:
■ Subtle to dramatic changes in LOC; restlessness, confusion, drowsiness,
stupor, coma.
■ Double or blurred vision, headache, nausea and vomiting, sensitivity to
light.
■ Decreased motor function.
■ Late findings: changes in VS (widening pulse pressure, bradycardia, and
increased respiratory rate).

IMMEDIATE INTERVENTIONS
■ Assess airway patency and breathing.
■ Assess VS.
■ Notify physician or NP of findings.
■ Elevate head of bed to 15"–30".
■ Provide high-flow O2 with a non-rebreather mask.
■ Keep head in neutral alignment.
■ Avoid flexion of the neck or hips.
■ Minimize environmental stimuli.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess neurological status (see Neurological Assessment in this tab and
GCS in this tab).
■ Assess cranial nerves as condition allows (see Cranial Nerve Assessment
in this tab).
■ Asses oxygen saturation, cardiac rhythm.
■ Assess for signs of decreased oxygenation (LOC, desaturation, cyanosis,
increase in respiratory rate).

STABILIZING AND MONITORING

■ Monitor neurological status and VS.
■ Keep systolic blood pressure between 100 and 160 mm Hg (check with
physician for parameters).

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■ Limit suctioning (increases ICP); suction for fewer than 10 seconds in

duration, and administer 100% O2 beforehand; limit to two passes.
■ Maintain SaO2 at 100%.
■ Maintain and assess I&O.
■ Monitor ABGs, electrolytes.
■ If necessary, insert an oral or nasal airway.
■ Maintain quiet environment; protect patient from injury.
■ Provide education/reassurance/comfort measures.
■ Document all findings, and communicate to physician or NP.
■ Obtain or perform chest physiotherapy as needed. Perform skin
assessment. Assess nutritional status; obtain consult if needed.

BE PREPARED TO
■ Assist with intubation if needed.
■ Establish IV access, and give medications (sedatives, osmotic diuretics,
corticosteroids, anticonvulsants).
■ Insert nasogastric tube or urinary catheter.
■ Transfer to ICU.

POSSIBLE ETIOLOGIES
■ Tumor, cranial abcess, intracranial bleed, cerebral hypoxia, hypertension,
hydrocephalus, head trauma.

Seizure
CLINICAL PICTURE
The patient may have:
■ Repetitive, jerking movements of the upper and lower extremities.
■ Extreme muscle rigidity.
■ LOC or disorientation.
■ Tongue or eye deviation.
■ Cyanosis or apnea.
■ Urinary or fecal incontinence.
■ Blinking or repetitive behaviors (e.g., playing with buttons).
■ Difficulty in arousing from stuporous state (postictal).
■ Aura (warning or recognition that seizure may occur).

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IMMEDIATE INTERVENTIONS
■ Ascertain that airway is not compromised by secretions or emesis.
Suction if necessary. Turn head/body to side, if able.
■ Protect patient from injury—clear immediate area of potentially harmful
objects; e.g., overbed table or glasses.
■ Raise siderails; if patient is OOB, guide to floor.
■ Stay with patient, and call for help.
■ Do not insert objects into patient’s mouth.

FOCUSED ASSESSMENT
■ Assess VS, airway patency, and respiratory status.
■ Note length, onset, duration, progression, and location (i.e., body parts
involved) of seizure activity.
■ Note tongue/eye deviation.
■ Note LOC, orientation, and responsiveness during seizure.
■ Assess pupil size, shape, and reactivity to light.
■ Assess for incontinence.

STABILIZING AND MONITORING

■ Suction the oropharynx, and clear secretions as needed.
■ Remove dentures.
■ Once seizure subsides (postictal phase), complete assessment, and
document findings. Include seizure description: aura; onset; duration;
body part in which seizure started; and progression of seizure activity;
LOC before, during, and after seizure; pupils; respiratory status; and any
precipitating factors.
■ Reorient patient if necessary.
■ Allow patient to sleep.
■ Provide reassurance and education.

BE PREPARED TO
■ Start an IV, and administer antiseizure medications. Check blood levels
of antiseizure medications.
■ Prepare patient with new onset seizures for extensive evaluation,
including CT scan, EEG, lumbar puncture, glucose level, Mg level, Ca
level, CBC, electrolytes, BUN, and creatinine levels.

POSSIBLE ETIOLOGIES
■ Inadequate blood levels of a prescribed anticonvulsant, arteriovenous
malformation, stroke, infection, trauma, tumor, metabolic disorders
(severe electrolyte disorders, low blood glucose level, renal failure,
hypoxia), drug or alcohol withdrawal.

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Spinal Cord Trauma/Syndrome

CLINICAL PICTURE
The patient may have:
■ History of recent back trauma with varying amounts of weakness and
sensory loss at and below the injury; pattern depends on whether cord
injury is complete or partial (incomplete).
■ Arm and/or leg weakness, paralysis.
■ Breathing difficulties.
■ Spasticity (increased muscle tone).
■ Altered sensation, numbness, pain.
■ Loss of bowel and bladder control.
■ Constipation, incontinence, bladder spasms.
■ Rapid blood pressure fluctuations; abnormal sweating and
thermoregulation (injuries to cervical or high thoracic cord).
■ Loss of sensation, reflexes, and mobility below level of injury.
■ Nausea and vomiting.

IMMEDIATE INTERVENTIONS
■ Immobilize cervical-spine (with light traction, hold head and neck in
neutral alignment with body).
■ If immobilizing entire body on a backboard, legs and torso must be
secured prior to securing head to board.
■ Assess airway, breathing, circulatory status.
■ Assess LOC, mental status.
■ Assess VS.

FOCUSED ASSESSMENT
■ Examine spine for lacerations, swelling, hematoma, deformity.
■ Assess mobility by asking patient to open and close fist, squeeze your
hand, and move toes and turn feet (see Neurological Assessment in this
tab).
■ Assess sensation by asking patient about numbness and altered sensation
and by touching patient lightly, beginning at shoulder and working down
arms and legs of both sides.

STABILIZING AND MONITORING

■ Frequently assess motor or sensory function—call physician or NP
immediately if condition changes.
■ Assess VS, O2 saturation, temperature.

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■ Assess for potential complications: neurogenic shock (hypothermia
and hypotension without tachycardia), spinal shock (urinary and bowel
retention leading to abdominal distention, ileus, and delayed gastric
emptying), autonomic hyperreflexia, respiratory compromise, nutritional
decline, skin breakdown, urinary retention, constipation.
■ Maintain spinal stabilization and immobilization. Move the patient
very carefully using logroll technique. Use a spine board with
restraints or other items, such as head blocks and pillows, to
maintain position.
■ Document findings, and communicate with physician or NP.
■ Assist with diagnostic studies (spine x-rays, CT, MRI).

BE PREPARED TO
■ Administer O2, and monitor O2 saturation.
■ Set up and assist with intubation.
■ Assist with placing patient in spinal traction.
■ Monitor cardiac rhythm and VS.
■ Assist with diagnostic testing.
■ Insert an indwelling urinary catheter.
■ Start an IV.
■ Administer IVF and medications (e.g., methylprednisone).
■ Assist with immobilization of neck and back.
■ Insert a nasogastric tube.

POSSIBLE ETIOLOGIES
■ Blunt or penetrating trauma, auto versus pedestrian, motor vehicle
accident, spinal lesion or abcess.

Sudden Neurological Deficit (Stroke/

Transient Ischemic Attack)
CLINICAL PICTURE
The patient may have:
■ Weakness or numbness of one side of the face or body.
■ Slurred speech, aphasia, difficulty finding words.
■ Difficulty swallowing.
■ Ataxia, clumsiness.
■ Double vision, severe headache.
■ Problems with respiratory function/gag reflex.
■ Tachycardia/bradycardia/hypertension.

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■ Changes in affect/memory/judgment.
■ Altered LOC, confusion, agitation.
■ Seizures.
■ Nausea/vomiting.

IMMEDIATE INTERVENTIONS
■ Maintain patent airway.
■ If in bed, elevate head of bed 30", and position head to one side to prevent
aspiration of secretions (if no signs of shock present).
■ Administer supplemental O2.
■ Assess VS.
■ Do not give anything by mouth.
■ Call physician or NP.
■ Stay with patient.
■ Document patient status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess airway, ability to clear secretions, breathing pattern, heart rate and
rhythm, oxygenation status, and blood pressure.
■ Assess LOC (see GCS in this tab).
■ If patient is conscious, assess level of orientation.
■ Assess pupillary response, vision, and facial symmetry.
■ Assess speech.
■ Assess motor strength and control (see Neurological Examination in
Tools tab).

STABILIZING AND MONITORING

■ Continue to maintain patent airway.
■ Reassess airway, ability to clear secretions, breathing pattern, heart rate
and rhythm, oxygenation status, and blood pressure every 15 minutes.
■ Initiate seizure precautions.
■ Suction the oropharynx as needed to clear secretions.
■ Assist with diagnostic testing (CT scan, MRI, ECG).
■ Monitor laboratory values, I&O.
■ Administer medications as ordered.
■ Stay with patient for continued monitoring and support.
■ Obtain nutrition assessment.
■ Perform skin assessment; initiate pressure ulcer prevention strategies.
■ Support patient, and provide safe environment.
■ Begin discharge/rehabilitation planning if stroke is confirmed.

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BE PREPARED TO
■ Aggressively manage airway.
■ Start an IV.
■ Administer O2.
■ Draw laboratory tests.
■ Accompany the patient to CT scan.
■ Assess if patient meets thrombolytic criteria.
■ Prepare patient for thrombolytic or anticoagulant therapy.
■ Transfer patient to a higher level of care.

POSSIBLE ETIOLOGIES
■ Embolic, thrombotic, or hemorrhagic stroke, TIA.

A & P Snapshot

Motor area
Premotor area General sensory area
Frontal lobe Sensory
association area
Parietal
lobe
Occipital
lobe
Visual
association
area
Visual area
Motor speech
area
Auditory
association
area Auditory area
Temporal lobe

Functional areas of the brain.

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OLFACTORY 1

OCULOMOTOR 3 OPTIC 2
TROCHLEAR 4
ABDUCENS 6

TRIGEMINAL 5

FACIAL 7

GLOSSOPHARYNGEAL 9

VESTIBULOCOCHLEAR 8

HYPOGLOSSAL 12

VAGUS 10
ACCESSORY 11

Cranial nerves.

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Central
canal
Interneuron Dorsal
Synapse column
Corticospinal tract
Dorsal root Rubrospinal
tract
Dorsal root
ganglion

Cell body
of sensor
neuron

Dendrite
of sensory
neuron

Receptor Ventral root

Axon of motor neuron
Spinothalamic
Synaptic knobs tract
White matter
Gray matter
Effector muscle
Cell body of
motor neuron

Cross section of the spinal cord.

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RENAL/F&E

Focused Renal/GU Systems Assessment

■ A focused nursing assessment of renal function includes:
■ Assessing blood work: blood urea nitrogen (BUN) and creatinine
values including BUN to creatinine ratio, electrolytes, other chemistries,
hemoglobin, hematocrit level, ABGs.
■ Assessing urine laboratory tests: specific gravity, urine osmolality,
creatinine clearance for renal function; urinalysis to screen for urinary
system dysfunction; urine C&S to assess for infection. (Many more
urine tests are available and are used to assess for diseases of systemic
or other body systems diseases. This tab cites only the urine tests used
specifically to assess the urinary system.)
■ Physical examination: vital signs; palpate for flank and CVA
(costovertebral angle) tenderness; assess hydration status.
■ Blood work:
■ BUN is a by-product of protein metabolism and is excreted by the
kidneys. A rise in BUN reflects a decrease in kidney function (kidneys
are less able to filter and excrete the urea). BUN is affected by other
variables (e.g., dehydration, upper GI bleed) and can remain within
normal range even when kidney function is markedly impaired.
Therefore, creatinine is a better measure of renal function, and
creatinine clearance is preferred among the three blood tests. A rise in
BUN without a rise in creatinine is most likely not related to a decline
in renal functioning.
■ Normal value: Adults: 5–20 mg/dL
■ Critical Level: !40 mg/dL (not dehydrated/no history of renal disease)
■ Critical Level: !100 mg/dL (patient with history of renal disease)
■ Critical Level: !20 mg/dL increase in 24 hr (indicates acute renal
failure)
Call physician or NP immediately with critical results.
■ Creatinine is a breakdown product of creatine phosphate in muscle.
It is generally produced at a constant rate by the body and then is
excreted by the kidney. It is used to estimate glomerular filtration rate.
A rise in serum creatinine reflects a decrease in glomerular filtration rate
(kidneys are less able to filter and excrete the creatinine, therefore, blood
levels rise).
■ Normal values: Adult: Male: 0.6–1.2 mg/dL; Female: 0.5–1.1 mg/dL
■ Critical level: !4 mg/dL

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Call physician or NP immediately with critical results.
■ Creatinine clearance (CrCl) compares the level of creatinine in urine
with the serum creatinine level. CrCl is used to determine safe dosing
of nephrotoxic drugs. Urine creatinine is based on a 24-hour urine
collection; blood for serum creatinine is collected at the end of the
24-hour period. However, CrCl is usually estimated by using a formula
based on age, mass, and serum creatinine. Normal values: Male:
107–139 mL/min; Female: 85–105 mL/min. CrCl of 10–20 mL/min is
indicative of renal failure and the need for dialysis.
■ Other urine tests include urinalysis for screening, urine osmolality and
specific gravity for assessing renal concentrating ability, and urine culture
and sensitivity for assessing urinary tract infection (UTI).
■ Assess urine for cloudiness, color, and volume.
■ Vital signs and ABGs: In coordination with other organs (lungs, adre-
nal glands, hypothalamus, endocrine system), the kidneys regulate
acid-base balance, electrolyte concentrations, blood volume, and BP.
The kidneys maintain BP through the renin-angiotensin system (RAS)
and regulate hydration status by retaining sodium in response to
aldosterone secretion. Therefore, kidney disorders may be reflected
in changes in BP, fluids and electrolytes, and acid-base balance. When
assessing BP, calculate the pulse pressure, which is the difference between
the systolic and diastolic pressures. High pulse pressure (!40 mm Hg) is
a risk factor for cardiac events. See Tab 3 for ABG interpretation. Briefly,
the sodium bicarbonate value represents the metabolic componet of the
ABG and is controlled by the kidneys.
■ Hydration status: Assess I&O, daily weights, mucous membranes,
sodium levels, BUN to creatinine ratio, urine osmolality, specific
gravity.
■ CVA tenderness: The angle created where the lowest ribs connect
with the vertebral column. CVA pain and tenderness with other UTI
symptoms suggests a kidney infection.
■ Focused assessment of the lower urinary tract includes:
■ Voiding patterns, including stress, urge, or overflow incontinence
and difficulties initiating stream.
■ Residual urine volume (amount of urine left in the bladder after
voiding).
■ Prostate examination in males.

RENAL/F&E
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RENAL/F&E

Electrolyte Imbalances
Electrolyte imbalances are encountered frequently in patients with all types
of conditions.
See p. 86 for hyperkalemia, p. 88 for hypokalemia, p. 87 for hypernatremia,
and p. 89 for hyponatremia

Hypocalcemia: Ca !8.4 mg/dL

S&S Treatment Nursing
Abdominal and Calcium gluconate Given by physician or NP on
muscle cramps, 10%*: 1 g in 50–100 general care units and by
lethargy, ↑ BP, mL of D5W over 1 hr, RNs in ICU. Do not infuse
tetany, seizure, then infusion of 1–2 too rapidly—is cardiotoxic
ECG changes. mg/kg/hr. and can cause ↓ BP.
Never given IM or
subcutaneously—causes
severe sloughing of tissue.
Check calcium and magne-
sium levels.
Antidote: IV magnesium
sulfate.
*Do not confuse with calcium chloride.

Hypercalcemia: Ca "10.2 mg/dL

S&S Treatment Nursing
Dehydration, renal D5NS at 250–500 Monitor electrolyte levels.
stones, confusion, mL/hr; furosemide Encourage fluid intake,
severe thirst, con- 20–80 mg IV over 2 provide ↑ fiber diet and
stipation, polyuria, min to bring Ca stool softeners.
shortening of QT down with Potentiate digoxin toxicity;
interval ↑ BP. diuresis. assess as indicated.
Monitor ECG, if available,
or assess pulse for
irregular beats.

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Hypomagnesemia Mg !1.5 mEq/L
S&S Treatment Nursing
Weakness, vertigo, 2 g magnesium Check other electrolyte
muscle twitching, sulfate in D5W over levels; can have ↓
tachycardia, 10–20 min, then 1 potassium, ↓ phosphate,
seizures, tetany, g/hr for 3–4 hr. ↓ calcium.
PVCs. Assess reflexes and monitor
Mg levels.

Hypermagnesemia Mg "2.1 mEq/L

S&S Treatment Nursing
Nausea, vomiting, Calcium gluconate Assess for changes in LOC.
↓ BP, weakness, 10%*: 1–10 mL in Assess reflexes.
drowsiness, hyper- 50–100 mL of D5W Hold medications contain-
reflexia, ↓ HR, over 10–20 ing magnesium, especi-
coma, respiratory minutes. ally in patients with renal
failure. failure.

*Do not confuse with calcium chloride.

Hypophosphatemia PO4 !2.5 mg/dL

S&S Treatment Nursing
Anorexia, weakness, Potassium or sodium Too rapid IV
muscle pain, confu- phosphate 2 mg/kg IV administration can
sion, rhabdomyoly- over 6 hr if PO4 level is cause severe
sis, hemolysis, !1–5 mg/dL. Oral hypocalcemia;
cardiac and respira- replacement with K- assess for tetany.
tory failure. Phos or Neutra-Phos if
depletion is less severe.

RENAL/F&E
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RENAL/F&E

Hyperphosphatemia PO4 !4.5 mg/dL

S&S Treatment Nursing
Limited symptoms; Phosphate binders, Teach patient about
possible tetany if possibly acetazolamide, avoiding foods and
calcium is low, low-phosphate diet OTC medications
which is a result high in phosphorus
of hyperphos-
phatemia.

Dehydration
CLINICAL PICTURE
The patient may have:
■ Increased thirst, dry mouth, and swollen tongue (see table below of Signs
and Symptoms of Progressive Dehydration).
■ Weakness, dizziness, palpitations.
■ Tachycardia, hypotension.
■ Confusion, sluggishness, fainting, seizure.
■ Decreased urine output.

IMMEDIATE INTERVENTIONS
■ Assess VS; check BP lying, sitting, and standing; note changes.
■ Assess current urine output and recent intake and output (I&O).
■ Make sure patient is comfortable and safe.
■ Notify physician.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess VS including temperature.
■ Assess skin for color, moistness, temperature, integrity.
■ Assess mucous membranes.
■ Assess LOC and orientation.
■ Assess for patent IV access.

STABILIZING AND MONITORING

■ Administer oral or IVF.
■ Closely monitor I&O.
■ Monitor urine output for adequate hourly rate.
■ Assess electrolytes, BUN, creatinine.

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■ Maintain safe environment.
■ Provide oral care.
■ Chart patient status and convey to physician or NP.

BE PREPARED TO
■ Obtain IV access.
■ Obtain a nutritional/dietary assessment.
■ Insert urinary catheter with a urometer to monitor hourly output.

Signs and Symptoms of Progressive Dehydration

Symptom/ Mild Moderate Severe

Sign Dehydration Dehydration Dehydration
LOC Alert Lethargic Obtunded
Capillary refill 2 sec 2–4 sec Greater than 4
sec, cool limbs
Mucous membranes Normal Dry Parched, cracked
HR Slight increase Increased Very increased
RR Normal Increased Increased and
hyperpnea
BP Normal Normal, but Decreased
orthostasis
Pulse Normal Thready Faint or
impalpable
Skin turgor Normal Slow Tenting
Urine output Decreased Oliguria Oliguria/anuria

POSSIBLE ETIOLOGIES
■ Gastroenteritis, stomatitis, diabetic ketoacidosis, febrile illness,
pharyngitis, burns, GI obstruction, heat stroke, diabetes insipidus,
thyrotoxicosis.

RENAL/F&E
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RENAL/F&E

Hyperkalemia
CLINICAL PICTURE
The patient may have:
■ Muscular weakness.
■ Cardiac dysrhythmias.
■ ECG abnormalities (tall, peaked T waves).
■ Nausea.

IMMEDIATE INTERVENTIONS
■ Assess VS; note cardiac rate and rhythm.
■ Administer oxygen.
■ Assess for patent IV access.
■ Assess recent laboratory results (BUN, creatinine, electrolytes).
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Monitor VS, and assess cardiac rhythm if available.
■ Assess LOC and orientation.
■ Assess musculoskeletal function.
■ Assess previous 2 days’ I&O.

STABILIZING AND MONITORING

■ Obtain IV access.
■ Administer potassium-binding resins (Kay-exalate) orally or rectally.
■ Monitor cardiac rhythm, I&O, serial potassium levels, and other laboratory
tests.
■ Chart patient status and convey to physician or NP.

BE PREPARED TO
■ Set up cardiac monitoring.
■ Administer IV calcium, sodium bicarbonate, insulin and glucose, or
furosemide per order.
■ Order or obtain laboratory tests.
■ Order a 12-lead ECG.
■ Transfer to telemetry unit.

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POSSIBLE ETIOLOGIES
■ Medication, chemotherapy, acute or chronic renal failure,
hypoaldosteronism trauma, hemolysis, digitalis poisoning, acidosis,
burns, insulin deficiency, uncontrolled hyperglycemia, excessive use of
salt substitutes, metabolic acidosis.

Hypernatremia
CLINICAL PICTURE
The patient may have:
■ Sodium level ! 144 mEq/L
■ Confusion, lethargy, seizures, coma (if imbalance is severe)
■ Restlessness, irritability, disorientation, hallucinations
■ Thirst (many older adults have an impaired sense of thirst and may not
express thirst) of flushed skin, peripheral edema
■ Postural hypotension, tachycardia

IMMEDIATE INTERVENTIONS
■ Assess recent lab values.
■ Assess vital signs; obtain orthostatic BP if possible.
■ Notify physician or NP, and document findings and discussion with
physician or NP in the chart.

FOCUSED ASSESSMENT
■ Assess total intake and output over previous several days.
■ Assess skin and mucous membranes; note dry cracked skin, sticky oral
membranes.
■ Assess mental status (see Mini Mental Status Examination in Tab 4)
■ Assess for intact IV site.

STABILIZING AND MONITORING

■ Insert IV, if necessary.
■ Administer parenteral fluids as ordered using a volume control infusion
device; make sure fluids do not infuse too quickly; doing so in the
presence of elevated sodium levels causes fluid shifts that can result in
cerebral edema and brain damage.
■ If patient is disoriented, move patient to a room near the nurse’s station
or ask if a family member can stay with the patient.
■ Continue assessment outlined above as treatment progresses.
■ Provide mouth care and measures to protect skin integrity.

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BE PREPARED TO
■ Change IVF as soon as a different concentration is ordered, depending
on changes in patient’s status
■ Monitor changes in mental status, laboratory values, VS

POSSIBLE ETIOLOGIES
■ Poor water intake due to inability to express thirst or insensible water
loss; diabetes insipidus, excess salt intake, near-drowning in salt water.

Hypokalemia
CLINICAL PICTURE
The patient may have:
■ Serum potassium !3.5 mEq/L.
■ Palpitations, ventricular dysrhythmias, bradycardia or tachycardia,
hypotension.
■ Malaise, fatigue, weakness, muscle cramps.
■ Nausea, vomiting, ileus, constipation.
■ Hypoventilation, respiratory distress.

IMMEDIATE INTERVENTIONS
■ Assess BP sitting and standing; note orthostasis.
■ Assess HR; note rhythm.
■ Assess LOC and muscle strength.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess recent I&O.
■ Assess cardiac rhythm if patient on telemetry.
■ Assess for digitalis toxicity, if indicated.
■ Assess recent laboratory results (BUN, creatinine, electrolytes,
magnesium level).
■ Assess medication history, use of diuretics or laxatives.
■ Assess for patent IV access.

STABILIZING AND MONITORING

■ Obtain IV access.

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89
■ Administer oral and/or IV potassium supplement. Oral supplementation
is much safer; IV rate should not exceed 200–400 mEq/24 hr (based on
serum potassium level of 2.0–2.5 mEq/L); never give as a bolus: may
precipitate cardiac arrest. Patient should be on telemetry if receiving
treatment level amounts of potassium.
■ Monitor potassium and other electrolyte levels.
■ Monitor HR and rhythm.
■ Maintain safety precautions due to muscle weakness.
■ Nutrition/dietary education, especially if taking diuretics.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Place patient on telemetry.
■ Order or obtain laboratory tests, urine sample for potassium, ECG.

POSSIBLE ETIOLOGIES
■ Deficient potassium intake, vomiting, diarrhea, fistulas, laxative abuse,
metabolic alkalosis, diuretic therapy, aldosteronism, excess adrenocortical
secretion, renal tubule disease, chronic respiratory acidosis.

Hyponatremia
CLINICAL PICTURE
The patient may have:
■ Mild: Na# !120 mEq/L: headache, nausea, vomiting, weakness, muscle
cramps.
■ Moderate: Na# 110–120 mEq/L: hallucinations, bizarre behavior,
hyperventilation, gait disturbance.
■ Severe: Na# !110 mEq/L: coma, respiratory arrest, hypertension, dilated
pupils, seizures.
■ Neurological symptoms usually reflect severe, sudden drop in serum
sodium level, which causes intracerebral osmotic fluid shifts and cerebral
edema. A gradual drop in serum sodium may be tolerated because of
neuronal adaptation.

IMMEDIATE INTERVENTIONS
■ Assess VS, LOC, feelings of weakness.
■ Make sure patient is comfortable and safe.
■ Check if blood for laboratory was drawn above a running IV site.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

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FOCUSED ASSESSMENT
■ Assess HR and BP lying, sitting, and standing (if possible); note changes
in BP and HR.
■ Assess fluid status: examine mucous membranes and skin turgor, assess
lung sounds, check for peripheral edema.
■ Assess recent I&O.
■ Assess for recent infusion of hypotonic IVF (common cause of ↓ Na#
in hospitalized patients) or use of continuous bladder irrigation (CBI).
■ Review medication and dietary history (salt and water intake).

STABILIZING AND MONITORING

■ Treament depends on patient’s volume status, duration and magnitude
of hyponatremia, and severity of symptoms (see Table on p. 91, Treatment
for Mild or Moderate Hyponatremia).
■ Monitor neurological status, laboratory values, I&O, VS.
■ Restrict fluids, and administer diuretics or IVF as ordered.
■ Chart patient status and convey to physician or NP.

BE PREPARED TO
■ Order or obtain laboratory tests (electrolyes, BUN, creatinine, urine
and serum osmolality, urine sodium concentration).
■ Obtain IV access.
■ Administer oral or IV diuretics.
■ Administer hypertonic saline solution IV if CNS symptoms present.
Caution: Must be administered slowly via an infusion pump. Too
rapid correction can cause permanent neurological impairment.

POSSIBLE ETIOLOGIES
■ Vomiting, diarrhea, excessive sweating, GI fistulas or drainage tubes,
pancreatitis, burns, acute or chronic renal insufficiency, medications
(thiazide diuretics, chlorpropamide, cyclophosphamide, clofibrate,
carbamazepine, oxcarbazepine, opiates, oxytocin, desmopressin,
vincristine, selective serotonin reuptake inhibitors, trazodone, or
tolbutamide), administration of hypotonic IV or irrigation fluids in the
immediate postoperative period, prolonged exercise in a hot environ-
ment, hepatic cirrhosis, congestive heart failure, nephrotic syndrome,
uncorrected hypothyroidism, cortisol deficiency, SIADH, use of the
recreational drug MDMA (ecstasy).

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Hypotonic Hyponatremia
Inability of the kidneys to excrete free water adequately. Categorized
according to the associated intravascular volume: hypovolemic,
hypervolemic, and euvolemic. Most common cause of hyponatremia in
surgical patients is infusion of hypotonic fluids.

Treatment for Mild or Moderate Hyponatremia

Type Cause Intervention

Hypovolemic ↑ sympathetic tone, ↓ renal Infuse 0.9% NS IV.
hyponatremia perfusion due to intravascular
volume depletion leading to ↑
renin and angiotensin excre-
tion, ↑ sodium absorption
and resultant impairment of
renal free water excretion.
Increase in serum ADH
further impairs free water
excretion.
Euvolemic Associated with SIADH arising Treat underlying
hyponatremia from many clinical conditions cause.
including CNS disturbances, Restrict free
major surgery, trauma, water.
pulmonary tumors, infection,
stress, and certain medica-
tions (e.g., chlorpropamide,
carbamazepine, cyclophos-
phamide, vincristine,
vinblastine, amitriptyline,
haloperidol, SSRI, and MAOI).
Hypervolemic ↑ in total body water and Restrict free
hyponatremia sodium with paradoxical ↓ in water.
circulating volume. Stimu- Possible diuretics.
lates the same pathophys-
iological mechanism of
impaired water excretion as
is found in hypovolemic
hypotonic hyponatremia.
Also called dilutional
hyponatremia.

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Oliguria (Low Urine Output/Acute Renal Failure)

CLINICAL PICTURE
The patient may have:
■ Urine output !500 mL in 24 hr.
■ Peripheral edema, neck vein distention, pulmonary crackles.
■ Orthostatic hypotension (if volume depleted), dry mucous membranes,
hypotension.
■ Electrolyte imbalance.
■ Fatigue, nausea, vomiting, abdominal pain.

IMMEDIATE INTERVENTIONS
■ Assess vital signs, recent I&O, LOC.
■ Assess for bladder distention.
■ Assess for patent IV access.
■ Notify physician or NP of low urine output.
■ Document patient status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess recent laboratory chemistry tests, especially BUN/creatinine.
■ Assess for orthostatic hypotension, mucosal membrane moisture, and
tissue turgor.

STABILIZING AND MONITORING

■ Insert IV access, and hang fluids to reverse hypovolemia.
■ Monitor I&O; assess for fluid overload.
■ Insert urinary catheter, and monitor urine output hourly.
■ Monitor BP, HR, capillary refill time, mental status.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Administer IVF challenge.
■ Obtain urine samples for analysis, culture, other studies.
■ Obtain or order laboratory tests including BUN/creatinine, chemistries, CBC.
■ Administer diuretics.
■ Transfer patient to ICU if invasive monitoring is required.
■ Educate patient and family about dialysis.

POSSIBLE ETIOLOGIES
■ Renal hypoperfusion (hypovolemia, CHF, sepsis, blood loss); renal arterial
disease; acute glomerulonephritis; acute tubular necrosis; tubular, ureteral,
or urethral obstruction; drugs (aminoglycosides, radiocontrast medium).

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Urinary Retention
CLINICAL PICTURE
The patient may have:
■ Difficulty initiating stream, feeling of not emptying bladder.
■ Inability to void.
■ Lower abdominal pain, bladder distention and spasm.
■ Voiding in frequent small amounts.

IMMEDIATE INTERVENTIONS
■ Palpate bladder to assess distention and tenderness.
■ Assist patient to assume natural voiding position if possible (stand male
patients, assist females to commode or raise HOB when using bedpan).
■ Implement triggers to help initiate stream (Credé’s maneuver, running
water, pouring warm water over perineum).
■ If patient still unable to empty bladder, check for PRN order to catheterize
patient.
■ If ordered, catheterize patient; note amount and characteristics of urine.
Remove catheter. Note: Do not catheterize patient if suspected pelvic
trauma or blood at meatus.
■ If patient does not have a straight catheter order or if residual volume is
excessive (!500 mL), call physician or NP, and relate findings.
■ Document patient status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess urine volume with a bladder scanner, if available.
■ Inspect and palpate for distention or tenderness of the lower abdomen.
■ Assess temperature; recent WBC count, if available.
■ Assess voiding patterns, recent urological procedure or procedure
requiring anesthesia, medications, history of BPH, urethral stricture,
history of incontinence.

STABILIZING AND MONITORING

■ Monitor I&O.
■ Evaluate subsequent attempts to void and PVR.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Collect sterile urine sample.
■ Initiate timed voiding and obtain postvoid residual (PVR) until PVR "100 mL.
■ Place indwelling urinary catheter.
■ Teach self-intermittent catheterization.
■ Instruct patient about urodynamic testing.

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POSSIBLE ETIOLOGIES
■ Obstruction in the bladder or urethra, neurogenic bladder (secondary
to CVA, spinal trauma/tumor, MS, neuropathy), long period of inactiv-
ity or bedrest, surgery, low fluid intake, benign prostatic hyperplasia
(BPH), kidney stones, urinary tract infection (UTI), medications—
antihypertensives, antihistamines (can be over-the-counter),
anticholinergics, sedatives, spinal anesthesia.

Urinary Catheterization
Straight Catheter
Also called red rubber catheter or “straight cath.” Straight catheters have
only a single lumen and do not have a balloon near the tip. Straight
catheters are inserted for only as much time as required to drain the bladder
or obtain a urine specimen.
Indwelling Catheter
Also called Foley or retention catheter. Indwelling catheters have two
lumens, one for urine drainage and one for inflation of the balloon near the
tip. Three-way Foley catheters are used for continuous or intermittent
bladder irrigation. They have a third lumen for irrigation.
Procedure
1. Prepare patient: explain procedure, and provide privacy.
2. Collect appropriate equipment.
3. Place patient in supine position (female: knees up, legs apart; male:
legs flat, slightly apart).
4. Open and set up catheter kit using sterile technique.
5. Don sterile gloves, and set up sterile field.
6. If placing indwelling catheter, test patency of balloon by filling
balloon with 5 mL sterile water. Check for leaks and proper inflation.
Remove water.
7. Lubricate end of catheter; saturate cotton balls with cleansing solution.
8. With nondominant hand and using forceps to hold cotton balls: female—
hold labia apart; swab from front to back, starting with the outer labia
and working inward toward the meatus. Use one swab per swipe (total of
five); male—retract foreskin; swab in a circular motion from the meatus
outward. Repeat at least three times, using a different swab each time.
9. Gently insert catheter (about 2–3 inches for females and 6–9 inches for
males) until return of urine is noted. Straight: collect specimen or drain
bladder, and remove catheter. Indwelling: insert an additional inch, and
inflate balloon.
10. Attach catheter to drainage bag, using sterile technique.
11. Secure catheter to patient’s leg according to hospital policy.
12. Hang drainage bag on bed frame below level of bladder.

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Patient Care
■ Wash hands with soap and water before and after handling catheter,
tube, or bag.
■ Keep bag below level of patient’s bladder at all times.
■ Check frequently to be sure there are no kinks or loops in tubing and that
patient is not lying on tubing.
■ Do not pull or tug on catheter.
■ Wash around catheter entry site with soap and water twice each day and
after each bowel movement.
■ Do not use powder around catheter entry site.
■ Periodically check skin around catheter entry site for signs of irritation,
redness, tenderness, swelling, or drainage.
■ Offer fluids frequently (if not contraindicated by health status), especially
water or cranberry juice.
■ Record urine output according to physician orders.
■ Empty collection bag each shift; note color, clarity, and odor.
■ Notify physician for any of the following:
■ Blood, cloudiness, or foul odor.
■ Decreased urine output (!30 mL/hr).
■ Irritation or leaking around catheter entry site.
■ Fever, abdominal or flank pain.
Removal
■ Don gloves.
■ Use a 10-mL syringe to withdraw all water from balloon.
■ Hold a clean 4 " 4 pad at meatus in the nondominant hand. With
dominant hand, gently pull catheter. If you meet resistance, stop and
reassess if balloon is completely deflated. If balloon appears to be
deflated and catheter cannot be removed gently, notify physician or
nursing supervisor for assistance.
■ Catheter should withdraw easily. Wrap tip in clean 4 " 4 pad as it is
withdrawn to prevent leakage of urine.
■ Provide bedpan, urinal, or assist patient to toilet. Measure spontaneous
void amount. Palpate bladder to ascertain it is empty.
■ Note time catheter discontinued.

Urinary Tract Infection (UTI)

CLINICAL PICTURE
The patient may have:
■ Lower UTI S&S (cystitis):
■ Dysuria, frequency, urgency, hesitancy.
■ Cloudy, foul-smelling, or bloody urine.

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■ Suprapubic pain.
■ Fever !101#F, chills, and malaise.
■ Upper UTI S&S (pyelonephritis):
■ Fever !101#F, shaking chills.
■ Nausea, vomiting, flank pain.
■ Elderly: altered mental status, delerium, anorexia, abdominal pain,
incontinence, or asymptomatic.

IMMEDIATE INTERVENTIONS
■ Assess VS.
■ Notify physician or NP of symptoms.
■ Obtain clean catheter urine specimen.
■ Offer acetaminophen (if ordered) and heating pad or hot water bottle
to relieve suprapubic pain.
■ Encourage patient to drink fluids to flush urinary system.
■ Document patient status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess history of UTI and usual voiding patterns.
■ Assess urine characteristics (odor, volume, color, cloudiness).
■ Assess for flank pain.

STABILIZING AND MONITORING

■ Administer antibiotics promptly and on schedule.
■ Administer phenazopyridine PRN for dysuria.
■ Monitor temperature. Encourage fluids.
■ Monitor for relief of symptoms or complications (urosepsis, onset of
upper UTI symptoms).

BE PREPARED TO
■ Insert saline lock for IV antibiotics for upper UTI.
■ Administer IVF.
■ Obtain catheterized urine sample.
■ Change or discontinue indwelling urinary catheter.

POSSIBLE ETIOLOGIES
■ Bacterial invasion of urinary tract (usually E. coli), factors that increase
risk: incomplete emptying of bladder secondary to benign prostatic hyper-
plasia, prostatitis, and urethral strictures, neurogenic bladder; lack of
adequate fluids, bowel incontinence, immobility or decreased mobility,
indwelling urinary catheters.

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A & P Snapshot

Ribs
Aorta
Inferior vena
cava
Left adrenal
gland
Superior
Diaphragm mesenteric
artery
Left renal
artery and
vein
Left kidney

Right Left ureter

kidney
Left common
iliac artery
and vein
Lumbar
Psoas vertebra
major
muscle Pelvis
lliacus Sacrum
muscle

Right
ureter

Opening of ureter
Urinary bladder Trigone of bladder
Symphysis pubis
Urethra
Urinary system.

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Parietal peritoneum Ureter

Detrusor muscle

Openings of
ureters
Rugae B
Ureter
Trigone
Prostate
gland

Prostatic
urethra
Trigone Membranous
Internal urethra
A urethral sphincter

External
Cavernous
urethral sphincter
(spongy)
urethra
Urethra
Cavernous
Urethral orifice (erectile)
tissue of
penis

Bladder and urethra. (A) Female. (B) Male.

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99
Focused GI Assessment
■ A focused nursing assessment of the GI system includes:
■ Investigation of abdominal pain, nausea, and vomiting.
■ Frequency and character of bowel sounds.
■ Amount of abdominal distention
■ Frequency and character of bowel movements (constipation or
diarrhea).
■ Appetite, intake, swallowing, and tolerance of foods and fluids.
■ Abdominal pain, nausea, and vomiting:
■ Ask the patient about the nature of the abdominal pain. Use the PQRST
guideline in the Basics tab.
■ Ask about nausea, and consider any recent procedures or new
medication.
■ If the patient has vomited, assess quantity and characteristics of
emesis.
■ Use a hemeoccult slide to test for blood in the emesis.
■ Fecal material in the emesis is rare but is an emergency if found.
■ Assess bowel sounds:
■ Assess bowel sounds before palpating the abdomen. Listen in all four
quadrants; however, most clinicians think that it is difficult to pinpoint
the origin of bowel sounds because they can be heard even when
ausculatating the lungs.
■ Bowel sounds provide supporting information to the clinical picture for
the patient with an evolving GI problem.
■ Normal bowel sounds are small gurgles heard every few seconds,
although there is considerable variability that is still considered normal.
■ Absence of bowel sounds can indicate an inflammatory process such
as peritonitis or a bowel obstruction.
■ High-pitched, frequent, tinkling bowel sounds can be heard in the initial
stages of a bowel obstruction.
■ Bowel sounds are absent after abdominal surgery and may take a few
days to return. Patients are not fed when bowel sounds are absent.
■ When bowel sounds return, which is usually accompanied with passing
flatus, it indicates that the intestinal tract is beginning to function again.
■ Assess abdominal distention:
■ The abdomen can be distended in many bowel problems; such disten-
tion is frequently associated with abnormal or absent bowel sounds.
The abdomen can be distended from constipation, excessive
abdominal gas, severe bowel dysfunction, obstruction, or infection.
■ Ascites, the abnormal accumulation of fluid in the peritoneal cavity, can
cause massive distention. For patients with ascites, mark the abdomen,
and measure girth at the same level each day to assess if ascites is
decreasing or increasing.

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GI

■ Bowel distention is usually observed; measurement as described above

is not done routinely, especially when the distention is of acute onset
as in a postoperative complication. Measurements only become
meaningful once a baseline is established.
■ Palpate or precuss the abdomen after listening to bowel sounds. Both
skills take practice to be helpful in an assessment. Refer to an
assessment textbook for more information.
■ Frequency and character of bowel movements (constipation
or diarrhea):
■ Monitor bowel movements, and ask the patient if he or she feels
constipated. Ask about normal bowel habits.
■ If the patient has diarrhea, ascertain the frequency and amount of stool.
Diarrhea, especially when accompanied by vomiting, can quickly cause
electrolyte imbalances and dehydration.
■ If the patient is constipated, look to the recent history (procedures),
medications that affect peristalsis (narcotics and many others), NPO
status, or other possible causes. If constipation is chronic, discuss
eating habits.
■ Assess for black, tarry stools (melena). Test the stool for blood when
GI bleeding is suspected.
■ Appetite, intake, swallowing, and tolerance of foods and fluids:
■ Any impairment in swallowing is serious and should be evaluated by a
speech pathologist. Suggest a consultation to the physician or NP.
■ If the patient complains of loss of appetite, find out more about the
problem. How long has it been; is there early satiety (feeling full after
eating small quantities); is there nausea, vomiting or weight loss?
■ If general food intake is low, especially in older adults, assess
dentition, and ascertain if foods have lost their taste to the patient.
■ Does the patient tolerate the foods and fluids offered? If not, why not?
Ask about allergies.
■ Decreased appetite is a symptom of many conditions, such as cancer,
COPD, esophageal problems, decline in acuity of taste buds, and others
and promptly needs to be evaluated.

Abdominal Pain and/or Distention

CLINICAL PICTURE
The patient may have:
■ Abdominal pain, tenderness, flank pain.
■ Nausea/vomiting/diarrhea.
■ Abdominal distention or rigidity.
■ High-pitched, hyperactive, hypoactive, or absent bowel sounds.

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IMMEDIATE INTERVENTIONS
■ Place patient in position of comfort.
■ If patient has a nasogastric tube (NGT) but is unattached to suction,
reconnect NGT to suction—note amount of immediate NGT drainage.
■ Assess vital signs (VS), including temperature.

FOCUSED ASSESSMENT
■ Ask patient to describe pain; use the PQRST guidelines in the Basics tab.
■ Assess recent bowel habits, recent laxative or enema use.
■ Inspect abdomen; auscultate bowel sounds.
■ Palpate abdomen for pulsations, tenderness, and rigidity. Assess from
area of least tenderness to area of most tenderness.
■ Assess hydration status and urine output (UO) by reviewing I&O record
for previous 2 days.
■ Check all recent laboratory values including WBC count.
■ Test emesis for occult blood.
■ Notify physician or NP of assessment findings. Document findings and
phone call.

STABILIZING AND MONITORING

■ Administer antiemetic and pain medication, if ordered.
■ Monitor VS as frequently as indicated.
■ Assess output from NGT (if placed).
■ Insert an IV and hang 0.9% NS (with order).
■ Clarify with physician or NP on alternative route for administration of
PO medications.
■ Obtain stool/emesis sample, and test for occult blood.
■ Monitor nutritional status.

BE PREPARED TO
■ Hang IVF.
■ Administer pain medication, antiemetics, antibiotics.
■ Insert an NGT, or set up suction.
■ Insert indwelling urinary catheter.
■ Order or obtain laboratory tests.
■ Facilitate diagnostic tests such as abdominal x-ray, CT, endoscopy,
ultrasound, and diagnostic imaging.

POSSIBLE ETIOLOGIES
■ Bowel obstruction, ileus, peritonitis, irritable bowel syndrome (IBS),
ascites, gastroenteritis, malignancy, liver disease, ulcers, appendicitis,
cholecystitis, pancreatitis.

GI
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NGT Insertion
Indications
■ Aspirate blood or fluids and gas from stomach.
■ Control nausea and vomiting.
Procedure
1. Explain procedure to the patient.
2. Position patient upright in high Fowler’s position. Instruct patient to keep
chin-to-chest posture during insertion. This helps to prevent accidental
insertion into the trachea.
3. Measure tube from tip of the nose to the ear lobe, then down to xyphoid.
Mark this point on the tube with a piece of tape.
4. Lubricate tube by applying water-soluble lubricant to tube. Never use
petroleum-based jelly.
5. Insert tube through nostril until the previously marked point on the tube
is reached. Instruct patient to take small sips of water during insertion to
help facilitate passing of the tube. Withdraw tube immediately if patient
becomes cyanotic or develops breathing problems.
6. Secure tube to patient’s nose using tape. Be careful not to block the
nostril. Tape tube 12–18 inches below insertion line. Then pin tape to
patient’s gown, allowing slack for movement.
7. Confirm proper location of tube.
■ Checking the pH of aspirate is the preferred method for
checking placement.
■ Pull back on plunger of a 20-mL syringe to aspirate stomach contents.
Typically, gastric aspirates are cloudy and green, or tan, off-white,
bloody, or brown in some cases. Gastric aspirate can look like
respiratory secretions.
■ Dip litmus paper into gastric aspirate. A reading of 1–3 suggests
placement in the stomach.
■ An alternate, but less reliable, method, is to inject 20 mL of air into tube
while auscultating the abdomen. Hearing a loud gurgle of air suggest
placement in the stomach. If no bubbling is heard, remove tube, and
reattempt. Withdraw tube immediately if patient becomes cyanotic or
develops breathing problems.
■ An inability to speak also suggests intubation of trachea instead of
stomach.
8. Assemble suction canister, liner, and attachment for wall suction. If using
portable suction, have ready at bedside.
■ Attach a connector to the end of tube.
■ Attach the extension tubing that comes with the suction canister to the
connector.

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■ Connect the other end of the tubing to suction canister where indicated.
■ Set suction as ordered.
Patient Care
■ Reassess placement of tube.
■ Assess amount and character of drainage.
■ Replace collection liner before it is full (full or nearly full liner prevents
thorough suction of GI material).
■ Flush tube with water after each feeding and after each medication.
■ Assess skin around nose for irritation and breakdown, and replace tape
as needed. Change at least every other day.
■ Gently wash around the nose with soap and water, and dry before
replacing tape.
■ Provide mouth care every 2 hours and PRN.
■ Mouthwash, water, toothettes: clean tongue, teeth, gums, cheeks, and
mucous membranes.
■ If patient is performing oral hygiene, remind him or her not to swallow
any water.
Removal
1. Explain procedure to patient. Don gloves.
2. Remove tape from nose and face. Offer patient some tissues as he or she
may gag slightly as the tube is withdrawn.
3. Clamp or plug tube (prevents fluid from entering lungs), and remove tube
in one gentle, swift motion.
4. Assess for signs of aspiration.

Constipation
CLINICAL PICTURE
The patient may have:
■ Complaints of constipation.
■ Infrequent stools accompanied by discomfort, bloating, flatulence.

IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT

■ Assess abdomen for bowel sounds. Bowel sounds may be infrequent;
listen for a full minute before concluding that bowel sounds are absent.
If no bowel sounds are heard, do not administer laxatives or PRN
enemas; notify physician or nurse practitioner with findings.
■ Assess for abdominal distention and pain.
■ Ask about last bowel movement and recent dietary intake.
■ Check MAR for medications that can cause constipation; check MAR for
PRN orders for laxatives and daily stool softener order.

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■ If the patient has bowel sounds, is on a solid diet, and has a PRN order
for a laxative, check how soon the laxative is designed to work, and
administer it at the appropriate time (e.g., some magnesium-containing
laxatives work very quickly; some are designed to work over 8 hrs).
■ If there is an order for a small-volume enema that can be self-
administered or an oral laxative, ask the patient which he or she would
prefer. Explain how to use the enema if the patient chooses that option.

STABILIZING AND MONITORING

■ Assess effectiveness of laxative and return of usual bowel function.
■ Review diet and medications for possible changes that can prevent or
treat constipation.
■ Assess need for daily stool softener or bulk-forming laxative. Stimulant
laxatives should be used infrequently.

BE PREPARED TO
Check for impaction; administer saline enemas.

POSSIBLE ETIOLOGIES
Medications such as diuretics, loperamide, opioids, antidepressants, and
medications containing iron, calcium, or aluminum; insufficient intake of
dietary fiber; dehydration; hypothyroidism; hypokalemia; injury to the anal
sphincter; diminished or absent peristalsis related to surgery, cancer,
diverticula, irritable bowel syndrome, functional incapacity.

Diarrhea
CLINICAL PICTURE
The patient may have:
■ Frequent loose, watery, bowel movements.
■ Loose stools containing blood, pus, or mucus.
■ Abdominal pain, cramps, flatulence.
■ Nausea, vomiting, dehydration.
■ Fatigue, temperature elevation.
IMMEDIATE INTERVENTIONS
■ Assess VS and mental status.
■ Provide comfort measures and perineal care.
■ Obtain stool samples.
■ Assess for patent IV access.

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■ Notify physician or NP of symptoms.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess hydration status (orthostasis, hypotension, and tachycardia; tissue
turgor, mucous membrane moisture, mentation, UO).
■ Assess recent GI history (onset, frequency and nature of stools, presence
or absence of blood and mucus, vomiting, cramps, and fever).
■ Assess recent antibiotic use, use of stool softeners and opiates (all
associated with increased risk of psuedomembranous colitis [PMC]
caused by Clostridium difficile).
■ Ask about recently eaten meals (raw eggs, contaminated food, raw
seafood) and travel history.
■ Assess recent blood chemistries (electrolyte levels).
STABILIZING AND MONITORING
■ Insert IV, and administer IVF (D5 1/2 NS with KCl) if dehydrated or unable
to tolerate oral fluids (with order).
■ Encourage fluids if able to tolerate.
■ Monitor I&O.
■ Administer appropriate antibiotic/anti-infective agent promptly and on
schedule.
■ Avoid use of antimotility drugs (diphenoxalate, loperamide) or opiates if
infectious diarrhea suspected.
■ Monitor for relief of symptoms or complications (toxic megacolon if PMC,
dehydration, electrolyte imbalance, skin breakdown).
■ Document patient’s status in medical record, and communicate to
physician or NP.

BE PREPARED TO
■ Insert IV access and administer IVF.
■ Obtain specimens.
■ Implement enteric precautions.

POSSIBLE ETIOLOGIES
■ Viral, bacterial, or parasitic gastroenteritis; food-borne diarrhea; ulcerative
colitis; Crohn’s disease; AIDS; pseudomembranous colitis; drug side effect;
inflammatory bowel disease.

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Feeding Tube Complications

CLINICAL PICTURE
The patient may have:
■ Occluded tube.
■ Tube displacement.
■ Extubation.
■ Stomal infection.
■ Stomal leak.
IMMEDIATE INTERVENTIONS
■ Assess site for leak.
■ Assess for signs and symptoms of infection (elevated temperature, pain,
redness, warmth, purulent discharge).
■ Assess for proper placement (is tube too far in tract, too far out, or
completely out?).
■ If tube is occluded, attempt to dislodge using method described in table
below.
■ Elevate HOB to minimize risk of aspiration.
■ For other complications or if attempt to dislodge tube is ineffective, notify
physician or NP.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess for signs and symptoms of aspiration (temperature, RR, lung
sounds).
■ Assess LOC/mental status.
■ Assess hydration status.
STABILIZING AND MONITORING
■ See table below for guide to ongoing interventions.
■ Monitor nutritional status.
■ Provide stomal care.
■ Obtain nutrition consult if indicated.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Obtain replacement tube, and assist with bedside reinsertion.
■ Obtain portable chest x-ray for placement if nasoenteric tube is inserted.
■ Resume tube feedings.

POSSIBLE ETIOLOGIES
■ Varies according to complication; see following table.

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Feeding Tubes: Preventing and Managing Complications

Complication/Cause Interventions
Leakage of gastric secretions: ■ Position patient upright for feeding.
Improper positioning of patient. ■ Stabilize tube with gauze pads; adjust
Tube migration. crosspiece.
Stomal erosion or widening. ■ Keep skin around stoma clean and
dry; use protective ointments and
gauze.
Tube migration: ■ Reposition tube.
Internal balloon deflates ■ Note length of tube outside of body,
or external tube suture, using either the external marks on
bumper, or disc falls out. the tube or a tape measure.
■ Document length in nursing record,
and measure each shift.
■ Check that disc, suture, or attachment
device is secure.
Extubation: ■ Tract can close within a few
Internal balloon deflates or suture, hours. Feeding tubes must be
bumper, or disc falls out. replaced within a few hours.
Stomal infection: ■ Correct cause of leakage.
Leakage around tube. ■ Carefully clean and protect stoma per
Inadequate stomal care. facility protocol.
Allergic reaction to soap. ■ If stoma site is irritated, use plain
water or change type of soap used.
Gastroesophageal reflux/ ■ Elevate patient’s head 30!–45! during
large residuals: feeding and for 1 hr after meal.
Delayed gastric emptying. ■ Check residuals before feeding. Hold
feeding if greater than 100 mL, and
call physician or NP.
■ Use gastric stimulant, if ordered, to
promote gastric emptying.
■ Consider continuous feeds or smaller,
more frequent boluses

(Continued on the following page)

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Feeding Tubes: Preventing and Managing Complications (continued)

Complication/Cause Interventions
Nausea, vomiting, cramps, ■ Change to a low-fat formula.
bloating: ■ Administer feeding at room
Too rapid administration temperature.
of feeding, lactose intolerance, ■ Reduce rate of administration.
fat malabsorption, contam- ■ Check residuals before bolus feeding
ination of food or feeding bag. or every 4 hr for continuous feeding.
Hold feeding if greater than 125 mL;
call physician or NP.
■ Refrigerate open cans of formula, and
keep only as long as manufacturer
suggests.
■ Clean tops of formula cans before
opening.
■ Hang only 4-hr amount of formula at a
time.
■ Clean feeding sets well, and replace
per facility policy.

Diarrhea: ■ Add fiber, or use a formula with fiber.

Too rapid increase in amount of ■ Reduce rate of administration.
feeding, too rapid admin- ■ Administer feeding at room
istration, feeding too cold, temperature.
lactose intolerance, tube ■ Do not add medication to formula.
migration from stomach
to small intestine ■ Retract tube to reposition against
stomach wall.

Feeding Tubes: Preventing and Managing Occlusions

Prevention
■ Flush with 30 mL of water every 4–6 hr and before and after
administering tube feedings, checking for residuals and administering
medications.
■ Use a feeding pump with an automatic water flush feature.
■ Dilute liquid medications with 20–30 mL of water.

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■ Obtain all medications in liquid form. If liquid form is not available, check
with pharmacist to see if medication can be crushed.
■ Administer each medication separately, and flush with 5–10 mL of water
between each medication.
■ Do not mix medications with feeding formula.
Management
■ Check the feeding tube for kinks.
■ Inject a small amount of air into tube.
■ Change patient’s position.
■ If no obvious kink is found, place flushing syringe (30 mL) into the tube
end, and gently pull back on the plunger to dislodge the occluding plug.
■ If tube still blocked, instill warm water into the tube. Gently depress, and
withdraw syringe plunger to remove obstruction. If unsuccessful, leave
instilled warm water in tube, clamp tube for 10–15 min, and try again.
■ Milk the tube with fingers from the insertion site out.
■ Do not instill meat tenderizer—can cause metabolic complications and
allergic reactions.
■ Commercial products that use thin plastic devices for clearing feeding
tubes or products that use a catheter and chemical declogging powder are
available; however, a physician or NP usually must perform the
procedure.
■ To prevent tube damage, do not use force to unclog, or use a syringe
smaller than 30 mL.

Hematemesis/Upper GI Bleed
CLINICAL PICTURE
The patient may have:
■ Bright red or dark coffee ground–appearing emesis.
■ Distended, rigid, and/or tender abdomen.
■ Nausea, black stools.
■ Tachycardia, hypotension.
■ Dizziness, weakness, SOB.
■ Anxiety.

IMMEDIATE INTERVENTIONS
■ To prevent aspiration of blood and subsequent respiratory compromise,
position patient to facilitate an open airway (upright or turned to one
side), particularly in patients who have inadequate gag reflexes or altered
LOC.
■ Provide emesis basin.
■ Assess BP, HR, RR, temperature.

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■ Differentiate that patient has vomited, not expectorated, blood.

■ Suction oropharynx if patient vomiting copious amounts of blood and
cannot clear vomitus/secretions.
■ Assess for patent IV.
■ Call physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess BP, HR, and RR. Check blood pressure supine and standing (if
feasible), and document difference.
■ Check oxygen saturation via pulse oximetry. Assess LOC.
■ Assess skin color and temperature, capillary refill.
■ Assess respiratory status and lung sounds.
■ Assess abdomen for distention, tenderness, guarding, peristalsis, and
rigidity.
■ Hematest emesis; assess amount and characteristics.
■ Assess for use of anticoagulants, NSAIDs, or steroids.
■ Check if patient has been previously typed and cross-matched and if any
blood products are available in the blood bank.

STABILIZING AND MONITORING

■ Insert a large-bore IV, and administer IVF per order.
■ Monitor VS frequently (every 5 min if unstable).
■ Place an NG tube (per level of practice and physician’s order). Connect
to low intermittent suction.
■ Monitor laboratory studies (CBC, electrolytes, BUN, PT/PTT/INR, ABGs;
type and cross-match).
■ Insert a urinary catheter, and monitor I&O.
■ Monitor serial Hgb/Hct.
■ Provide oral hygiene and other comfort measures after episodes of
vomiting.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Start an IV (two large-bore IVs if vomiting copious amounts of blood).
■ Assist with central line placement.
■ Give IVF or blood products.
■ Administer H2 blockers.
■ Set up gastric suction, and perform room temperature saline lavage.
■ Obtain ECG, laboratory and diagnositic studies (x-ray, endoscopy).
■ Prepare for ICU transfer if hemodynamically unstable.

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POSSIBLE ETIOLOGIES
■ Gastric ulcer, duodenal ulcer, gastric erosions, esophagitis, esophageal
varices, Mallory-Weiss syndrome, carcinoma, peptic ulcer, polyps,
salicylates, NSAIDs, corticosteroids, leukemia, uremia, blood dyscrasias,
hemorrhagic gastritis.

Lower GI Bleed/Melena
CLINICAL PICTURE
The patient may have:
■ Frankly bloody or melanotic stool or stool tests positive for occult blood.
■ Abdominal cramping.
■ Signs and symptoms of hypovolemic shock (acute bleed): hr !110
beats/min, SBP $100 mm Hg, orthostatic drop in systolic BP of !16 mm,
oliguria, cold clammy extremities, mental status changes.
■ Anemia, fatigue, pallor, dizziness, chest pain (chronic bleed).

IMMEDIATE INTERVENTIONS
■ Assist patient to bed.
■ Administer supplemental oxygen.
■ Assess VS; check for orthostasis.
■ Notify physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess VS (HR, BP, RR, and temperature).
■ Assess LOC and orientation; assess oxygen saturation.
■ Assess skin color, moistness, and temperature; assess capillary refill.
■ Assess abdomen (distention, tenderness, pain, bowel sounds).
■ Obtain detailed GI history (history of tarry stools, use of NSAIDs,
associated symptoms).
■ Check recent CBC.
■ Check if patient has been previously typed and cross-matched and if any
blood products are available in blood bank.
■ Assess for patent IV access.

STABILIZING AND MONITORING

■ Monitor VS, hemodynamic status, and UO.
■ Insert large-bore IV access.
■ Record frequency and character of stools.
■ Chart patient status, and convey to physician or NP.

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BE PREPARED TO
■ Obtain or order laboratory tests including coagulation studies (platelet
count, PT, PTT, INR), electrolytes, BUN, creatinine, serial Hb and Hct; type
and cross-match.
■ Start an IV, and administer IVF or blood products.
■ Insert NGT, and check aspirate for blood; remove if negative.
■ Prepare patient for or assist with anoscopy or colonoscopy.
■ Insert a urinary catheter, and monitor UO.

POSSIBLE ETIOLOGIES
■ Diverticulitis, GI polyps, anal fissures, hemorrhoids, ulcerative colitis,
Crohn’s disease, ischemic colitis, upper GI bleed.

Nausea
CLINICAL PICTURE
The patient may have:
■ Sensation/urge to vomit.
■ Tachycardia, bradycardia.
■ Diaphoresis, skin pallor.
■ Decreased or high-pitched bowel sounds.
■ Abdominal pain.

IMMEDIATE INTERVENTIONS
■ Elevate HOB to high Fowler’s position; provide emesis basin.
■ Place weak, confused, or debilitated patient in a side-lying position to
reduce risk of aspiration.
■ Offer a cool compress to the forehead or nape of neck.
■ Keep NPO.

FOCUSED ASSESSMENT
■ Assess patient’s ability to protect airway.
■ Assess VS.
■ Assess for chest pain, SOB, headache, visual disturbances.
■ Assess onset of symptoms and associated events (e.g., eating,
medication, activity).
■ Assess hydration status (orthostatic hypotension, skin turgor, mucous
membranes, recent I&O).
■ Assess for patent IV access.

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STABILIZING AND MONITORING
■ Determine if nausea is an anticipated side effect of treatment (anesthesia,
chemotherapy).
■ Check MAR for as-needed antiemetic; administer if clinically indicated.
■ If nausea is not expected given the patient’s clinical problem, notify
physician or NP.
■ Clarify with physician or NP whether to withhold PO medication or give
by alternate route.
■ Monitor and record I&O.
■ Document patient status, phone call to physician or NP, and physician
or NP response.

BE PREPARED TO
■ Administer antinausea medication as ordered.
■ Start an IV, and give IVF for hydration.
■ Monitor serial electrolytes, nutritional status, and UO.
■ Facilitate diagnostic studies.
■ Insert NGT if bowel obstruction is present.
■ Call for an ECG if associated with chest pain; SOB; slow, fast, or
irregular HR.

POSSIBLE ETIOLOGIES
■ Gastroenteritis, appendicitis, bowel obstruction, other GI disorder,
vascular headache, head injury, meningitis, other neurological cause,
pregnancy, drug side effect, infection, pain, motion sickness, stress,
chemotherapy.

Vomiting
CLINICAL PICTURE
The patient may have:
■ Small or large amounts of emesis.
■ Tachycardia, bradycardia, diaphoresis, skin pallor.
■ Abdominal pain, decreased or high-pitched bowel sounds.

IMMEDIATE INTERVENTIONS
■ Elevate HOB to high Fowler’s position; provide emesis basin.
■ Place weak, confused, or debilitated patient in a side-lying position to
reduce risk of aspiration.
■ Offer a cool compress to the forehead or nape of neck.
■ Keep NPO.

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FOCUSED ASSESSMENT
■ Assess patient’s ability to protect airway.
■ Assess VS.
■ Assess for chest pain, SOB or other symptoms (headache, dizziness,
abdominal pain, diarrhea).
■ Assess onset of symptoms and associated events (e.g., eating,
medication, activity).
■ Inspect emesis for color, odor, amount, and contents.
■ Assess abdomen for distention and tenderness.
■ Note if vomiting is projectile.
■ Assess hydration status (orthostatic hypotension, tissue turgor, mucous
membranes, recent I&O).
■ Assess for patent IV access.

STABILIZING AND MONITORING

■ Determine if vomiting is an anticipated side effect of treatment
(anesthesia, chemotherapy).
■ Check MAR for as-needed antiemetic; administer if clinically indicated.
■ If vomiting is not expected given the patient’s clinical problem, notify
physician or NP.
■ Clarify with physician or NP whether to withhold PO medication or give
by alternate route.
■ Monitor and record I&O.
■ Administer IVF if ordered.
■ Monitor laboratory tests for electrolyte imbalances (from loss of fluid) or
metabolic alkalosis (from loss of gastric acid).
■ Document patient status, response to treatment, phone call to physician
or NP, and physician or NP response.

BE PREPARED TO
■ Start an IV, and give IVF for hydration.
■ Facilitate diagnostic studies.
■ Insert NGT if bowel obstructed or vomiting continues.
■ Administer antinausea medication as ordered.
■ Monitor serial electrolytes, nutritional status, and UO.
■ Call for an ECG if associated with chest pain; SOB; slow, fast, or irregular
heart rate.

POSSIBLE ETIOLOGIES
■ Gastroenteritis, appendicitis, bowel obstruction, other GI disorders,
vascular headache, head injury, meningitis, other neurological cause,
pregnancy, drug side effect, infection, pain, motion sickness, stress,
chemotherapy.

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A & P Snapshot

Tongue

Teeth
Parotid gland
Pharynx
Sublingual
gland Esophagus
Submandibular
gland

Stomach (cut)
Liver Left lobe

Spleen

Right lobe Duodenum

Gall bladder
Bile duct Pancreas

Transverse
colon (cut) Descending
colon

Ascending Small intestine

colon

Cecum Rectum

Vermiform Anal canal

appendix

Digestive system.

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ENDO

Focused Endocrine Assessment

The endocrine system comprises hormone-secreting glands. These
hormones are instrumental in all aspects of homeostasis. The glands and
the hormones they secrete include:
■ Hypothalamus and pituitary: antidiuretic hormone (ADH), oxytocin,
growth hormone (GH), thyroid-stimulating hormone (TSH), adrenocor-
ticotropic hormone (ACTH), follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and prolactin (PRL)
■ Thyroid: thyroxine (T4), triiodothyronine (T3), and calcitonin
■ Parathyroids: parathyroid hormone (PH)
■ Adrenals: medulla: epinephrine and norepinephrine; cortex: glucocorti-
coids (cortisol), mineralocorticoids (aldosterone), and adrenal androgens
■ Endocrine pancreas: insulin; glucagon, somatostatin
■ Ovaries or testes: sex hormones
Physical assessment of the endocrine system is difficult in that the thyroid
gland is the only palpable gland, and signs and symptoms can be vague or
attributable to other causes. Diagnostic testing is the cornerstone of
endocrine assessment.
Some physical signs and symptoms that may be the result of endocrine
malfunction include:
■ Change in appearance of hair, nails, and skin
■ Increased or decreased energy, insomnia, fatigue
■ Heat or cold intolerance, hypothermia or fever
■ Tremors, tetany, muscle aches
■ Tachycardia, hypertension or hypotension
■ Kidney stones, pathological fractures, muscle weakness, memory loss
■ Polyuria, polydipsia, polyphagia (excessive eating and drinking, excessive
urination)
■ Anorexia, weight gain or loss, constipation, dehydration
■ Change in thought processes, agitation, confusion
Laboratory and diagnostic tests consist of radioimmunoassay of hormone
levels, blood glucose levels, and other tests, 24-hour urine studies, and
radiological scans.

Diabetic Ketoacidosis (DKA)

CLINICAL PICTURE
The patient may have:
■ Rapid onset excessive thirst, nearly constant urination.
■ Abdominal pain, N&V

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■ Lethargy progressing to coma (in later stages).
■ Dehydration leading to hypotension and shock.
■ Blood glucose level of 250–800 mg/dL.
■ Abnormal ABGs indicating metabolic acidosis (pH !7.3, bicarbonate
!15 mEq/L).
■ Multiple electrolyte abnormalities, including high potassium levels.
■ Hyperventilation (Kussmaul’s respirations), and fruity-smelling breath
(somewhat like nail polish remover).

IMMEDIATE INTERVENTIONS
■ Assess VS, LOC, and ability to protect airway.
■ Assess for patent IV access.
■ Notify physician or NP of elevated glucose; decreased LOC, if present;
and other findings.
■ Document findings, phone call to physician or NP, and the response.
■ Insert IV and hang IVF (NS, with order); administer medications (regular
insulin) as ordered.
■ Stay with patient.

FOCUSED ASSESSMENT
■ Assess electrolyte values, ketones, and osmolality.
■ Continue to assess LOC and VS—hypotension can be severe.
■ Assess ABG results.
■ Assess for other complications of diabetes (e.g., skin infections, peripheral
neuropathy, poor circulation to feet and toes).

STABILIZING AND MONITORING

■ Ongoing assessment of VS, LOC, and ability to protect airway.
■ Monitor blood glucose and electrolytes.
■ Monitor I&O.

BE PREPARED TO
■ Obtain blood work.
■ Hang IVF.
■ Administer IV insulin.
■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES
■ An infection in an otherwise well-controlled diabetic patient; too little
insulin or failure to take any insulin; new onset of diabetes; underlying
medical illness.

ENDO
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ENDO

Hyperglycemia*
CLINICAL PICTURE
The patient may have:
■ Blood glucose level 180–300 mg/dL on routine fingerstick.
■ Usually there are few or no symptoms or signs other than blood glucose
level
■ Can have:
■ Flushed, dry skin; poor skin turgor, and dry mucous membranes.
■ Fruity breath odor (like acetone).
■ Blurred vision, generalized weakness, and dizziness.
■ N&V, cramping, increased urination.
IMMEDIATE INTERVENTIONS
■ Obtain a blood glucose level if not already done.
■ Check MAR for regular insulin sliding scale based on blood glucose level.
■ Administer appropriate dose of regular insulin, based on sliding scale.
■ If patient is symptomatic, if MAR does not contain a sliding scale, or if
blood glucose level exceeds parameters of sliding scale, notify physician
or NP.
FOCUSED ASSESSMENT
■ Assess HR, BP, RR; assess LOC if indicated.
■ Assess for signs of dehydration (dry mucous membranes, poor skin
turgor, and dry scaly skin).
■ Ask patient about recent health changes, usual level of glucose control,
and if there has been a recent change in diabetic management.
■ Assess if infusing IVF contains dextrose (if applicable).
STABILIZING AND MONITORING
■ Continue to assess LOC and orientation.
■ Reassess blood glusose level at appropriate intervals.
■ Discuss diabetic management with health-care team.
■ Consider nutrition consult.
■ Assess patient’s understanding of disease process and treatment; educate
as needed.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Administer insulin as ordered.
■ Obtain serial blood glucose levels.
■ Dipstick urine for ketones.

*This is a discussion of uncomplicated, moderately elevated blood glucose, not

diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic coma (HHNC).

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POSSIBLE ETIOLOGIES
■ New-onset DM, infection, illness, stress, trauma, noncompliance with
insulin and diet regimen, certain medications such as cortisone.

Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC)

CLINICAL PICTURE
The patient may have:
■ Hyperglycemia ("600 mg/dL)
■ Polyuria, excessive thirst, weight loss.
■ Dehydration—dry mucous membranes, dry skin.
■ Confusion, delirium, lethargy to coma.
■ Visual changes.
■ Hypotension, tachycardia.

IMMEDIATE INTERVENTIONS
■ Call physician or NP as soon as the serum glucose level is known or if the
patient’s LOC has changed. If patient’s LOC is declining from drowsiness to
stupor or coma (which can happen rather quickly), assess ability to protect
airway.
■ Check for a patent IV access; if none, gather needed supplies for IV
insertion. Take NS to keep the vein open (with order) until treatment-level
IV orders are written.

FOCUSED ASSESSMENT
■ Check ABGs as frequently as indicated, possibly every 15 min. Assess LOC
at the same time. Note shallow, rapid respirations.
■ Monitor BP; shock can develop quickly. Assess for orthostasis (drop in
systolic BP "10 mm Hg when position changes from lying to standing
or lying to sitting upright if standing is not possible).
■ Assess HR apically or with ECG monitoring, if available. Note
dysrhythmias, tachycardia.
■ Check electrolytes for hypokalemia, ↑ BUN, ↑ serum osmolality ("350
mOsm/L).
■ Assess for focal neurological changes, including aphasia and hemiparesis,
which can resemble signs of stroke.
■ Assess for history of type 2 diabetes (HHNC occurs almost exclusively in
this group).
■ Assess for underlying illness, possibly infection, that triggered HHNC.

STABILIZING AND MONITORING

■ Continue all assessments as outlined above.
■ Hang IVF as ordered.

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■ Begin insulin drip, and monitor glucose levels.

■ Monitor serum chemistries, and replace electrolytes as ordered.
■ Assess for signs or symptoms of venous thrombosis (due to dehydration,
blood becomes hyperosmolic, meaning the blood is very thick. This
predisposes the patient to thrombosis.).
■ Assess coagulation studies for signs of disseminated intravascular
coagulation (DIC), a complication of HHNC.
■ Assess for other serious complications, such as adult respiratory distress
syndrome (ARDS) and multiorgan dysfunction syndrome (MODS).

BE PREPARED TO
■ Obtain ABGs.
■ Facilitate blood tests and other diagnostic tests.
■ Assist with intubation.
■ Assist with insertion of a central venous catheter.
■ Insert a nasogastric tube.
■ Transfer to ICU.
■ Teach patient about process of HHNC to avoid recurrence.

POSSIBLE ETIOLOGIES
■ Preceding or concomitant illness that triggers dehydration (pneumonia
and urinary tract infection are common triggers); stress response to
illness that raises glucose levels; drugs that raise glucose levels, inhibit
insulin, or cause dehydration.

Hypoglycemia
CLINICAL PICTURE
The patient may have:
■ Cool, pale, and diaphoretic skin.
■ Agitation, disorientation, slurred speech, blank stare.
■ Headache, palpitations/tachycardia, trembling, hunger.
■ ↓ LOC progressing to coma and/or seizures if not treated.

IMMEDIATE INTERVENTIONS
■ Obtain a blood glucose level by fingerstick.
■ Assess VS and LOC.
■ Give oral, rapidly absorbed carbohydrates (orange juice) if alert and no
risk of aspiration.
■ Notify physician or NP.
■ If patient has ↓ LOC, position patient to protect airway.

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■ If patient has ↓ LOC, give 1 amp (25 g in 50 mL) of 50% dextrose IV push
(with order).
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess time the insulin or oral hypoglycemic agent was taken and amount.
■ Ascertain that dose/type of insulin/oral hypoglycemic given was accurate.
■ Assess if patient has eaten.
■ Assess other medications for potential to affect glucose control.
■ Assess response to oral or IV administration of glucose.
STABILIZING AND MONITORING
■ Repeat serum glucose test, and reevaluate patient as needed.
■ Once symptoms improve, provide more slowly absorbed carbohydrates
(e.g., milk, crackers).
■ Consult dietitian/nutrition support.
■ Monitor for hypokalemia.
■ Reassess insulin dosages with team.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Start a peripheral IV.
■ Administer glucagon or other medications if necessary.
■ Obtain serial blood glucose levels.
■ Assist with airway management and intubation if needed.
■ Manage seizure activity if needed.
POSSIBLE ETIOLOGIES
■ Diabetic patients: overdose of insulin or oral hypoglycemic agent,
increased activity, too little food intake, alcohol, drugs, emotional stress,
infections; nondiabetic patients: liver disease, excessive alcohol
consumption, drug reaction (beta-adrenergic blockers and sulfonylureas
are most common).

Myxedema Coma
CLINICAL PICTURE
The patient may have:
■ Low body temperature, cold intolerance.
■ Confusion, depression.
■ Hypoventilation.
■ Weakness.
■ Edema.

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IMMEDIATE INTERVENTIONS
■ Assess LOC, VS, and ability to protect airway.
■ Assess patent IV access.
■ Provide blankets (not a warming blanket—can cause vasodilation and
lower BP even further).
■ Call physician or NP; document phone call and response.
FOCUSED ASSESSMENT
■ Assess laboratory values—may have low sodium, low glucose, low
calcium, high CPK and high creatinine. Will have high T4 and low TSH.
■ Assess respiratory pattern and ABGs; may have ↓ pH, ↓ oxygen
saturation, with ↑ carbon dioxide (respiratory acidosis).
■ Assess for other signs and symptoms of hypothyroidism:
■ Altered mentation, such as apathy, confusion, psychosis, or coma.
■ Alopecia; coarse, sparse hair.
■ Dry, cool, skin.
■ Elevated diastolic BP in early stages; hypotension later.
■ Bradycardia.
■ Decreased GI motility, abdominal distention, myxedema megacolon
(late).
■ Low temperature.
■ Generalized facial swelling, ptosis, periorbital edema.
STABILIZING AND MONITORING
■ Continued assessment of cardiac and respiratory status.
■ Administer IV thyroid hormone replacement, cortisol, or electrolytes
as ordered.
■ Provide blankets.
BE PREPARED TO
■ Assist with obtaining laboratory studies, inserting and hanging IVF,
administering medications as appropriate to the unit.
■ Transfer patient to ICU.
POSSIBLE ETIOLOGIES
■ New infection in an otherwise well-controlled hypothyroid patient; medi-
cations such as diuretics, opioids, beta blockers, tranquilizers, and others
in a hypothyroid patient; GI bleed; stroke; surgery; trauma.

Thyroid Storm
CLINICAL PICTURE
The patient may have:
■ Tachycardia, palpitations, widened pulse pressure, atrial fibrillation.

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■ Anxiety, irritability, restlessness to unresponsiveness.
■ Elevated free thyroxin level (T4), low TSH.
■ SOB, chest pain.
■ Warm, flushed skin, high fever (105#–106#F).

IMMEDIATE INTERVENTIONS
■ Assess VS, cardiac rhythm, LOC, and ability to protect airway.
■ Check oxygen saturation by pulse oximetry.
■ Assess patent IV access.
■ Call physician or NP with findings. Document phone call and response.

FOCUSED ASSESSMENT
■ Continued assessment of cardiac, respiratory, and neurological status.
■ Assess for signs and symptoms of heart failure.
■ Assess electrolyte levels, if recent ones are available.
■ Assess for signs and symptoms consistent with hyperthyroidism:
■ Edematous legs and feet.
■ Intolerance to heat; increased sweating.
■ Labile mood, possible psychosis.
◆ Exophthalmia (bulging eyeballs).
◆ Weakness.
◆ Pretibial myxedema—itchy lesions on the legs and feet (not to
be confused with myxedema as seen in hypothyroidism).

STABILIZING AND MONITORING

■ Continue frequent assessments.
■ Insert IV if no access; hang IVF.
■ Administer electrolytes as ordered.
■ Administer medications as ordered, propylthiouracil (PTU) or methimazole
(MMI) to control T4 production, hydrocortisone, and propranolol to control
signs and symptoms.
■ Reduce fever with acetaminophen, cooling blanket, and/or tepid baths
if needed.

BE PREPARED TO
■ Assess glucose level; obtain other laboratory values.
■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES
■ Lung infections, discontinuing hyperthyroid medications, excessive dose
of thyroid replacement medications, thyroid surgery in patients with
overactive thyroid gland.

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A & P Snapshot

PITUITARY (HYPOPHYSIS) GLAND

Anterior: GH, TSH, ACTH
HYPOTHALAMUS FSH, LH, Prolactin
Releasing hormones Posterior: ADH, Oxytocin
for anterior pituitary

PINEAL GLAND
Melatonin
THYROID GLAND
Thyroxine and T3 PARATHYROID GLANDS
Calcitonin PTH

THYMUS GLAND
Immune hormones

ADRENAL (SUPRARENAL)
GLANDS
PANCREAS Cortex: Aldosterone
Insulin Cortisol
Glucagon Sex hormones
Medulla: Epinephrine
Norepinephrine

OVARIES
Estrogen
Progesterone
Inhibin
TESTES
Testosterone
Inhibin

The endocrine system.

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Focused Assessment of Musculoskeletal System
■ Assess the musculoskeletal system on all patients with an orthopedic
problem or recent trauma, patients with arthritis or who have been on
bedrest, and patients with neurological (e.g., stroke) or neuromuscular
disease.
■ Clinicians usually assess the peripheral nervous system simultaneously.
Assessment includes evaluation of dressings and wound drainage
systems.
■ Assessment of musculoskeletal status includes:
■ Gait.
■ Joint mobility.
■ Neurovascular status (CMS: circulation, motion, sensation); an
assessment of circulatory compromise and/or nerve damage.
■ Pain.
■ Fall risk.
■ Gait
■ Assess patient’s ability to ambulate independently.
■ Assess need for assistive devices. If the patient uses an assistive
device, asses if he or she is using it safely.
■ Joint range of motion (ROM)
■ Ask patient to put shoulders, elbows, wrists and fingers, hips, knees,
and ankles through full range of joint motion as indicated. Neck and
back can be included if appropriate.
■ As a nursing assessment, joint ROM evaluation may be necessary only
with initial assessment. If the patient is receiving physical therapy to
increase that joint’s ROM, then the physical therapist will assess the
extent to which the joint can move.
■ If the patient is not able to move or participate, passively move the
joints to assess ROM.
■ Do not push a joint past its range, even if limited.
■ Do not push the joint if the patient has pain.
■ Neurovascular status (CMS: Circulation, Motion, Sensation)
■ Palpate peripheral pulse and check capillary refill.
■ Note skin color of extremity; compare with that of opposite extremity.
■ Have patient move hands and fingers, flex and extend feet. Focus on
the extremity of interest, but initially compare with the contralateral
arm, hand, leg, or foot.
■ Assess strength by having patient push or pull against resistance.
■ Ask about paresthesias (numbness and tingling, odd sensations);
lightly trace your finger over different surfaces of the at-risk area

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to assess sensation. Have the patient close his or her eyes while
you do this.
■ Ask about pain. (See Pain Assessment in Basics tab.)

Focused Assessment of Skin Integrity

■ Assess skin integrity each shift for patients at risk for skin breakdown and
patients with incisions, pressure ulcers, or wounds.
■ Assessment of skin integrity includes:
■ Skin condition.
■ Surgical or traumatic wounds.
■ Bandages, casts, wound dressings, and drainage systems.
■ Pressure points.
■ Pressure ulcers.
■ Skin condition
■ Note if skin is dry, moist, abraded, or fragile.
■ Assess for skin tears, which are common in older patients, and other
disruptions in skin integrity such as surgical incisions.
■ Surgical or traumatic wounds
■ If dressings are not to be removed, assess for bleeding or drainage on
dressings, intactness of dressings, and any tubes or drains exiting from
the periwound area.
■ When changing the dressing, assess for intactness of sutures or
staples, drainage, swelling, or signs of infection.
■ Assess for skin problems related to bandaging. For example,
tape covering a postoperative dressing can cause skin macera-
tion and blistering. The tape is secured to the surface of the skin,
but as the skin stretches with swelling, the tape causes a shear
injury by pulling the skin. This sometimes occurs in the total hip
replacement dressing, especially in the older person who has
fragile skin.
■ Bandages, casts, wound dressings, and drainage systems
■ Assess for signs of skin breakdown or pressure points from casts.
Be extra vigilant if the patient is diabetic, as circulation to lower
extremities is decreased.
■ Casts and circular dressings can abrade skin and impair circulation.
Assess the tightness of these dressings, which can become irritating
and quite injurious.

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■ Pressure points
■ Assess pressure points; do not massage reddened areas.
■ Use position changes, pillows, and preventive mattresses to alleviate
pressure.
■ Pressure ulcers
■ Perform and document a thorough wound assessment and staging (see
pressure ulcer later in this tab).
■ Assess healing. Note that ulcers may progress to a later stage but do
not “regress” as they heal. The correct term, for example, is “healing
stage 3 ulcer,” with a description of signs of healing (granulation tissue,
decreased circumference).

Compartment Syndrome
■ Muscle groups are contained within a tough, inelastic tissue called fascia.
This envelope of tissue creates a compartment that contains muscles,
nerves, veins, and arteries.
■ After injury or surgery, swelling of the muscles in the fascial compartment
causes increased pressure because the fascia cannot expand with the
swelling. The increased pressure closes off capillaries, arterioles and,
eventually, arteries, causing ischemia that will progress to necrosis if not
treated.
■ Compartment syndrome is more common in the extremities, particularly
the anterior or posterior compartments of the lower leg, but is possible at
other sites of injury such as the abdomen. This discussion is focused on
the arm or leg.

CLINICAL PICTURE
■ The patient may have or complain of the “5 Ps.”
■ Severe Pain not relieved by opioid analgesics and unusual for the
injury. The pain worsens with stretching of the involved muscles. This
pain is the first symptom to appear. Once the other Ps are evident, the
process is well established, and tissue damage is probable.
■ Pallor—paleness of the involved extremity.
■ Pulselessness—loss of pulses or markedly diminished pulses of the
affected extremity.
■ Paresthesia—numbness and tingling.
■ Paralysis—loss of ability to move the extremity.
■ Diminished capillary refill time (!3 seconds).

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IMMEDIATE INTERVENTIONS
■ The extreme pain is the first warning sign. When pain is more severe than
expected, immediately consider compartment syndrome, and notify
physician or NP.
■ Although pain medication should not be delayed or withheld, do not
simply medicate and return later to see if the medication is working.
■ Stay with the patient, and perform a focused assessment.
■ Elevate the extremity to the level of the heart to prevent further swelling
and increase venous return.
■ Do not put ice bags on the extremity.
■ Document phone call to physician or NP and physician or NP response.

FOCUSED ASSESSMENT
■ Palpate pulses. Use a Doppler if not palpable.
■ Note skin color and if pallor is present.
■ Blanch the skin, and check capillary refill time.
■ Assess nerves in the affected extremity. Is there altered sensation or
impaired mobility?

STABILIZING AND MONITORING

■ Continue to monitor vascular status. Pain indicates ischemia, but if pallor
or pulselessness develops, tissue necrosis and permanent damage will
occur.
■ Remain with patient until the physician or NP arrives. Loss of pulses
and/or the extreme pain that accompanies compartment syndrome
constitutes a surgical emergency. The physician or NP must rapidly
determine the treatment plan and if immediate surgery is necessary.

BE PREPARED TO
■ Assist with pressure measurements of the affected compartment.
■ Get the patient ready for an emergency fasciotomy in the OR: draw blood,
start an IV, etc. Make sure the time of the patient’s last meal or fluids is
documented and easy to find.

POSSIBLE ETIOLOGIES
■ Severe muscle injury, burns, fractures.

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Hip Fracture
CLINICAL PICTURE
The patient may have:
■ Groin, knee, or hip pain.
■ Inability to bear weight on affected extremity.
■ Shortened and externally rotated leg.
■ Inability to move affected leg.

IMMEDIATE INTERVENTIONS
■ Do not move leg; allow patient to maintain position of comfort.
■ Inspect and palpate for deformity, hematoma, laceration, and asym-
metry.
■ Call 4–6 staff members to help transfer patient from stretcher to bed
or, if patient has fallen, to lift patient into bed.
■ Assess vital signs (VS); assess for patent IV access.
■ Call physician or NP.

FOCUSED ASSESSMENT
■ If patient has experienced trauma, perform a primary survey and
stabilize ABCs. Then perform a secondary survey to detect associated
injuries.
■ Assess VS, and observe for signs and symptoms of shock such as cool,
clammy skin; mental status changes; and decreased urine output (blood
loss from hip fracture can be as much as 1500 mL).
■ Assess VS, level of consciousness (LOC), and orientation.
■ Inspect affected leg for shortening and rotation as compared with the
opposite leg.
■ Do not assess ROM unless x-ray is negative.
■ Assess distal circulation, sensation, and ability to move toes.

ONGOING CARE AND ASSESSMENT

■ Administer pain medication (determine that there is no associated head
injury first).
■ Avoid PO medications because patient may need surgery.
■ Monitor patient’s response to pain management.
■ Insert a urinary catheter, and monitor urinary output.

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BE PREPARED TO
■ Start an IV.
■ Obtain laboratory work, x-rays, possible CT or MRI.
■ Assist with set-up and application of traction.

POSSIBLE ETIOLOGIES
■ Osteoporosis, trauma.

Necrotizing Fasciitis (NF)

A very rapidly progressing infection by Streptococcus pyogenes of the
deeper layers of skin and tissue, requiring immediate intervention. Very high
mortality rate.

CLINICAL PICTURE
The patient may have or be:
■ Minor skin disruption, no disruption at all, or major disruption (e.g.,
surgical incision).
■ Severe or worse than expected pain at site, which gets progressively
worse.
■ Cellulitis-like appearance of affected area, which is hot and painful to the
touch.
■ Swollen, purplish, blistered tissue with foul-smelling, watery discharge.
■ High fever with flu-like symptoms.
■ Dehydrated and hypotensive.
IMMEDIATE INTERVENTIONS
■ Take the patient’s vital signs.
■ Circle the affected area on the dressing, if present, or apply a dressing,
and circle the area so that rapid spreading can be ascertained.
■ Call physician or NP, describe the affected area and patient’s condition.
■ Document your findings, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess and document VS frequently, at least every half hour.
■ Assess area for rapid progression of swelling and erythema and
crepitance.
■ Assess for changes in skin such as a grayish color beneath the skin,
blackened areas (necrotic tissue), purple blisters, foul drainage.
■ Assess laboratory values; ↑ BUN and hematocrit level, and ↓ hemoglobin
are characteristic of dehydration; ↓ sodium, ↓ albumin, ↑ WBCs, and ↑
bilirubin level are common with NF.

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STABILIZING AND MONITORING
■ Obtain wound cultures immediately so that antibiotics (penicillin and
clindamycin) can be given.
■ Insert an IV, and hang ordered IV fluids.
■ Administer antibiotics immediately; delay in administration of the correct
antibiotics is associated with a higher mortality rate.
■ Facilitate assessment of laboratory values.
■ Administer pain medication.
■ Insitute contact isolation or precautions.
■ Change dressings as ordered.

BE PREPARED TO
■ Assist with bedside débridement, or get the patient ready for the OR.
■ Obtain x-rays or CT.
■ Start a heparin drip (to decrease risk of vasculitis and thrombosis).
■ Transfer the patient to ICU.

POSSIBLE ETIOLOGIES
■ Infection with Group A beta-hemolytic streptococcus alone or in com-
bination with S aureus; infection with Clostridium, Peptococcus, E. coli,
Pseudomonas, S. pyogrenes, S. aureus, or S. marcescens.

Pathological Fracture
CLINICAL PICTURE
The patient may have:
■ Sudden pain in leg/hip/back/shoulder/arm while moving in bed,
transferring to wheelchair or stretcher, or ambulating. Audible crack may
be heard.
■ Abnormal or limited motion of extremity.
■ Back pain (with spinal compression fracture).
■ Unexplained ecchymosis, edema over bone or joint.
■ Obvious deformity of extremity.

IMMEDIATE INTERVENTIONS
■ Immobilize extremity in its position. Do not attempt to realign bone.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

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FOCUSED ASSESSMENT
■ Assess VS.
■ Assess extremity for swelling or hematoma.
■ Assess sensation and mobility of fingers or toes distal to injury if
extremity fracture is suspected.
■ Assess mobility and sensation of arms and legs if spinal fracture
suspected.
■ Assess history of falls or fractures.

STABILIZING AND MONITORING

■ Medicate for pain as indicated. Monitor for signs of respiratory depression
or excessive sedation.
■ Assist with diagnostic procedures (x-ray or bone scan).
■ Prepare patient for surgery, if applicable.
■ Assist with casting or immobilization with splint or traction.
■ Monitor foot or hand of affected extremity for peripheral neurovascular
dysfunction.
■ Initiate rehabilitation consultation.
■ Initiate care to prevent complications of restricted mobility, such as foot
and ankle exercises to decrease risk of deep venous thrombosis, early
mobilization, and cough and deep-breathing exercises.

BE PREPARED TO
■ Initiate pressure ulcer prevention strategies.
■ Manage pain so that patient is comfortable but not sedated.
■ Protect patient from additional injury.
■ Obtain assistive devices for ambulation or self-care activities.
■ Initiate discharge planning and collaborate with home care nurse for
follow-up care and prevention.

POSSIBLE ETIOLOGIES
■ Osteoporosis, osteomalacia, primary bone tumors, metastatic bone
lesions, Paget’s disease.

Patient Fall
CLINICAL PICTURE
The patient may have or be:
■ Found on floor, unexplained abrasions, or reported falling.

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IMMEDIATE INTERVENTIONS
■ Do not move patient if he or she is unconscious, complains of severe
pain, or has a deformity of an extremity (obvious fracture, internal
rotation of hip or knee).
■ If unconscious, get help, assess ABCs, immobilize cervical spine (with
light traction, hold head and neck in neutral alignment with body).
■ If conscious, have patient lie still while you call for help.
■ If the patient is alert with no obvious injuries, assist to bed or chair with
help from another staff member.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

FOCUSED ASSESSMENT
■ Assess LOC and orientation.
■ Assess VS and pain level.
■ Assess ability to move all extremities.
■ Assess alignment and symmetry of extremities.
■ Assess soft tissue and skin for abrasions, swelling, deformity.
■ Assess for acute underlying condition, such as infection, transient
ischemic attack, urinary tract infection, hypotension, or cardiac
dysrhythmia.
■ Assess for orthostasis, problems with gait, changes in mental status, and
recent changes in functional status.
■ Review records for preexisting conditions, medication use, and previous
falls.
■ Assess medication administration record for polypharmacy or medication
that may have contributed to fall.
■ Ask if patient felt dizzy or lightheaded before falling.
■ Assess environment for potential cause of fall and safety hazards.

STABILIZING AND MONITORING

■ Treat minor injuries—clean and dress abrasions; apply ice to contusions
or areas of swelling.
■ Assess for injuries.
■ Monitor patient closely for changes in condition, especially changes in
mental status, which can suggest brain injury.
■ Assess distal circulation, sensory, and motor function of injured
extremities.
■ Assess history of falls.

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BE PREPARED TO
■ Assist with x-rays or other diagnostic test.
■ Modify environment to eliminate hazards.
■ Arrange for one-on-one care if patient is confused.
■ Administer oxygen.
■ Order laboratory tests.
■ Complete an incident report.

POSSIBLE ETIOLOGIES
■ Sedation, debilitation, unfamiliar surroundings, side rails left down, call-
bell malfunction or not left within easy reach, drug reaction, improper use
of restraints, dysrhythmias, altered LOC, altered proprioception, spill on
the floor.

Fall Risk Factor and Nursing Interventions

Risk Factor Nursing Intervention

Polypharmacy Review medications with physician or NP.
Eliminate medications if possible; reduce
dosages if possible. Limit number of PRN
medications. Assess drug interactions for
additive CNS effects
Specific medications: benzo- Avoid medications known to cause adverse
diazepines, antipsychotics, events in older patients.
hypnotics, sedatives, anti-
depressants
Deconditioning Start physical therapy for strengthening
exercises, balance training.
Postural hypotension; Tell patient to get out of bed or up from a
change in proprioception chair slowly; avoid turning on heels quickly.
Uneven surfaces, poor Tell patient to consciously look around and
lighting evaluate the walking surface. Make sure to
be aware of where one surface changes to
another and the potential for thresholds in
doorways. Make sure path from bed to
bathroom is well lit and that objects the
patient can use for support (cane, walker)
are within reach

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Pressure Ulcer
CLINICAL PICTURE
The patient may have:
■ Reddened, blistered, open skin over pressure point such as sacrum, coccyx,
scapula, trochanter, or heel.
■ History of immobility, decreased sensorium, incontinence.

IMMEDIATE INTERVENTIONS
■ Relieve the pressure by turning patient or supporting extremity with pillows.
■ Do NOT massage the area; massage can cause tissue damage under the skin.
■ Do NOT use doughnut-shaped or ring-shaped cushions or sock-like heel
booties; these items impede circulation.
■ Assess wound using Wound Assessment Guidelines and/or Pressure Ulcer
Stage chart in this tab.
■ Assess patient for other areas of pressure and skin breakdown.
■ Notify physician or NP.
■ Document patient status, characteristics of wound, phone call to physician or
NP, and physician or NP response.

FOCUSED ASSESSMENT
■ Assess temperature, VS.
■ Assess wound (size, depth, edges, undermining, type and amount of necrotic
tissue [color, consistency adherence, and amount], exudate type and amount,
color of skin surrounding wound, peripheral tissue edema, induration,
granulation tissue, infection). See Wound Assessment Guide in this tab.
■ Assess patient’s pain level.
■ Assess for pressure ulcer risk.

STABILIZING AND MONITORING

■ Perform dressing changes as ordered. (See Wound Care Products for Pressure
Ulcers in this tab.)
■ Turn and reposition patient at least every 2 hours.
■ Keep wound free of contamination from urine and stool.
■ Assess nutritional status; consult dietitian.

BE PREPARED TO
■ Clean, dress, pack the wound.
■ Obtain special wound care products.
■ Obtain specialized support surface for bed or wheelchair.

POSSIBLE ETIOLOGIES
■ Pressure or shearing forces, immobility.

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Pressure Ulcer Assessment and Intervention Guides

Braden Scale Risk Assessment

The Braden Scale assesses six domains or risk factors:

■ Activity—Amount of physical activity.
■ Nutrition—Usual food intake pattern.
■ Friction and Shear—Extent to which skin is subject to friction and shear
forces.
■ Mobility—Ability to change or control body position.
■ Sensory perception—Ability to respond meaningfully to pressure-related
discomfort.
■ Moisture—Extent to which skin is exposed to moisture.
The patient is assigned a score of 1–4 (1–3 for Friction and Shear), depending
on amount of impairment. The total possible score is 23. The lower the score,
the greater the risk.
There are other scales as well; find out which pressure risk assessment tool
is used in your facility.

Pressure Ulcer Prevention Strategies

■ Inspect skin daily, document findings.
■ Effectively manage urinary and fecal incontinence. Clean skin
promptly, using a mild, nonirritating, nondrying cleansing
solution. Avoid friction during cleansing.
■ Use topical moisture barriers and moisture absorbing pad for incontinent
patients.
■ Position patient to alleviate pressure and shearing forces.
■ Reposition patient every 2 hours when in bed and every hour when in
a chair.
■ Teach the patient to shift his or her weight every 15 minutes while in
a chair.
■ Use positioning devices and foam padding. Do not use doughnut-shaped
devices.
■ Avoid placing the patient on his or her trochanters or directly on a wound.
■ Maintain the lowest head elevation possible to prevent sacral pressure.
■ Use lifting devices such as draw sheets or a trapeze.
■ Prevent contractures.
■ Provide adequate nutrition and hydration.
■ Do not massage reddened areas over bony prominences.

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137
Wound Assessment and Documentation Guide
■ Measure length, width, and depth using a centimeter ruler.
■ Assess characteristics of wound edges (i.e., attached, not attached,
fibrotic).
■ Assess for undermining: Insert a cotton-tipped applicator under the
wound edge; gently advance it until resistence is met. Using a felt-tipped
pen, mark the skin where applicator is felt. Continue around the wound.
■ Describe necrotic tissue type:
■ White/gray.
■ Nonadherent yellow slough.
■ Loosely adherent yellow slough.
■ Adherent, soft black eschar.
■ Firmly adherent, hard black.
■ Describe exudate type:
■ Bloody.
■ Serosanguineous.
■ Serous.
■ Purulent.
■ Foul purulent.
■ Describe exudate amount:
■ None—wound tissues dry.
■ Scant—wound tissues moist; no measurable exudates.
■ Small—wound tissues wet; drainage involved 25% of dressing.
■ Moderate—wound tissues saturated; drainage involved 25%–75% of
dressing.
■ Large—wound tissues bathed in fluid; drainage involves !75% of
dressing.
■ Assess and describe skin color surrounding wound: Assess tissues
within 4 cm of wound edge. For light-skinned persons, note if skin is
reddened. For dark-skinned persons, note if skin is reddened or darker or
purplish around wound edges.
■ Assess wound edge for tissue edema: Note if edema is pitting or
nonpitting and if wound is crepitant (crackly noises when tissue is palpated).
Notify physician immediately if wound is crepitant: may indicate gas
gangrene.
■ Assess amount of induration: Induration is abnormal firmness of tissues
with margins. Assess by gently pinching the tissue distal to wound edge; if
indurated, you will be unable to pinch a fold of skin.
■ Assess for granulation tissue: Granulation tissue is present in the
healing wound. It is the regrowth of small blood vessels and connective
tissue. Healthy granulation tissue is bright, beefy red, shiny, and granular.
Poorly vascularized tissue supply appears pale pink, dull, or dusky red.
■ Stage the pressure ulcer: (see the following table).

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Pressure Ulcer Stages and Treatment

MSKEL/
INTEG
Stage Ulcer Characteristics Interventions
I Intact skin. Nonblanchable erythema of No dressing. Prevent continued injury from
intact skin. For patients with darker pressure or shearing forces. Monitor frequently.
skin: discoloration, edema, redness,
and warmth over a bony prominence.

II Clean wound base. Partial-thickness Use a dressing that will keep ulcer bed
skin loss involving epidermis, dermis, continuously moist. Keep surrounding intact
or both. Ulcer is superficial and looks skin dry. Fill wound dead space with loosely
like an abrasion, blister, or shallow packed dressing material to absorb excess
crater. drainage and maintain a moist environment.

138
III Eschar and necrosis. Full-thickness skin Same as stage II treatment plus débride eschar
loss involving damage or necrosis of and necrotic tissue. (Heel ulcers with dry eschar
subcutaneous tissue. May extend down and no edema, erythema, or drainage may not
to fascia. The ulcer looks like a deep need to be débrided.) Débridement may be
crater with or without undermining of done surgically with enzymatic agents or
adjacent tissue. mechanically with wet-to-dry dressings, water
Copyright © 2008 by F. A. Davis.

jets, or whirlpool. Do not use topical

antiseptics.

IV Extensive tissue damage. Full- Same as stages II and III plus remove all dead
thickness skin loss. Extensive tissue, explore undermined areas, and remove
destruction and necrosis or damage to the skin “roof.” Use clean, dry dressings for
muscle, bone, or supporting structures. 8–24 hours after sharp débridement to control
Undermining and sinus tracts present. bleeding, then resume moist dressings.

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Wound Care Products for Pressure Ulcers

MSKEL/
INTEG
Product Characteristics Indications Nursing Considerations
Transparent ■ Semipermeable ■ Stage I and II wounds. ■ Transparency allows visual
Films membrane. ■ Work best on inspection of wound.
■ Tegaderm ■ Waterproof. superficial wounds, ■ Can be a secondary dres-
■ CarraFilm ■ Permeable to oxygen and blisters, and skin tears. sing over alginates or gels.
■ OpSite water vapor. ■ Dressing change up to three
■ BIOCLUSIVE ■ Provide moist healing times per week. Do not
environment and prevent absorb exudates; change
bacterial contamination. when fluid collects
underneath.
Hydrogels ■ Water- or glycerin-based ■ Stage II, III, and IV ■ Reduce pain and promote
■ Hypergel gels, impregnated gauzes, wounds. soothing effect. Easy to
■ CarraSorb or sheet dressings. apply and remove.
139

■ Nu-gel ■ Provides moist wound ■ Require secondary dressing.

■ Curafil environment. Helps clean ■ Do not absorb large
and débride by supplying amounts of exudate due to
liquid to dry, sloughy large water content.
wounds. ■ Change once daily.
Copyright © 2008 by F. A. Davis.

Hydrocolloid ■ Occlusive and adhesive ■ Stage II and III wounds. ■ Conformable for easy
dressings wafer dressings, or ■ Granulating and application; help reduce
■ Tegasorb hydrocolloid powders and epithelizing wounds pain at wound site.
■ Comfeel pastes. with low to moderate ■ Breakdown of product may
■ DuoDERM ■ Facilitate rehydration and amounts of exudate. produce residue and foul
■ Restore autolytic débridement of odor; do not confuse with
dry, sloughy, or necrotic infectious process.
wounds. ■ Changed up to three times/
week.
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Wound Care Products for Pressure Ulcers (continued)

MSKEL/
INTEG
Product Characteristics Indications Nursing Considerations
Alginates ■ Soft nonwoven fibers ■ Stage III and IV ■ Highly absorbent, therefore
■ CURASORB derived from seaweed. wounds with good for packing exudating
■ AlgiDERM ■ Available in pads, ropes, moderate to heavy wounds.
■ Sorbsan or ribbons. exudate, but not ■ Require secondary dressing.
■ Algosteril ■ Can absorb up to 20 wounds with eschar ■ Usually changed once daily.
times their weight. or dry wound beds.
Foam dressings ■ Highly absorbent ■ Stage III and IV ■ Highly absorbent foam may
■ Flexzan dressings made from wounds. allow less frequent dressing
■ CURAFOAM hydrophilic ■ Heavily exudating changes.
■ Mepilex polyurethane foam. wounds, especially ■ Can be left undisturbed for
■ Some have adhesive during inflammatory 3–4 days.

140
borders. phase following ■ Decrease maceration of
débridement and surrounding tissue.
desloughing. Comfortable and
■ Deep cavity wounds conformable.
and weeping ulcers ■ Usually changed up to three
such as venous stasis times/week.
Copyright © 2008 by F. A. Davis.

ulcers.
Enzymatic ■ Agents selective in ■ Stage III and IV ■ Surgical débridement may
débriding removing necrotic wounds. be avoided in some cases
agents tissues from wound ■ Tunneling wounds with use of enzymatic
■ Panafil bed. (may remove debris débriding agents.
■ Santyl in areas that cannot ■ Require prescription.
■ Accuzyme be visualized).

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141
Surgical Site Infection/Complication
CLINICAL PICTURE
The patient may have:
■ Warm, reddened, tender, swollen, painful wound.
■ Low-grade fever.
■ Separation of wound edges with serous-sanguineous or purulent drainage
from wound.
■ Purulent discharge from wound drain.
■ Feeling of wound tearing or opening.
■ Exposure or protrusion of abdominal contents through open wound.

IMMEDIATE INTERVENTIONS
■ Examine wound for evisceration—total separation of deep wound layers
(fascia and muscle) with protrusion of internal organs and viscera;
dehiscence—partial or complete separation of deep wound layers; or
superficial wound separation—separation of skin and subcutaneous
tissue.
■ Abdominal wound: If there is evidence of dehiscence or evisceration, place
the patient in semi-Fowler’s position, with knees bent to decrease tension on
abdominal wall. Saturate a sterile dressing with normal saline, and cover the
open wound. Place a large sterile dressing over top. Do not manipulate
viscera or attempt to replace. Keep patient NPO and NOTIFY PHYSICIAN OR
NP STAT. Stay with patient and offer support and reassurance.
■ For dehiscence of wounds elsewhere on the body, position patient to
alleviate tension on suture line, then saturate a sterile dressing with normal
saline, and cover the open wound. Place a large sterile dressing over top.
Notify physician or NP immediately.
■ For superficial wound separation, cover wound with a sterile normal saline
wet-to-dry dressing. Notify physician or NP.
■ If evidence of infection, obtain wound culture.
■ Assess for patent IV access.
■ Assess pain level, and medicate per order.
■ Document patient’s status, phone call to physician or NP, and physician or NP
response.

FOCUSED ASSESSMENT
■ Assess temperature, VS.
■ Assess wound: determine or describe size, depth, edges, undermining, type
and amount of necrotic tissue (color, consistency adherence, and amount),
exudate type and amount, color of skin surrounding wound, peripheral tissue
edema, induration, granulation tissue, infection. (See Wound Assessment
Guide in this tab).
■ Assess patient’s pain level.

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INTEG

STABILIZING AND MONITORING

■ Perform dressing changes as ordered.
■ Administer antibiotics.
■ Assess nutritional status; consult dietitian.
■ Document assessment findings.

BE PREPARED TO
■ Prepare the patient for surgery.
■ Clean, dress, pack the wound.
■ Start an IV.

POSSIBLE ETIOLOGIES
■ Infection, excessive tension on suture line (vomiting or coughing),
dehydration, long surgery time, hematoma, abdominal distention, obesity,
poor nutritional status, diabetes, insufficient suturing, stretching or pulling
at suture site (trauma), higher risk in geriatric patients.

Wound Vacuums
Vacuum-assisted closure (VAC) units are negative pressure devices that help
promote wound healing by removing exudate and other fluids with
continuous and/or intermittent subatmospheric pressure; in other words, by
suction. The suction, in conjunction with the system, also helps pull the
wound edges together, stimulates granulation tissue, and improves blood
flow to the wound bed.
Setting up the wound VAC:
■ Wash your hands, don gloves, and clean the wound using aseptic
technique.
■ Apply skin preparation to peri-wound area to help secure the dressing.
■ Cut foam to fit wound, and place in the wound; do not push it in, just
place it on the wound.
■ Apply Tegaderm-like plastic sheet over foam and onto healthy skin; put it
on in patches, if necessary.
■ Cut a small hole in the plastic sheet over the foam. This is essential for
suction to reach wound bed.
■ Apply suction disc over the hole in the plastic dressing.
■ Connect suction tubing, remove kinks, and set suction as ordered.
■ Remove gloves, discard old dressing properly, wash hands.

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143

Dressing before suction is turned on.

Dressing appearance after suction is applied.

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INTEG

A & P Snapshot

Zygomatic arch Skull (cranium)

Maxilla Cervical vertebrae

Mandible Thoracic vertebrae
Clavicle
Sternum Scapula

Humerus
Ribs

Lumbar
vertebrae
Radius

Ulna
Ilium
Carpals Sacrum
Metacarpals Coccyx
Phalanges
Pubis
Ischium
Femur

Patella

Tibia
Fibula
Tarsals
Metatarsals
Phalanges

Skeletal system.

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145

Receptor
for touch Stratum
(encapsulated) Pore germinativum
Stratum
corneum
Epidermis
Papillary
Sebaceous layer with
gland capillaries
Dermis
Pilomotor
muscle
Hair
follicle

Receptor Fascia of
for pressure muscle
(encapsulated) Adipose
tissue Subcutaneous
Nerve Eccrine tissue
Arteriole sweat gland
Venule Free nerve ending
Skin structure.

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Standard Precautions
Use standard precautions for the care of all patients. Add contact, droplet,
or airborne precautions, depending on the mode of transmission.
Handwashing:
■ Wash hands.
■ After touching blood, body fluids, secretions, excretions, and
contaminated items.
■ Immediately after gloves are removed.
■ Between patient contacts.
■ To avoid transfer of microorganisms to other patients or environments.
■ Between tasks and procedures on the same patient to prevent cross
contamination of different body sites.
Gloves:
■ Wear clean, nonsterile gloves:
■ When touching blood, body fluids, secretions, excretions, and
contaminated items.
■ Before touching mucous membranes and nonintact skin.
■ Change gloves between procedures on the same patient after contact
with contaminated material.
■ Remove gloves promptly after use and before touching noncontaminated
items and environmental surfaces. Wash hands immediately.
Mask, Eye Protection, Face Shield:
■ Wear mask and eye protection or face shield when patient-care activities
are likely to generate splashes or sprays of blood, body fluids, secretions,
or excretions.
Gown:
■ Wear a clean, nonsterile gown when patient-care activities are likely
to generate splashes or sprays of blood, body fluids, secretions, or
excretions.
Patient-Care Equipment:
■ Prevent skin, mucous membrane, and clothing exposure to contaminated
equipment.
■ Do not use reusable equipment for another patient until cleaned
appropriately.
■ Discard single-use items properly.
Linen:
■ Prevent skin, mucous membrane, and clothing exposure to contaminated
linen.

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147
Preventing Needle and Sharps Injuries
Never recap used needles or manipulate them using both hands.
■ Do not direct needle point toward self.
■ Use one-handed “scoop” technique.
■ Do not remove used needles from disposable syringes by hand; do not
bend, break, or manipulate used needles by hand.
■ Place used disposable syringes and needles, scalpel blades, and other
sharp items in appropriate puncture-resistant containers.

Airborne Precautions
For patients who are or may be infected with microorganisms transmitted
by airborne droplet nuclei.
■ Private room with:
■ Monitored negative air pressure in relation to the surrounding
area.
■ 6 to 12 air changes per hour.
■ Monitored high-efficiency filtration of room air.
■ Door closed.
■ Keep patient in room.

Droplet Precautions
For patients who are or may be infected with microorganisms transmitted
by large-particle droplets that occur with coughing, sneezing, talking.
■ Private room or in room with patient who has active infection with same
microorganism but no other infection.
■ If private room not possible, maintain at least 3 ft of space between
infected patient and other patients and visitors.
■ Door may be open.
■ Wear a mask when working within 3 ft of patient.
■ Place mask on patient when leaving the room, if possible.

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Contact Precautions
For patients who are or may be infected or colonized with microorganisms
transmitted by direct contact with the patient or indirect contact with
environmental surfaces or patient-care items.
■ Private room or in room with patient who has active infection with same
microorganism but with no other infection.
■ Wear clean, nonsterile gloves when entering the room.
■ Remove gloves before leaving patient room, and immediately wash hands
with antimicrobial or waterless antiseptic agent.
■ Do not touch potentially contaminated surfaces once gloves are removed
and hands washed.
■ Wear clean, nonsterile gown when entering room if clothing will have
contact with patient, surfaces, or items in the room or if patient is
incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage
not contained by a dressing.
■ Remove the gown before leaving room.

Clostridium-Associated Diarrhea
(CDAD, Psuedomembranous Colitis)
CLINICAL PICTURE
The patient may have:
■ Frequent, watery diarrhea, possibly with blood.
■ Fever.
■ Loss of appetite, nausea.
■ Abdominal cramping, pain, and tenderness.

IMMEDIATE INTERVENTIONS
■ Assess hydration status, electrolyte balance, and recent I&O records
(to assess hydration).
■ Note trends in recent VS assessment; reassess as needed.
■ Assess for recent antibiotic use; if patient is still on antibiotics, with-
hold until you speak with the physician or NP. Clostridium difficile
infection is usually caused by antibiotic-induced derangement of
normal intestinal flora, and discontinuation of the antibiotic is part
of the treatment.
■ Call physician or NP about the character and frequency of the stool.
■ Document findings, phone call, and physician or NP response.
■ Move patient to a private room, and initiate contact precautions.
■ Obtain stool sample for laboratory testing.

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149
FOCUSED ASSESSMENT
■ Assess for IV access as rehydration may be necessary.
■ Assess stool for blood or pus, which can occur with severe infection.
■ Auscultate bowel sounds, and palpate abdomen for tenderness.

STABILIZING AND MONITORING

■ Make sure all visitors wear gloves when touching the patient, and
wash their hands with soap and water each time before they leave
the room.
■ Administer oral metronidazole or Vancomycin as ordered.
■ Collect stools for testing as ordered—usually three stools from three
separate bowel movements on consecutive days.
■ Provide incontinence care, if needed, and monitor perianal skin for
breakdown.
■ Monitor hydration status and food intake
■ Monitor electrolytes, albumin, WBC count.
■ Assess for complications of severe infection including anasarca,
dehydration, toxic megacolon, and colonic perforation.

BE PREPARED TO
■ Transfer patient to high-acuity unit if infection is severe with
complications.
■ Insert an IV, and hang IV fluids.

POSSIBLE ETIOLOGIES
■ C. difficile, which produces two toxins that cause tissue damage;
inflammation of colonic tissues.

Fever
CLINICAL PICTURE
The patient may have:
■ Temperature elevation (low-grade fever: T !101!F; high-grade "101!F).
■ Fatigue, weakness.
■ Flushed, dry skin.

IMMEDIATE INTERVENTIONS
■ Assess VS.
■ Offer cool compress for forehead.

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FOCUSED ASSESSMENT
■ Auscultate lungs for diminshed breath sounds, crackles, rhonchi.
■ Assess for stiff neck, headache, photophobia, irritability, confusion.
■ Assess IV sites, surgical incisions for redness, warmth, tenderness,
swelling.
■ Assess legs for swelling, warmth, pain (do not massage calves).
■ Assess for urinary symptoms.
■ Assess for GI symptoms.
■ Evaluate medications for possible drug fever; note any rashes.
■ Assess mucous membranes, I&O.
■ Ask about prosthetic implants (heart valve, artificial joint).
■ Check recent laboratory test for ↑WBC count.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.

STABILIZING AND MONITORING

■ Encourage patient to cough, breathe deeply, and use incentive spirometer.
■ Encourage fluids (unless contraindicated by renal or cardiac disease).
■ Check medication administration record for order for PRN antipyretic.
Administer if patient feels uncomfortable.
■ Obtain cooling blanket, or give tepid bath, if ordered.

BE PREPARED TO
■ Obtain sputum, blood, or urine sample for Gram stain, culture, and
sensitivity.
■ Obtain or change IV access.
■ Order a chest x-ray.
■ Order or obtain laboratory tests.

POSSIBLE ETIOLOGIES
■ Numerous potential causes include bacterial, viral, or fungal infection;
deep venous thrombosis; medications; tumor; neutropenia.

Fever With SIRS/Sepsis

Terms:
■ Infection: Inflammatory response to microorganisms, or the invasion
of normally sterile host tissue by those organisms.

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■ Systemic Inflammatory Response Syndrome (SIRS): Systemic
inflammatory response to severe clinical insults, including infection,
pancreatitis, trauma, and burns. This response is manifested by two
or more of the following conditions:
■ Core temperature "38!C (100.4!F) or #36!C (96.8!F).
■ HR "90 beats/min.
■ RR "20 breaths/min or PaCO2 #32 mm Hg.
■ WBC count "12,000/mm3, #4000/mm3, or the presence of "10%
immature neutrophils.
■ Sepsis: A systemic inflammatory response to infection that initiates a
cascade of biochemical events resulting in hypotension, coagulopathy,
suppression of fibrinolysis, and multisystem organ dysfunction. Sepsis is
diagnosed when there is a documented infection with at least two of the
four systemic inflammatory response criteria.
■ Severe sepsis: Sepsis with dysfunction of one or more organ systems,
hypoperfusion, or hypotension.
■ Septic shock: Sepsis with hypotension (systolic BP #90 mm Hg or a
reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation
and with perfusion abnormalities that include lactic acidosis, oliguria, or
change in mental status.
■ Multiple organ dysfunction syndrome: Altered organ function in an
acutely ill patient such that homeostasis cannot be maintained without
intervention.

CLINICAL PICTURE
The patient may have:
■ Temperature "38!C (100.4!F) or #36!C (96.8!F).
■ Chills, sweating.
■ Tachypnea, respiratory alkalosis.
■ Tachycardia.
■ Elevated or depressed WBC count.
■ Change in mental status.
■ Abdominal or flank pain.
■ Rash; warm, dry, flushed skin.
Progressive Indications:
■ Restlessness, confusion, altered LOC.
■ Hypotension, widening pulse pressure.
■ Oliguria.
■ Rapid thready pulse, delayed capillary refill.
■ Decreased urinary output.

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INFECT

■ Hypoactive bowel sounds.

■ Rapid shallow breathing.
■ Cold, clammy, mottled skin.

IMMEDIATE INTERVENTIONS
■ Assess HR, BP, RR, and temperature (rectally).
■ Administer supplemental oxygen.
■ Assess for patent IV access.
■ Obtain SaO2 via pulse oximetry.
■ Review recent WBC count if available.
■ Notify physician or NP.
■ Obtain large-bore IV access if needed.
■ Obtain IV fluids (NS) for administration.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess airway status, LOC, and VS (HR, RR, BP) frequently.
■ Assess SaO2 via pulse oximetry.
■ Assess VS and capillary refill.
■ Assess onset, recent history of fever.
■ Assess for possible source of infection.

STABILIZING AND MONITORING

■ Obtain and administer prescribed antibiotic STAT.
■ Administer isotonic IV fluids to correct hypovolemia (due to vasodilation
and capillary leak) and restore blood pressure and tissue perfusion.
■ Monitor for signs of volume overload: dyspnea, pulmonary crackles,
jugular vein distention.
■ Monitor mental status, HR, BP, capillary refill, and urinary output.
■ Monitor coagulation studies, BUN, and creatinine.

BE PREPARED TO
■ Obtain urine, blood, wound, and sputum samples for culture.
■ Assist with line placement.
■ Assist with central line placement.
■ Order or obtain laboratory tests.
■ Facilitate diagnostic testing such as x-rays or CT scan.
■ Insert indwelling urinary catheter.
■ Administer vasoactive drugs to treat hypotension.

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153
■ Assist with intubation and airway management.
■ Call a code.
■ Transfer patient to ICU or monitored unit.

POSSIBLE ETIOLOGIES
■ Head and neck infections; chest and pulmonary infections; GI infections;
pelvic/genitourinary infections; bone, soft-tissue, and skin infections.

Hepatitis
Inflammation of liver cells that results in necrosis and obstruction of bile.
There are many forms of hepatitis, including viral, bacterial, alcoholic, and
drug-induced hepatitis.
The various forms of viral hepatitis are named with a letter of the alphabet,
using A through G.

CLINICAL PICTURE
The patient may have:
■ Fever, loss of appetite, nausea, and vomiting
■ Fatigue, headache.
■ Tea-colored urine, clay-colored stools, jaundice.
■ Right upper quadrant abdominal pain.

IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT

■ Assess laboratory values for positive hepatitis test.
■ Institute contact precautions if needed (see following table).
■ Assess pain, activity tolerance, appetite.
■ Assess for jaundice.
■ Observe urine for characteristic tea color and stools for the absence
of bile, which renders them clay-colored.
■ Document findings.

STABILIZING AND MONITORING

■ Continue ongoing assessment.
■ Implement energy-conserving routines for self-care.
■ Teach patient about self-care during recovery and how to prevent trans-
mission to others.

POSSIBLE ETIOLOGIES
■ Viral infection.

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Precautions for Major Types of Viral Hepatitis

Route of
Type Transmission Precautions
HAV Fecal-oral route; Standard precautions plus contact precautions.
exposure to Found in feces; spread under poor sanitary
contaminated conditions and poor personal hygiene. Can
food or water also be transmitted through oral and anal
sexual activity, drinking contaminated water,
eating raw shellfish taken from contami-
nated water, or eating fruits and vegetables
contaminated during handling.
HBV Parenteral: blood- Standard precautions.
to-blood contact Spread by blood-to blood contact via
punctures of the skin with blood-
contaminated needles or scalpels, blood
splashes to open skin or mucous
membranes, or indirectly when dried blood
on a surface or instrument gets transferred
to open skin or mucous membranes.
Saliva can contain very low concentrations of
hepatitis B virus, thus disease can be spread
by a bite. Spread by sharing needles and
through unprotected sexual contact.
Feces, nasal secretions, sputum, sweat, tears,
urine, and emesis do not spread hepatitis B
unless visibly contaminated with blood.
Not transmitted by casual contact.
HCV Parenteral: Standard precautions.
blood-to-blood Spread by blood-to-blood contact or exposure
contact of contaminated blood to open skin or
mucous membranes.
People may get hepatitis C by sharing needles
to inject drugs or through exposure to blood
in the workplace. Can be sexually trans-
mitted. Not spread by casual contact or
through food or water.
HDV Parenteral: blood- Standard precautions.
to-blood contact See Hepatitis B.
HEV Fecal-oral: possi- Standard precautions plus contact precautions.
ble person-to- See Hepatitis A.
person contact

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Meningitis
Inflammation of the meninges, which cover the brain and spinal cord. May
be septic meningitis, which is caused by bacteria, or aseptic, which is viral or
secondary to a lymphoma, leukemia, or a brain abscess. Bacterial meningitis
is much more severe than viral meningitis and will be fatal if not treated
promptly.

CLINICAL PICTURE
The patient may have:
■ Fever, headache, nausea and vomiting.
■ Confusion, delirium, seizure.
■ Neck stiffness, lethargy, rash.
■ Photophobia, sore throat, weakness.

IMMEDIATE INTERVENTIONS
■ Assess VS, LOC, SaO2.
■ Start antibiotics immediately.
■ Institute droplet precautions for meningococcal meningitis; maintain until
48 hours after antibiotics are started.
■ Discuss diagnosis with physician or NP for information about causative
organism.
■ Document findings.

FOCUSED ASSESSMENT
■ Assess cranial nerves for possible complication (hearing loss, visual im-
pairment, nerve palsy). See cranial nerve assessment in Neurological tab.
■ Assess for Brudzinski’s sign (hip and knee flexion in response to forced
flexion of the neck).
■ Assess for Kernig’s sign (inability to completely extend the legs).
■ Initiate seizure precautions.

STABILIZING AND MONITORING

■ Record I&O, and observe patient for signs of dehydration.
■ Administer IV fluids and medications, as ordered by the physician.
■ Monitor patient’s vital signs and neurological status and record. Use
Glasgow Coma Scale in this tab for accuracy and consistency.

BE PREPARED TO
■ Assist with lumbar puncture.
■ Obtain blood for CBC, blood cultures, protein.
■ Send patient for CT scan or MRI.

POSSIBLE ETIOLOGIES
■ Bacterial, viral, fungal, amoebic, neonatal, or TB infection.

INFECT
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INFECT

Pneumonia
Acute infection of the lungs. Alveoli become inflamed and fluid-filled.
The patient may have:
■ Cough, chest pain, fever, tachycardia.
■ Shortness of breath, cyanosis, tachypnea, hemoptysis.
■ Joint pain, muscle aches.
■ Loss of appetite, fatigue.

IMMEDIATE INTERVENTIONS
■ Assess VS, and determine if patient has SOB.
■ Apply O2 if already ordered.
■ Assess HR and RR; note if patient is short of breath or struggling
to breathe.
■ Listen to lung sounds, assess use of accessory muscles.
■ Notify physician or NP of assessment findings.
■ Document phone call and physician or NP response.

FOCUSED ASSESSMENT
■ Assess sputum quantity and character.
■ Assess oxygen saturation by pulse oximetry.
■ Assess LOC and orientation.
■ Assess for pleuritic chest pain, chills.
■ Assess for cyanosis.
■ Assess appetite.
■ Assess for patent IV line.

STABILIZING AND MONITORING

■ Administer antibiotics as soon as they are available.
■ Maintain O2, and check oxygen saturation frequently.
■ Keep patient well hydrated.
■ Provide diet high in protein.
■ Assess for complications such as empyema, respiratory distress, or
superinfection (worsening signs and symptoms despite treatment).

BE PREPARED TO
■ Obtain sputum culture and sensitivity, blood cultures, ABGs, or other
laboratory work.
■ Assist with thoracentesis, and monitor for complications (pneumothorax).
■ Obtain chest x-ray STAT.
■ Suction the patient; assist with bronchoscopy.

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POSSIBLE ETIOLOGIES
■ Viral, fungal, bacterial infection; prolonged bedrest; mechanical
ventilation; TB; aspiration; smoking; malnutrition; upper respiratory
tract disorder.

MRSA and Vancomycin-Resistant Staph Infection

Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by
S. aureus bacteria, which are often found in hospitals. S. aureus is resistant
to the broad-spectrum antibiotics commonly used to treat it. A patient or
health-care worker can be colonized with MRSA, which means the bacterium
lives on the skin and nares but does not cause infection. The danger with
colonization is that the patient or health-care worker can transmit the
bacteria to others, who may develop the hard-to-treat infection. CA-MRSA
is community-acquired MRSA. MRSA can be fatal. Vancomycin is one of the
few antibiotics that effectively treat MRSA; however, vancomycin-resistant
staph has begun to emerge.

CLINICAL PICTURE
The patient may have:
■ Small red pimple-like bumps that may look like boils or spider bites.
■ Erythema, swelling, and warmth around bumps; purulent drainage.
■ Fever, SOB, chest pain, muscle aches.
■ Painful skin abscesses.
■ Infection of bone, joints, incisions, blood, cardiac valves, lungs.

IMMEDIATE INTERVENTIONS
■ Using gloves, cover the wound(s), abscesses, or bumps with a clean,
dry, dressing; wash hands thoroughly.
■ Assess VS.
■ Notify physician or NP of possible staph infection.
■ Document phone call and physician or NP response.

FOCUSED ASSESSMENT
■ Assess for signs and symptoms of internal infection: auscultate lungs
for adventitious sounds; take apical pulse, and listen for murmurs;
assess urine for cloudiness; check BUN and creatinine for signs of
renal impairment.
■ Ask patient about general aches and pains, chills, headache, feeling
unwell (malaise).

INFECT
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INFECT

■ Obtain culture of wound and drainage.

■ Obtain blood cultures.
■ If pneumonia is suspected, obtain sputum culture.
■ If urinary tract infection is suspected, obtain urine culture.

STABILIZING AND MONITORING

■ Initiate contact precautions (See Contact Precautions in this tab).
■ Move patient to private room.
■ Wear a mask if patient has a productive cough.
■ Start antibiotics promptly.
■ Do not discontinue contact precautions until two sets of cultures, taken
24 hours apart and 48 hours after all antibiotics are discontinued, are
negative for MRSA.

BE PREPARED TO
■ Transfer patient to ICU if septic.
■ Teach family about preventing spread of MRSA.
■ Assist with incision and drainage of skin abscesses.

POSSIBLE ETIOLOGIES
■ S. aureus colonization or infection.

Tuberculosis
CLINICAL PICTURE
The patient may have:
■ Productive cough, worse in the morning.
■ Hemoptysis.
■ Chest pain, SOB.
■ Fever, night sweats.
■ Extreme weight loss if disease is advanced.

IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT

■ Institute airborne precautions (see Airborne Precautions in this tab).
■ Auscultate lungs for possible diminished breath sounds, bronchial
breathing, coarse crackles.
■ Assess findings of chest x-ray: cavitation, calcification (indicates healed
disease), and nodes in the upper lobes suggest pulmonary TB.
■ Assess sputum production and patient’s ability to clear airway.

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STABILIZING AND MONITORING
■ Obtain early morning sputum specimens for 3 consecutive days for
culture and acid-fast bacilli (AFB). Obtain proper medium for AFB
specimen.
■ Administer standard therapy, and teach patient that it is critical that he
or she take medications as prescribed for the duration of therapy (6 to
18 months). A combination of the following drugs is standard treatment:
■ Isoniazid (INH).
■ Rifampin (RM).
■ Pyrazinamide (PZA).
■ Ethambutol (EMB).
■ Vitamin B6 for neuropathy of hands/feet.
■ Assess for signs and symptoms of tuberculosis outside the lungs
(meningitis, peritonitis, renal or bone involvement, pericarditis).

BE PREPARED TO
■ Assist with bronchoscopy.
■ Assist with chest tube placement (ruptured TB granuloma, empyema).

POSSIBLE ETIOLOGIES
■ Mycobacterium tuberculosis.

INFECT
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EMERG

Assessment in an Emergency
This assessment guideline was developed for the multiple trauma patient
brought into the emergency department (ED). However, the basic primary
survey—the ABCs (airway, breathing, circulation)—take precedent in
any emergency situation, whether in the ED, ICU, or general care floor. The
primary survey should be accomplished within the first few minutes.
■ Put on gloves and face mask with visor.
■ Check that needed equipment is readily available.
■ Ensure that needed staff is available.

Primary Survey: Airway, Breathing, Circulation

The primary survey is a crucial, rapid (less than 5 minutes) assessment. The
highest priorities are to establish an airway, supplement breathing or provide
ventilation, and support circulation. These are the ABCs and must always be
addressed first in any situation in which a patient’s status is deteriorating. The
order of assessment is critical (a blunt clinical saying: “If you do not have A
and B, you can forget about C.”). If the team encounters a problem with the
ABCs, an intervention to correct or improve the problem is initiated immedi-
ately, and its efficacy is assessed before proceeding. Once ABC is established,
proceed to D (disability) and E (expose) and then to the seconday survey.
Throughout, the team ALWAYS reassesses ABCs—if problems arise in ABCs,
all attention is directed to the problem.
■ During the primary survey all patients are
■ Given high-flow O2.
■ Assessed multiple times by cardiac monitoring, pulse oximetry, and
BP measurement
■ Penetrating objects are NOT removed. This should be done only in the
OR. Otherwise, catastrophic bleeding or additional injury can occur.

A: Airway
Assessment (with cervical spine immobilized):
■ Ask “are you all right?” Can the patient speak? If so, ABC is functional to
some extent. If there is no answer, rapidly begin more in-depth airway
and breathing assessment.
■ Look in the oropharynx for foreign objects, blood, teeth, vomitus, etc.
You may hear abnormal sounds such as wheezing or stridor.

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Interventions:
■ Immobilize cervical spine.
■ Establish patent airway with:
■ Jaw thrust/chin lift maneuver.
■ Consider a nasal airway. Do not use an oral airway in a conscious
patient as it may induce vomiting and aspiration.
■ Suction fluid from oropharynx.
■ If patient is not breathing or the airway cannot be cleared, endotracheal
intubation will be attempted. This will help:
■ Protect airway and ensure patency.
■ Correct hypoxemia.
■ Provide access for some medications.
■ If the patient cannot be intubated, a tracheotomy will be performed.

B: Breathing
Assessment:
■ Some patients are not breathing in an emergency (see CPR Quick
Reference in this tab). In a hospital, the code team will take over, and an
anesthesiologist, respiratory therapist, or other highly skilled individual
will assess the airway.
■ If the patient is breathing and you hear any noises with breathing, open
the mouth, and inspect the airway. Remove any obstructing material by
sweeping with a gloved finger.
■ Assess rate and ease of breathing. Check nailbed and circumoral area
for cyanosis.
■ Is the patient restless, thrashing about, extremely anxious? You will see
this in an emergency unless the patient has had a head injury and is
unconscious.
■ Feel trachea, examine the chest, and auscultate lungs.
■ Evaluate ABG results.
Interventions:
■ Provide high-flow supplemental O2; manually ventilate if necessary.
■ Identify and treat major thoracic injuries:
■ Pneumothorax (simple, open, or tension).
■ Hemo-pneumothorax.
■ Rib fractures.
■ Flail chest.

EMERG
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EMERG

C: Circulation
Assessment:
■ Check cardiac rate and rhythm and BP. Recheck every few minutes.
■ Check peripheral perfusion.
Interventions:
■ Control external bleeding.
■ Insert two large-bore IV accesses.
■ Send blood for laboratory tests, and type and crossmatch.
■ Infuse a warmed crystalloid.
D: Disability
Assessment:
■ Initial neurological assessment is limited to checking pupils and assessing
LOC (responsiveness) using the AVPU scale:
■ A ! Alert
■ V ! responds to Voice
■ P ! responds to Pain
■ U ! Unresponsive
■ Any change in AVPU requires reassessment of ABC.
E: Exposure
■ Remove clothing (expose), and inspect for obvious injuries.
■ Cover patient to reduce heat loss.

Secondary Survey

■ Follows primary survey and resuscitation.

■ Involves head-to-toe systematic assessment to detect injuries.
■ Includes AMPLE history (allergies, medications, past medical history, last
meal eaten, events prior).
■ Includes continuous reassessment of primary survey.
■ Provides for assessment of each body area for signs of deformity,
contusion, abrasion, hemorrhage, penetrating injury, altered perfusion,
and altered function.

Head and Face

■ Inspect and palpate head and face for lacerations, contusions, fractures, or
other injury.
■ Eyes (injury, hemorrhage, contact lens, dislocation of lens).
■ Ears and nose for CSF.
■ Mouth.
■ Cranial nerves.

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Cervical Spine and Neck
■ Inspect for signs of injury, tracheal deviation.
■ Palpate for tenderness, deformity, swelling, subcutaneous emphysema.
■ Auscultate for carotid bruits.

Chest
■ Inspect for injury, use of accessory muscles.
■ Auscultate lungs, and compare left with right.
■ Palpate entire chest for tenderness, crepitation, and injury.
■ Percuss.

Abdomen
■ Inspect for distention, skin condition.
■ Auscultate for bowel sounds.
■ Percuss.
■ Palpate; soft or rigid, tender or nontender?

Extremities
■ Inspect for signs of injury or deformity.
■ Palpate for sensation, tenderness, crepitation, abnormal movement.
■ Check all pulses.

Perineum
■ Inspect for rectal blood, sphincter tone.
■ Assess for bleeding or other injury to genitalia.

Back
■ Inspect for injuries, swelling.
■ Assess for flank pain, hematoma.

Fractures
■ Assess for bone/joint deformity.
■ Assess for loss of function.

Neurological
■ Reevaluate pupils and LOC.
■ Determine GCS.
■ Evaluate for paralysis, paresis, motor and sensory responses of
extremities.

EMERG
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EMERG

Diagnostic Studies
■ Type and crossmatch for blood.
■ Hemoglobin and hematocrit levels.
■ WBC count.
■ Glucose.
■ Urinalysis.
■ Amylase.
■ Cardiac and liver enzymes.
■ Arterial blood gas.
■ Cervical-spine radiographic series.
■ Chest x-ray.
■ Head CT.
■ Abdominal CT.

Advance Directives and Do Not Resuscitate Orders

First, make sure you know the patient’s wishes (or family’s, if the patient is
unable to make decisions) regarding “heroic measures.” Ideally, all patients
should have advance directives in the medical record indicating whether
they wish to be resuscitated and to what extent resuscitative efforts should
be carried out. Admission personnel often ask this of the patient when he or
she is admitted. However, sometimes this is not possible, and if there is any
doubt as to the interpretation or whereabouts of a patient’s advance direc-
tives a code must be called and resuscitative efforts initiated. Therefore,
make sure this document is always available in the record.
■ Help patients and families address end-of-life care issues.
■ Suggest discussing with a religious leader of their faith.
■ Keep in mind the role of culture, ethnicity, and religion in end-of-life
questions.
■ Always treat the patient as an individual.
■ Tell patients that they will not be abandoned or given substandard care
if they or their advance directive limit medical interventions.

Rapid Response Teams

Patients typically go through several hours of subtle changes in condition
before a respiratory or cardiac arrest. HR and BP changes, changes in
mentation, breathing difficulties, and other signs precede a full-blown code.
Intervening earlier in the downward spiral of events vastly increases the

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patient’s chance of survival. The nurse’s role is critical in getting the right
help for the patient. Many hospitals have rapid response teams that can
be and should be called when the patient’s condition changes, even if you
cannot say for sure what it is (“something’s different/wrong”). The rapid
response team may consist of:
■ Resident, NP, or physician’s assistant.
■ ICU nurse.
■ Nurse anesthetist or respiratory therapist.
The staff nurse is usually responsible for:
■ Calling the rapid response team.
■ Calling the attending physician.
■ Providing the recent history and background information.
■ Continuing to assess the patient.
■ Obtaining and administering medications.
■ Providing other noncritical care.
If your facility does not have a rapid response team, notify the nurse
manager or nursing supervisor, who can help you get the resources
needed.

What to Do If Your Patient Codes

If you are by yourself:
■ Establish unresponsiveness, call for help, and check ABC; clear airway
by sweeping your fingers in the patient’s mouth or by suctioning.
■ If you have no help, call the code before proceeding. As you do this,
pull the call bell out so that the light flashes continually, ask any visitors
to wait outside the room, and pull the curtain if another patient is
present.
■ Note if the patient has a running IV or an IV access device.
■ Place the patient in a supine position in bed, if possible.
■ Place the arrest board under the patient’s back, if you have help. If not,
proceed until a second person arrives.
■ Next, assess breathing for 5 seconds, using the head-tilt/chin-lift maneuver
(see first figure below). If the patient is not breathing, initiate ventilations,
preferably with a bag-valve-mask device. If one is not available, quickly
apply a barrier, and give two breaths of 11/2–2 seconds each.

EMERG
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EMERG

■ Check for a pulse. If the patient has no pulse, begin one-person CPR until
another person or the code team arrives (see CPR Quick Reference in this
tab).
When another nurse arrives to help:
■ Bring the crash cart into the room.
■ Get an IV of NS running.
■ Switch to bag-valve-mask ventilations by:
■ Inserting an oral airway.
■ Connecting the bag-valve-mask to oxygen tubing.
■ Setting up the flowmeter.
■ Turning on the oxygen to 12–15 L/min.
■ Make sure the seal around the patient’s airway is tight, and resume CPR.
■ Once the code team arrives, someone will relieve you and begin other
resuscitative interventions.
■ Once you are relieved:
■ Make sure one nurse is documenting and another nurse is retrieving
medications and supplies as needed from the code cart.
■ Stay in the room to be available to the team.
■ Many other tasks may be required of you in a code situation, including
obtaining laboratory tests and transporting them to the laboratory,
inserting an IV or Foley catheter, suctioning the airway, administering
medications, calling the attending physician, arranging for a bed in the
ICU, etc. Do not practice beyond your level of expertise.
■ Offer support to any visitors who are present.
■ Document all events up to and including time code was called. Document
after time the code ended. Check that the code record is complete and on
the chart.
■ If the patient survives, write a transfer note, and give report to
receiving unit. If you work in an ICU and the patient is not being moved,
detail the events in your end-of-shift report, and document on the ICU
flowsheet.
■ If the patient does not survive, leave all tubes in place, and check with
your supervisor to determine what can be removed. If an autopsy will be
performed, you will not remove anything.
■ Clean and cover the patient, and straighten the room before the family
views the body. If family members were present at the time the patient
coded, sensitively ask them if they would like you to do this first. It may
be unbearable for them to wait. ALWAYS consider the family’s needs first.

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Adult/Child CPR, Hemlich, and Recovery Positions

Head—tilt, chin—lift. Jaw thrust maneuver.

Hand placement. Heimlich maneuver.

Heimlich maneuver:
abdominal thrusts if
unresponsive. Recovery position.

EMERG
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EMERG

Infant CPR and Heimlich Positions

Head—tilt, chin—lift. CPR hand placement.

Heimlich maneuver: back blows; Heimlich maneuver: chest thrusts;

support head. support head.

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CPR Quick Reference

Determine unresponsiveness
■ Adult: Call 911: get help—obtain AED if available.
■ Child or infant: Call 911 after 2 min (5 cycles) of CPR.
Open airway
■ All ages: head—tilt, chin—lift
■ If trauma suspected, use jaw-thrust method.
Assess for breathing
■ If not breathing, give two slow breaths at 1 sec/breath.
■ If unsuccessful, reposition airway, and reattempt to ventilate. If still
unsuccessful, refer to Choking Quick Reference below.
Check for a pulse for 10 seconds
■ If pulse is present but patient is not breathing, begin rescue breathing (see
table below).
■ If no pulse after 10 seconds, start chest compressions.

CPR Parameters for Adults, Children, Infants, and Neonates

Adult Child and Infant Newborn

Ventilations 10–12/min 12–20/min 40–60/min
Pulse check Carotid Child: Carotid Brachial
location Infant: Brachial Umbilicus
Compression 100/min 100/min 120/min
rate
Ratio of com- 30:2 (1 or 30:2 (15:2 if 3:1 (1 or
pressions 2 rescuers) 2 rescuers) 2 rescuers)
to breaths
Compression 11/2–2 inches 1/2–1/3 the depth 1/3 the depth
depth of the chest of the chest

If a defibrillator is available
Power on, and follow voice prompts (AED)
■ Perform 2 minutes of CPR between each shock.
■ Adults: Do not use pediatric pads.
■ Child: Use after 2 min (5 cycles) of CPR (may use adult pads if pediatric pads
are unavailable).
Note: Recheck pulse every 2 minutes and after each shock. Check without
interrupting chest compressions.

EMERG
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EMERG

Choking Quick Reference

Conscious Patient

1. Assess for airway obstruction

■ Adult or child: Ask victim if he/she is choking; can he/she speak or make
any sounds?
■ Infant: Cannot cry or ineffective cough.
2. Attempt to relieve obstruction
■ Adult or child: Abdominal thrusts until the obstruction is relieved or
victim becomes unresponsive (see step 3 below).
■ Pregnant or obese patients: Chest thrusts until the obstruction is
relieved or the patient becomes unresponsive (see step 3 below).
■ Infant: 5 back blows and 5 chest thrusts until the obstruction is relieved
or victim becomes unresponsive (see step 3 below).

Unresponsive Patient

3. Determine unresponsiveness
■ Adult: Get help or call 911 prior to any intervention.
■ Child or infant: Get help or call 911 after 1 min.
4. Open airway
■ Head—tilt, chin—lift.
■ If trauma suspected, use the jaw-thrust method.
5. Assess breathing and attempt to ventilate
■ If unsuccessful, reposition airway, and reattempt ventilation.
■ If still unsuccessful, begin CPR (for all ages).
6. Inspect mouth and remove obstruction
■ Adult, child, and infant: Use a tongue-jaw lift while opening the airway
during CPR.
■ Perform a finger sweep only to remove a visible foreign body.
7. Repeat manuevers
■ Inspect, sweep, ventilate.
■ Perform CPR until obstruction relieved.
Note: If patient resumes breathing, place into recovery position, and
reassess ABCs every minute.

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Automatic External Defibrillators (AEDs)
■ Assessment: Determine unresponsiveness and assess ABCs.
■ Children 1–8 years: get help/AED after 2 min of CPR.
■ Adults ≥8 years: get help/AED immediately.
■ Perform CPR until AED arrives.
■ Power: Turn on the AED, and follow voice prompts.
■ Attach pads: Stop CPR, attach appropriate-size pads to patient, and plug
pad cable into the AED unit if needed.
■ Upper right sternal border and cardiac apex.
■ Analyze: Press the “Analyze” button, and wait for instructions (do not
make contact with patient while AED is analyzing rhythm).
■ Shock: Announce “Shock indicated, stand clear,” and assure that no one
is in contact with the patient.
■ Fully automatic units analyze rhythm and shock if indicated.
■ Semiautomatic units analyze rhythm, and then instruct the operator to
press the “shock” button if indicated.

Transcutaneous Pacing (TCP)

INDICATIONS
■ Symptomatic 2nd-degree AV block type II or 3rd-degree AV block.
■ Symptomatic bradycardia unresponsive to atropine.
■ Bradycardia with ventricular escape rhythms.
■ Overdrive pacing of tachycardia refractory to drug therapy or electrical
cardioversion (to be performed by physician only).

PACING MODES
■ Demand (synchronous) mode senses the patient’s heart rate and paces
only when the HR falls below the clinician-set rate.
■ Fixed (asynchronous) mode does not sense the HR, but rather paces at the
rate set by the clinician.

PROCEDURE
■ Pads: Apply pacing electrodes to patient per package instructions.
■ Power: Turn on pacemaker, and assure all cables are connected.
■ Rate: Set demand rate to approximately 80 bpm.
■ Current: Output ranges 0–200 mA
■ Bradycardia: Increase mA from minimum setting until a consistent
capture is achieved, then increase by 2 mA.
■ Asystole: Begin at full output. If capture occurs, slowly decrease until
capture is lost, then increase by 2 mA.

EMERG
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EMERG

Emergency Conditions
INJURY AND ILLNESS ■ Lactic acidosis
■ Appendicitis (leading to peritonitis) ■ Thyroid storm
■ Chest pain or sudden severe
abdominal pain NEUROLOGICAL
■ Cholecystitis ■ Cerebrovascular accident (stroke)
■ Compound fracture ■ Meningitis
■ Drug overdose or withdrawal ■ Seizure
■ Gangrene ■ Syncope (fainting)
■ Head trauma
■ Hypothermia or hyperthermia OPHTHALMOLOGICAL
■ Intestinal obstruction ■ Acute angle–closure glaucoma
■ Malignant hyperthermia ■ Orbital perforation/penetration
■ Necrotizing faciitis ■ Retinal detachment
■ Pancreatitis
■ Peritonitis
■ Septicemia blood infection
RESPIRATORY
■ Acute asthma
■ Severe burn
■ Agonal breathing
■ Spreading wound infection
■ Asphyxia secondary to
■ Spinal injury
angioedema, choking. drowning,
smoke inhalation
CARDIAC AND CIRCULATORY ■ Epiglottitis or severe croup
■ Air embolism ■ Pneumothorax
■ Aortic aneurysm (ruptured) ■ Pulmonary embolism
■ Aortic dissection ■ Respiratory failure
■ Cardiac arrest
■ Cardiac arrhythmia
■ Cardiac tamponade
SHOCK
■ Anaphylaxis
■ Hemorrhage
■ Cardiogenic shock
■ Hypertensive emergency
■ Hypovolemic or hemorrhagic shock
■ Myocardial infarction
■ Neurogenic shock
■ Subarachnoid hemorrhage
■ Septic shock
■ Subdural hematoma, acute
■ Ventricular fibrillation
UROLOGICAL, GYNECOLOGICAL,
METABOLIC AND OBSTETRIC
■ Acute renal failure ■ Eclampsia
■ Addisonian crisis ■ Ectopic pregnancy
■ Dehydration, advanced ■ Gynecological hemorrhage
■ Diabetic ketoacidosis ■ Obstetrical hemorrhage
■ Electrolyte disturbance, severe ■ Paraphimosis
■ Hepatic encephalopathy ■ Priapism
■ Hypoglycemic coma ■ Testicular torsion
■ Urinary retention

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Anaphylaxis
CLINICAL PICTURE
The patient may have:
■ Angioedema, hives, itching.
■ Feelings of impending doom, anxiety, restlessness.
■ Bronchospasm, laryngeal edema, respiratory distress.
■ Hypotension, dysrhythmia.
■ Nausea, vomiting, diarrhea.

IMMEDIATE INTERVENTIONS
■ Call physician and respiratory therapist or anesthesiologist STAT. Get help.
Have someone bring code cart or emergency medications box to room.
■ Establish patent airway. Administer high concentrations of supplemental
O2, or manually assist ventilations with an Ambu-bag.
■ Initiate continuous cardiac and VS monitoring.
■ Obtain IV access.
■ Anticipate need for mechanical ventilation.
■ Assess recent exposure to allergen (food, insect sting, medication, blood
product, contrast medium, latex).
■ Document patient’s status, phone call to physician, and physician response.

FOCUSED ASSESSMENT
■ Assess airway status, LOC, and VS (HR, RR, BP) on a continuous basis.
■ Assess SaO2 via pulse oximetry.
■ Assess skin for color, temperature, turgor, moistness, and capillary refill.

STABILIZING AND MONITORING

■ Monitor VS every 5 min. or more frequently.
■ Administer medications, IV fluids as ordered.
■ Provide emotional support to family/patient.
■ Record patient’s status in chart, and communicate to physician.

BE PREPARED TO
■ Administer epinephrine subcutaneously.
■ Call a code.
■ Assist with intubation and airway management.
■ Assist with obtaining central venous access.
■ Administer IV fluids and medications (vasopressors, diphenhydramine,
steroids, volume expanders).
■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES
■ Exposure to antigen.

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Transfusion Reaction
CLINICAL PICTURE
The patient may have:
■ Fever, chills, tachycardia, hypotension.
■ Chest pain, SOB.
■ Apprehension, restlessness.
■ Burning at infusion site.
■ Nausea, vomiting, diarrhea.
■ Urticaria, pruritus, skin erythema.
■ Flank, back, or joint pain.
■ Hematuria.

IMMEDIATE INTERVENTIONS
■ Stop the transfusion. Run normal saline through the IV to maintain
IV access.
■ Assess airway, breathing, and circulation. Get help.
■ Check VS.
■ Administer supplemental O2.
■ Notify physician or NP.
■ Recheck patient ID and blood labels for error. Notify blood bank of
reaction.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess LOC, orientation, and VS (temperature, HR, RR, BP).
■ Assess SaO2 via pulse oximetry if available.
■ If patient on telemetry or cardiac monitor, assess rhythm strip.
■ Assess skin for color, turgor, moistness, and temperature.

STABILIZING AND MONITORING

■ Return unused portion of blood product to blood bank for analysis.
■ Administer prescribed medications and O2.
■ Document specific reaction.
■ Continue to monitor VS, temperature, respiratory status, LOC, and
urine output.
■ Chart patient status, and convey to physician or NP.

BE PREPARED TO
■ Administer epinephrine, treat shock, initiate CPR if necessary.
■ Administer IV fluids.

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■ Insert indwelling catheter to monitor hourly urine output.
■ Administer medications such as:
■ Antihistamine, antipyretic, steroids, and furosemide (Lasix) IV.
■ Acute hemolytic reaction: IV normal saline with diuretics to maintain
urine output of 100 mL/hr.
■ Allergic response: corticosteroids such as Solu-Medrol.
■ Urticaria: diphenhydramine 25–50 mg IV, deep IM.
■ Fever: acetaminophen.
■ Septicemia: antibiotics, IV fluids, vasopressors.
■ Kidney failure and shock: IV fluids and vasopressors.
■ Obtain or order STAT laboratory tests.
■ Titrate O2 to keep SaO2 "90%.
■ Obtain two large-bore IV accessories.

POSSIBLE ETIOLOGIES
■ ABO incompatibility, blood contamination, allergic response.

Types of Reactions

Type Cause Signs and Symptoms

Acute hemolytic ABO incompatibility Fever, chills, low back pain,
reaction to RBC flushing, tachycardia,
antigens. hypotension, vascular
collapse, cardiac arrest.

Febrile Sensitization to donor Fever, chills, headache,

nonhemolytic WBCs, platelets, or flushing, muscle aches,
plasma proteins. respiratory distress,
cardiac dysrhythmias.

Anaphylactic Administration of Restlessness, urticaria,

donor’s IgA pro- wheezing, shock, cardiac
teins to recipient with arrest.
anti-IgA antibodies.

Allergic Sensitivity to foreign Hives, urticaria, fever,

proteins. flushing, itching.

Bacteremia Infusion of bacteria- Chills, fever, hypotension,

contaminated blood. vomiting, diarrhea,
septic shock.

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Shock
CLINICAL PICTURE
The patient may have:
■ Anxiety (early), lethargy and coma (later).
■ Hypotension.
■ Decreased urine ouput.
■ Tachycardia (bradycardia in neurogenic shock).
■ Delayed capillary refill ("3 sec), diminished peripheral pulses (!"2).
■ Cool, pale, mottled, or cyanotic skin (hypovolemic shock).
■ Tachypnea.
■ Diaphoresis.
■ Throat tightness, stridor, flushing, urticaria (anaphylactic shock).

IMMEDIATE INTERVENTIONS
■ Call physician or NP STAT. Get help from other staff.
■ Establish patent airway.
■ Insert nasal or oral airway, and suction oropharynx if needed.
■ Administer high-flow O2 via nonrebreather mask (10–15 L/min), or
manually assist ventilations with an Ambu-bag (mask-valve device).
■ Anticipate need for mechanical ventilation.
■ Obtain IV access.
■ Set up cardiac monitoring.
■ Place patient in a supine position with legs elevated above heart level to
increase circulation to vital organs. Note: This position is contraindicated
if the airway is compromised; to maintain airway patency, place patient
in supine or low Fowler’s position (HOB slightly elevated).
■ Control bleeding with direct pressure if patient hemorrhaging.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.

FOCUSED ASSESSMENT
■ Assess LOC, orientation, and VS (HR, RR, BP).
■ Assess SaO2 via pulse oximetry if available (may be unreliable due to
decreased peripheral perfusion).
■ Assess skin for color, temperature, turgor, moistness, and capillary refill.
■ Evaluate previous 2-hour I&O.

STABILIZING AND MONITORING

■ Monitor VS every 5 minutes or more frequently.
■ Manage various types of shock accordingly:
■ Hypovolemic: O2; IVF; volume replacement with crystalloids, colloids,
plasma volume expanders, and/or blood; elevate lower limbs (if not
contraindicated); control bleeding; arterial line placement.

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■ Cardiogenic: O2; IVF; vasopressors, cardiotonics, antidysrhythmics (i.e.,
dopamine, dobutamine, lidocaine); correct dysrhythmias; arterial line
placement and hemodynamic monitoring.
■ Septic: O2; IVF; volume replacement; antibiotics, vasopressors,
antipyretics; arterial line placement.
■ Anaphylactic: O2; IVF; epinephrine, antihistamines (Benadryl/Atarax),
steroids; intubation and airway management; arterial line placement.
■ Neurogenic: O2; IVF; spinal stabilization; vasopressors; intubation and
airway management; arterial line placement; insert Foley’s catheter.
■ Provide emotional support to family/patient.
■ Record patient’s status in chart, and communicate to physician or NP.

BE PREPARED TO
■ Call a code.
■ Assist with intubation and airway management.
■ Assist with obtaining central venous access.
■ Administer fluids, blood products, and medications as ordered.
■ Order or obtain specific laboratory tests to be drawn STAT (Hgb, Hct,
WBC, cardiac markers, electrolytes, ABG, UA).
■ Transfer to ICU.

POSSIBLE ETIOLOGIES
■ Blood loss, vomiting, dehydration (hypovolemic shock), MI, profound
brady/tachycardia, pump failure (cardiogenic shock), infection, endo/
exotoxin release (septic shock), exposure to antigen (anaphylactic), spinal
cord injury, anesthesia (neurogenic shock), pharmacological overdose.

Comparison of Different Types of Shock States

Signs and
Type Pathophysiology Symptoms Interventions
Anaphylactic: Massive vasodi- Respiratory dis- O2, airway
Acute, life- lation; fluid tress (stridor); management,
threatening shifts out of ↓ BP; edema; epinephrine,
allergic reaction intravascular rash, hives; antihistamines,
to a specific space; ↓ tissue cool, pale skin; steroids, IV
antigen. perfusion; possible fliuds.
peripheral and seizure activity,
laryngeal tight chest.
edema;
bronchospasm.
(Continued on the following page)

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Comparison of Different Types of Shock States (continued)

Signs and
Type Pathophysiology Symptoms Interventions
Cardiogenic: Inadequate car- Hypotension, O2, IV fliuds,
Pump failure diac output weak pulse, vasopressors,
due to MI, PE, due to lack of tachycardia, cardiotonics,
cardiac tampon- contractile clammy skin, antidysrhyth-
ade, heart failure, force to create altered LOC; mics.
aneurysm. BP; decreased dysrhythmias.
tissue
perfusion.
Hypovolemic: ↓ Decrease in intra- Hypotension; O2, control
circulating volume vascular tachycardia; bleeding,
due to hemor- volume with weak pulse; ↓ fluid replace-
rhage, burns, which to create capillary refill; ment with
dehydration, a BP; cyanosis; crystalloids,
third spacing decreased dysrhythmias; colloids,
of fluids. tissue altered LOC; volume
perfusion. cool, clammy, expanders,
pale skin. blood.
Neurogenic: Profound vasodi- Hypotension, O2, IV fluids,
Spinal shock lation that bradycardia, airway
secondary to results in lack or tachycardia; management,
spinal cord injury, of peripheral tachypnea; spinal
anesthesia. vascular resis- possible stabilization,
tance sufficient flaccid possible
to sustain BP; paralysis and vasopressors.
decreased absent
tissue reflexes.
perfusion.
Septic: Septicemia Circulatory Fever or low O2, IV fluids,
secondary to failure due to temperature; blood
endo/exotoxin systemic bounding cultures, UA,
release, most inflammatory pulse; ↓ urine sputum C&S
commonly Gram- response; output; antibiotics,
negative bacteria. capillary leak flushed, warm, vasopressors.
syndrome; moist to
decreased diaphoretic
tissue skin; increased
perfusion. HR/RR.

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Cardiogenic Shock

Ineffective Pump

Ventricular Emptying Stroke Volume

End-diastolic Volume Cardiac Output

Filling Pressures Tissue Perfusion

Cardiogenic shock.

Hypovolemic Shock

Volume

Venous Return

Filling Pressures

Stroke Volume

Cardiac Output

Tissue Perfusion

Hypovolemic shock.

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Neurogenic Shock

Massive Vasodilation

Venodilation Arteriolar Dilation

Venous Return Peripheral Resistance

Filling Pressures

Stroke Volume

Cardiac Output Blood Pressure

Tissue Perfusion

Neurogenic shock.

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High-Alert Medications
High-alert medications are those medications that have a high risk of causing
injury or death when improperly handled or administered. Many of these
drugs are used commonly in the general population or are used frequently
in urgent clinical situations. The Joint Commission monitors the five most
often prescribed high-alert medications: insulin, opiates and narcotics,
injectable potassium chloride (or phosphate) concentrate, IV anticoagulants
(heparin); and sodium chloride solutions above 0.9%. Exercise extreme
caution when administering these medications:
■ Adrenergic agonists (e.g., epinephrine, isoproterenol, norepinephrine).
■ Cardioplegic solutions.
■ Chemotherapeutic agents.
■ Chloral hydrate (in pediatric patients).
■ Colchicine injection.
■ High-concentration dextrose (greater than 10% dextrose).
■ Hypoglycemic agents (oral).
■ Hypertonic sodium chloride injection (#0. 9% concentration).
■ Insulin.
■ IV adrenergic antagonists (propranolol, esmolol, metoprolol).
■ IV calcium.
■ IV digoxin.
■ IV magnesium sulfate.
■ IV potassium (phosphate and chloride).
■ Lidocaine/benzocaine; other topical anesthetics.
■ Midazolam.
■ Neuromuscular blocking agents.
■ Opiates (opioids).
■ Thrombolytics, heparin, warfarin.

Safe Medication Administration

■ Carefully read product packaging to note strength of solution, dosage,

and/or route of administration.
■ Double-check with a pharmacist about dose range.
■ Have a colleague double-check dosage calculations and infusion pump
programming.
■ Use the Five Rights (right drug, right dose, right patient, right route, right
time) as a guide.

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■ Clarify any order that is incomplete, contains abbreviations, is confusing

or hard to read, or raises a question.
■ Suspect a missed decimal point, and clarify any order if the dose requires
more than 3 dosing units.
■ If taking a verbal order, ask prescriber to spell out the drug name and
dosage to avoid sound-alike confusion (e.g., hearing Cerebyx for
Celebrex, or fifty for fifteen).
■ Read back the order to the prescriber after you have written it in the chart.
■ Do not borrow medications from other patients or begin new medications
before the order has been received in the pharmacy; to do so circumvents
the built-in checks that can detect a prescribing error.
■ Review each patient’s medications for:
■ Medication use without an indication.
■ Contraindications.
■ Improper drug selection.
■ Overdose/subtherapeutic dose (consider age, renal/hepatic impairment).
■ Medication duplication.
■ Efficacy.
■ Adverse drug reactions/toxicity.
■ Potential drug or food interactions.
■ Weight changes requiring dosage adjustments.
■ Appropriate duration of therapy.
■ Adherence with prescribed medication therapy.

Patient Education and Medication Use

Educating patients about their medications is a critical nursing function

that promotes proper medication use and improved outcomes. It also can
prevent adverse drug reactions or early or improper discontinuation of a
medication. Many issues related to medication errors, such as ambiguous
directions, unfamiliarity with a drug, and confusing packaging, affect the
patient as well as the health-care providers, thereby emphasizing the need
for careful education. Patient education also enhances compliance, which
is a factor in proper medication use.
■ All patients need clear written and verbal instruction for all medications.
■ Present information in a format the patient can understand.
■ Use an interpreter if provider and patient speak different languages.
■ Do not rush.
■ Include family members.
■ Have the patient repeat the information you provide.

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■ Make sure to tell the patient:
■ The brand and generic names of the medication.
■ The purpose of the medication.
■ The strength and dose and when to take the medication.
■ Possible side effects and what to do if they occur.
■ How long to take the medication.
■ What medications or foods to avoid and why they should be avoided.
■ How to store the medication.
■ What to do if a dose is missed.
■ What activities, if any, should be avoided while on the medication.
■ Signs and symptoms of adverse drug reactions.

Error-Prone Abbreviations and Symbols

Abbreviations Symbols
■ $g ■ (dram) ■ MTX
■ AD, AS, AU ■ (minim) ■ Nitro drip
■ OD, OS, OU ■ @ (at) ■ Norflox
■ BT ■ & (and) ■ PCA
■ cc ■ # (hour) ■ PTU
■ D/C ■ / (slash) ■ T3
■ IJ ■ $ (plus) ■ TAC
■ IN ■ % (minus) ■ TNK
■ HS, hs ■ # (greater than) ■ ZnSO4
■ IU ■ ! (less than) General Tips
■ o.d., OD ■ Apothecary symbols ■ Avoid using a zero
■ OJ Drug Names after a decimal point.
■ per os ■ ARA A ■ Use a zero before a
■ q.d., QD ■ AZT decimal point.
■ q1d ■ CPZ ■ Use commas for
■ q6PM, etc. ■ DPT dosing units at or
■ SC, SQ, sub q ■ DTO above 1,000.
■ ss ■ HCl ■ Place adequate
■ SSRI, SSI ■ HCT space between a
■ 1/d ■ HCTZ drug name, dose,
■ TIW, tiw ■ IV Vanc and the unit of
■ U, u ■ MgSO4 measure.

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IV Fluid Drip Rate Table (drops/min)

Rate: mL/
hr → TKO 50 75 100 125 150 175 200 250
10 gtt/ 5 8 13 17 21 25 29 33 42
mL set
12 gtt/ 6 10 15 20 25 30 35 40 50
mL set
15 gtt/ 8 13 19 25 31 37 44 50 62
mL set
20 gtt/ 10 17 25 33 42 50 58 67 83
mL set
60 gtt/ 30 50 75 100 125 150 175 200 250
mL set
Note: TKO is 30 mL/hr.

Emergency Medications (62 Medications)

Note: This list is a reference only. It is not meant to be exhaustive. Always
consult an authoritative, current reference about dose, dilution, interactions,
and route and rate of administration before administering medications,
especially IV medications. Have a second licensed person independently
check dose calculations, preparation, original orders, and infusion pump
programming for high-alert medications.

ACE Inhibitors (Antihypertensive)

Common Agents: Captopril, Enalapril, Lisinopril.
Indications: MI, heart failure without hypotension, ST elevation.
Dose: See individual order and drug for route and dosage.
Contraindications: Hypotension, pregnancy, angioedema.
Side Effects: Dizziness, HA, fatigue, hypotension, altered LOC.
Precautions: Lower doses in renal failure.

Activated Charcoal (Absorbent)

Indications: Overdose and poisoning.
Dose: 25–100 g PO, NG tube.
Contraindications: Concurrent use with syrup of ipecac.
Side Effects: Constipation, N&V, diarrhea.
Precautions: Ineffective in iron (heavy metals) OD.

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Adenosine (Adenocard®) (Antidysrhythmic)
Indications: Narrow complex PSVT.
Dose: 6 mg IV. Repeat with 12 mg IV in1–2 min if needed. A third dose
of 12 mg may be given in 1–2 min. Max: 30 mg.
Contraindications: Drug- or poison-induced tachycardia.
Side Effects: Flushing, chest pain, tightness, bradycardia, heart block,
asystole, ventricular ectopy, VF.
Precautions: Ineffective in treating atrial fibrillation, atrial flutter, or VT.
Avoid in patients on dipyridamole or with a history of MI or cerebral
hemorrhage.

Albuterol (Ventolin®) (Bronchodilator)

Indications: Reversible airway restriction due to acute bronchospasm,
asthma, or COPD.
Dose: 1.25–5 mg nebulized in 3-mL saline.
Contraindications: Hypersensitivity to adrenergic amines.
Side Effects: Nervousness, restlessness, tremor, tachycardia, anxiety, N&V,
diarrhea, HA, HTN, hyperglycemia.
Precautions: Tachydysrhythmias, cardiac disease, elderly, hypersensitivity.
Alteplase (Activase®, t-PA) (Thrombolytic, Fibrinolytic)
Indications: Within 4–6 hr of acute MI and 3 hr from onset of symptoms
in acute ischemic stroke, pulmonary embolus.
Dose: Per order.
Contraindications: Active internal bleeding within 10 days (except
menses), history of neurovascular event within 2 months, major surgery
or trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN,
bleeding disorder, prolonged CPR, lumbar puncture within 1 week.
Side Effects: Hypotension, reperfusion dysrhythmias, heart failure, HA,
increased bleeding time, deep or superficial hemorrhage, flushing, urticaria,
anaphylaxis.
Precautions: Patients with severe renal or hepatic disease.
Alupent (Metaproterenol®) (Adrenergic Agonist [Bronchodilator])
Indications: Reversible airway restriction due to asthma or COPD.
Dose: 10–15 mg nebulized in 3-mL saline.
Contraindications: Hypersensitivity to adrenergic amines.
Side Effects: Nervousness, restlessness, tremor, tachycardia, anxiety, N&V,
diarrhea, HA, HTN, hyperglycemia.
Precautions: Tachydysrhythmias, cardiac disease, elderly, hypersensitivity.
Aminophylline (Truphylline®) (Bronchodilator)
Indications: Long-term control of reversible airway obstruction due to
asthma or COPD.
Dose: Per order.

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Contraindications: Uncontrolled dysrhythmias, hyperthyroidism.

Side Effects: Seizures, dysrhythmias, anxiety, N&V, tremors.
Precautions: Geriatric patients, patients with CHF or liver failure, obesity;
multiple drug interactions.
Amiodarone (Cordarone®) (Antidysrhythmic)
Indications: Wide- and narrow-complex tachycardia, VF, and pulseless VT.
Dose: 150 mg over first 10 min (15 mg/min), 360 mg over next 6 hr (1 mg/
min), 540 mg over next 18 hr (0.5 mg/min).
Contraindications: Sinus bradycardia, cardiogenic shock, 2nd- or 3rd-
degree heart block.
Side Effects: Hypotension, prolonged QT interval, ARDS, CHF, PSVT.
Precautions: Avoid concurrent use with procainamide.
Amyl Nitrate (Antidote to Cyanide Poisoning)
Indications: Cyanide poisoning.
Dose: Inhale vapors from crushed ampules for 30 sec of every min
continuously.
Contraindications: Cerebral hemorrhage, head trauma, hypotension,
glaucoma, recent MI, hypersensitivity to nitrates or nitrites.
Side Effects: HA, hypotension, tachycardia, N&V.
Precautions: Increased hypotension with alcohol consumption.

Aspirin (Acetylsalicylic Acid) (Antiplatelet, Analgesic)

Indications: Analgesic, acute coronary syndrome.
Dose: 160–325 mg PO nonenteric-coated for antiplatelet effect.
Contraindications: Known allergy to aspirin, pregnancy.
Side Effects: Anorexia, nausea, epigastric pain, anaphylaxis.
Precautions: Active ulcers and asthma, blood dyscrasias.

Ativan® (Lorazepam) (Anticonvulsant,

Anxiolytic, Sedative, Hypnotic)
Indications: Status epilepticus, acute ETOH withdrawal.
Dose: 50 $g (0.05 mg)/kg, maximum 4 mg each dose; may be repeated after
10–15 min, not to exceed 8 mg/12 hr or 2 mg/min IV infusion.
Contraindications: Allergy to benzodiazepines, narrow-angle glaucoma.
Side Effects: Dizziness, drowsiness, lethargy, apnea, cardiac arrest,
paradoxical excitation, N&V, diarrhea.
Precautions: Severe hepatic, renal, pulmonary impairment.

Atracurium (Tracrium®) (Neuromuscular

Blocking Agent [Nondepolarizing])
Indications: Paralysis to facilitate endotracheal intubation.

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Dose: 0.4–0.5 mg/kg IV bolus, may repeat subsequent boluses of 0.1 $g/kg
q 15–20 min or an infusion of 5–9 $g/kg/min.
Contraindications: Myasthenia gravis, asthma, Eaton-Lambert syndrome,
severe electrolyte imbalances.
Side Effects: Bronchospasm, flushed skin, hypotension, tachycardia,
urticaria, hypersensitivity.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order; multiple drug interactions.
Time Action Profile: Onset 2–2.5 min; peak 1–2 min; duration 30–40 min.

Atropine (Anticholinergic)
Indications: Sinus bradycardia, asystole, PEA with rate !60, organophos-
phate and neurotoxin (nerve gas) exposure, antidote to cholinergic drug
toxicity and mushroom poisoning.
Dose: Bradycardia: 0.5–1 mg IV (may give via ET tube at double the dose)
q 3–5 min, maximum 0.04 mg/kg; cardiac arrest: 1 mg q 3–5 min, maximum
0.04 mg/kg; nerve gas and organophosphate exposure: 2–6 mg IV or IM
depending on severity of symptoms, may repeat in 2-mg increments q 3 min
titrated to relief of symptoms.
Contraindications: Atrial fibrillation, atrial flutter, glaucoma.
Side Effects: Tachycardia, HA, dry mouth, dilated pupils, VF/VT.
Precautions: Use caution in hypoxia. Avoid in hypothermic bradycardia and
2nd-degree (Mobitz) type-II HB.

Beta Blockers (Antihypertensive)

Common Agents: Atenolol, Labetalol, Metoprolol, Propranolol.
Indications: MI, unstable angina, PSVT, atrial fibrillation, atrial flutter, HTN.
Dose: See individual order and drug for route and dosage.
Contraindications: HR !50, SBP !100, 2nd- or 3rd-degree HB, left
ventricular failure.
Side Effects: Hypotension, dizziness, bradycardia, HA, N&V.
Precautions: Concurrent use with calcium channel blockers can cause
hypotension; use caution in patients with a history of bronchospasm;
multiple drug interactions.

Benadryl® (Diphenhydramine) (Antihistamine)

Indications: Anaphylactic reaction, extrapyramidal symptoms.
Dose: 10–50 mg IV or deep IM up to 100 mg; not to exceed 400 mg/24 hr.
Contraindications: Asthma, pregnant, lactating.
Side Effects: Dry mouth, drowsiness, hypotension.
Precautions: Elderly, severe liver disease, narrow angle glaucoma,
pregnancy.

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Bretylium (Bretylol®) (Antidysrhythmic)

Indications: Ventricular dysrhythmias.
Dose: VF, pulseless VT 5 mg/kg IVP, repeat 10 mg/kg q 15 min, maximum
30 mg/kg in 24 hr; VT w/pulse 5–10 mg/kg in 50–100 mL over 10 min;
maintenance drip 1–2 mg/min.
Contraindications: Severe aortic stenosis, severe pulmonary hypertension.
Side Effects: Hypotension, N&V, CP, bradycardia.
Precautions: Digoxin toxicity, renal failure.

Calcium Chloride (Minerals/Electrolytes/Calcium Salt)

Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, antidote
to calcium channel blockers and beta blockers, given prophylactically with
calcium channel blockers to prevent hypotension.
Dose: Antidote to calcium channel blocker: 2–4 mg/kg IV, may be repeated
as needed; given prophylactically prior to IV calcium channel blockers 8–16
mg/kg IV; hyperkalemia: 2.25–14 mEq; may repeat in 1–2 min; give amount
sufficient to return ECG to normal; hypocalcemia: 2.3–9.3 mEq as needed
or 7–14 mEq if emergent need elevates Ca""; hypermagnesemia: 2–7 mEq
slows IVP, may be repeated in 10 min, then observe for response before any
additional dose administered.
Contraindications: Hypercalcemia, VF, digoxin toxicity.
Side Effects: Bradycardia, asystole, hypotension, VF, N&V.
Precautions: Incompatible with sodium bicarbonate; administered
undiluted IVP.

Calcium Gluconate (Minerals/Electrolytes/Calcium Salt)

Indications: Hypocalcemia, hypocalcemic tetany, hyperkalemia with cardiac
toxicity, hypermagnesemia.
Dose: Hypocalcemia: 7–14 mEq IV; hypocalcemic tetany: 4.5–16 mEq IV,
repeat until symptoms are controlled; hyperkalemia with cardiac toxicity:
2.25–14 mEq IV, may repeat in 1–2 min; hypermagnesemia: 4.5–9 mEq IV.
Contraindications: Hypercalcemia, renal calculi, VF.
Side Effects: Cardiac arrest, dysrhythmias, phlebitis, N&V, bradycardia,
tingling, syncope.
Precautions: Monitor blood pressure, pulse, and ECG; do not administer
IM due to potential for tissue necrosis.

Cardizem® (Diltiazem) (Calcium Channel Blocker)

Indications: Atrial fibrillation, atrial flutter, PSVT refractory to adenosine.
Dose: 15–20 mg IVP over 2 min (0.25 mg/kg). May repeat in 15 min at 20–25
mg IVP over 2 min (0.35 mg/kg); maintenance drip: start at 5–15 mg/hr, and
titrate to HR.

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Contraindications: Drug or poison induced tachycardia, wide-complex
tachycardia of uncertain type, WPW syndrome, cardiogenic shock, pulmonary
edema.
Side Effects: Hypotension, BBB, ventricular extrasystoles.
Precautions: Severe hypotension in patients on beta blockers; do not
withdraw abruptly.

Dantrolene (Dantrium®) (Skeletal Muscle Relaxant)

Indications: Emergency treatment of malignant hyperthermia.
Dose: 1–3 mg/kg IVP, may repeat as needed, maximum 10 mg/kg.
Contraindications: Pregnancy.
Side Effects: Drowsiness, muscle weakness, confusion, HA.
Precautions: Cardiac, pulmonary, or liver disease.

Decadron® (Dexamethasone) (Glucocorticoid, Anti-inflammatory)

Indications: Anaphylaxis, cerebral edema, spinal trauma, shock.
Dose: 10 mg IVP.
Contraindications: Ulcer, infection, alcohol intolerance.
Side Effects: Peptic ulceration, HTN, N&V.
Precautions: Tissue necrosis with infiltration.

Demerol® (Meperidine) (Opioid-Narcotic Analgesic [Agonist])

Indications: Moderate to severe pain.
Dose: 25–100 mg IM or 15 to 35 mg/hr continuous IV infusion.
Contraindications: Concurrent or recent use of MAO inhibitors, pregnancy,
respiratory depression, epilepsy or convulsive states, increased ICP, asthma.
Side Effects: Respiratory depression, confusion, sedation, seizure, CNS
toxicity, hypotension, N&V.
Precautions: Head trauma, elderly.

Dextrose 50% (Caloric Agent)

Indications: Hypoglycemic coma/altered LOC.
Dose: 25 g slow IVP.
Contraindications: CNS bleed, allergy to corn, hyperglycemia.
Side Effects: Hyperglycemia, fluid overload.
Precautions: Tissue necrosis with infiltration.

Digibind® (Digoxin Immune fab) (Antidote to Digoxin, Digitoxin)

Indications: Symptomatic digoxin toxicity or acute ingestion of unknown
amount of digoxin.
Dose: Dependent on serum digoxin levels. One 40 mg vial binds to
approximately 0.6 mg of digoxin.
Contraindications: Allergy only, otherwise, none known.

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Side Effects: Worsening of CHF, atrial fibrillation, hypokalemia, increased

serum digoxin levels.
Precautions: Patients with allergies to sheep proteins.

Digoxin (Lanoxin®) (Inotropic, Antidysrhythmic)

Indications: Atrial fibrillation and atrial flutter, CHF, pulmonary edema.
May be used as an alternative treatment for PSVT.
Dose: Loading dose of 10–15 $g/kg.
Contraindications: Uncontrolled atrial dysrhythmias, AV block, idiopathic
hypertrophic subaortic stenosis (IHSS), constrictive pericarditis.
Side Effects: Dysrhythmias, particularly VF, AV block, atrial fibrillation,
fatigue, bradycardia, N&V, blurred or yellow vision, HA, hypersensitivity,
hypokalemia.
Precautions: Avoid electrical cardioversion of stable patients. If unstable,
use lower current settings such as 10–20 joules; elderly; pregnancy.

Dobutamine (Dobutrex®) (Inotropic)

Indications: Short-term treatment of cardiac decompensation in organic
heart disease or cardiac surgical procedures.
Dose: Per order.
Contraindications: Idiopathic hypertrophic subaortic stenosis.
Side Effects: Ventricular ectopy, chest pain, hypersensitivity,
bronchospasm.
Precautions: Safe use in acute MI not established. Ensure adequate
hydration prior to infusion.
Dopamine (Intropin®) (Vasopressor, Inotropic)
Indications: Cardiogenic shock d/t MI, trauma, endotoxic septicemia, open
heart surgery, renal failure, and chronic cardiac decompensation.
Dose: Per order.
Contraindications: Pheochromocytoma, uncorrected tachycardia, VF, and
pediatric clients.
Side Effects: Tachycardia, angina, hypo- and hypertension, palpitations,
vasoconstriction, dyspnea, N&V.
Precautions: Adjust dosage in elderly patients and in those with occlusive
vascular disease. Extravasation may result in sloughing of tissue. Ensure
adequate hydration prior to infusion.
Epinephrine (Adrenalin®) (Adrenergic Agonist)
Indications: All cardiac arrest, anaphylaxis. Also used for symptomatic
bradycardia refractory to atropine, dopamine, and TCP; severe hypotension,
acute asthma attack, and vasopressor shock.

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Dose: Cardiac arrest: 1 mg IV of 1:10,000 solution q 3–5 min; double the
dose if administering via ET tube; anaphylaxis: 0.1–1 mg SQ or IM of 1:1000
solution; asthma: 0.1–0.3 mg SQ or IM of 1:10,000 solution; refractory
bradycardia and hypotension: 2–10 $g/min (1 mg of 1:1,000 solution in 500
mL of saline and start at 1–5 mL/min).
Contraindications: Hypersensitivity to adrenergic amines, narrow-angle
glaucoma.
Side Effects: Angina, HTN, tachycardia, VT, VF, nervousness, restlessness,
tremors, pallor, cerebral or subarachnoid hemorrhage and aortic rupture,
suicidal/homicidal tendencies.
Precautions: Use caution in HTN, tachydysrhythmias, cardiac disease,
hyperthyroidism, glaucoma, DM, elderly, pregnancy, multiple drug
interactions.
Esmolol (Brevibloc) (Selective Beta Blocker, Antidysrhythmic)
Indications: SVT in those with atrial fibrillation or atrial flutter,
noncompensatory ST, tachycardia and HTN during induction or emergence
from anesthesia.
Dose: 80 mg over 30 sec followed by 150 $g/kg/min. May repeat dose.
Contraindications: Dosage has not been established in children.
Side Effects: Flushing, pallor, induration, burning and/or edema at site of
infusion, urinary retention, midscapular pain, asthenia.
Precautions: Avoid use in children.
Glucagon (Hormone)
Indications: Antidote to beta-blocker and calcium channel blocker overdose;
hypoglycemia when IV access unavailable and patient cannot protect airway
(cannot take oral glucose); used to decrease GI motility during GI
procedures.
Dose: Antidote to calcium channel blocker: 2 mg IV; antidote to beta
blocker: 50–150 $g/kg IVP followed by a 1–5 mg/hr infusion; hypoglycemia:
0.5–1 mg IV, IM, SC; to decrease GI motility: 0.25–1 mg slow IVP or up to
2 mg IM.
Contraindications: Known allergy to beef or pork protein.
Side Effects: N&V.
Precautions: Use caution in patients with insulinoma or
pheochromocytoma.

Glycoprotein IIb and IIIa Inhibitors (Platelet Aggregation Inhibitor)

Common Agents: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban
HCl (Aggrastat®).
Indications: Acute coronary syndrome without ST-segment elevation,
adjunct to percutaneous coronary intervention in patients with high risk of
abrupt closure of treated coronary vessel.

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Dose: See individual order and drug for route and dosages.
Contraindications: Active internal bleeding within 30 days, history of
neurovascular event within 1 month (within 2 years of surgery or trauma
within 1 month) aortic dissection, severe (uncontrolled) HTN, within 6 weeks
of a known GI or GU bleed, known bleeding disorder.
Side Effects: Increased bleeding and bruising, GI irritation.
Precautions: Increased chance of bleeding; use with caution in elderly, in
patients with history of GI disease, or those receiving thrombolytics; multiple
herb interactions.

Heparin (Anticoagulant)
Indications: Acute pulmonary/peripheral embolism, atrial fibrillation with
emoblization, treatment of DIC.
Dose: Per order.
Contraindications: Active bleeding, blood dyscrasias, thrombocytopenia,
liver disease, suspected intracranial hemorrhage, ulceration of the GI tract,
subendocarditis, shock, threatened abortion, severe HTN, hypersensitivity.
Side Effects: Minor to major hemorrhage, thrombocytopenia, anaphylaxis.
Precautions: Use with caution in menstruating women, post-partally,
following CVA, and in the elderly; multiple herb interactions.

Histamine Blockers (H2-Receptor Antagonists)

Common Agents: Cimetidine (Tagament®), famotidine (Pepcid®), nizatidine
(Axid®), ranitidine (Zantac®).
Indications: Duodenal and gastric ulcers; management of gastroesophageal
reflux disease (GERD); upper GI bleed.
Dose: See individual order and drug for route and dosages.
Contraindications: Hypersensitivity, impaired renal or hepatic function.
Side Effects: Confusion, dizziness, agitation, drowsiness, HA, site pain,
N&V, constipation, bradycardia, tachycardia, PVCs, cardiac arrest,
bronchospasm, anaphylaxis.
Precautions: Assess elderly and severely ill patients for confusion routinely.

Ibutilide Fumarate (Corvert®) (Antidysrhythmic)

Indications: SVT, including atrial fibrillation and atrial flutter.
Dose: Patients ! 60 kg: 1 mg slow IVP over 10 min, may repeat same
dose in 10 min; Patients !60 kg: 0.01 mg/kg slow IVP over 10 min, may
repeat in 10 min.
Contraindications: Known allergy, concomitantly with other antidysrhyth-
mics such as quinidine, procainamide, amiodarone.
Side Effects: Severe ventricular dysrhythmias such as torsades de pointes,
HA, N&V, hypotension, bundle branch block, HTN, nodal dysrhythmias.
Precautions: CHF, LV dysfunction, pregnancy, multiple drug interactions.

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Inamrinone (Inocor®) (Inotropic)
Indications: Short-term treatment of CHF unresponsive to traditional
therapies.
Dose: Per order.
Contraindications: Hypersensitivity to bisulfates, IHSS.
Side Effects: Dyspnea, dysrhythmias, hypotension, N&V, diarrhea,
hepatotoxicity, hypersensitivity, tachyphylaxis.
Precautions: Use cautiously in atrial fibrillation or atrial flutter, electrolyte
imbalances, renal impairment, and geriatric patients.
Ipecac Syrup (Emetic)
Indications: OD/poisoning of noncaustic substance.
Dose: 15–30 mL PO followed by 240 mL of water, may repeat 15 mL in 30
min if ineffective.
Contraindications: Altered LOC, ingestion of caustic substance, severe
inebriation, shock, TCA OD, seizures.
Side Effects: Diarrhea, dysrhythmias, atrial fibrillation, sedation, coughing
or choking with emesis.
Precautions: Pregnancy, abuse in bulemic or anorexic patients.
Isuprel® (Isoproterenol) (Inotropic)
Indications: Symptomatic bradycardia, torsades de pointes refractory to
magnesium, bradycardia in heart transplant patients, beta-blocker OD,
bronchospasm.
Dose: 2–10 $g/min titrated to desired heart rate.
Contraindications: Cardiac arrest, concurrent use with epinephrine, high
dosages (except in beta-blocker OD), heart block caused by digitalis
intoxication, angina, tachydysrhythmias.
Side Effects: Hypotension, HA, VT, VF, tachycardia, pulmonary edema,
cardiac arrest.
Precautions: Increase cardiac ischemia, consider Isuprel last, cautious use
in persons with tuberculosis.
Kayexalate® (Sodium Polystyrene Sulfonate)
(Cation Exchange Resin)
Indications: Mild to moderate hyperkalemia.
Dose: 15 g PO or 25–100 g rectally as a retention enema 1–4 times daily in
water or sorbitol (if severe, more immediate measures such as sodium
bicarbonate IV, calcium, or glucose/insulin infusion should be instituted).
Contraindications: Life-threatening hyperkalemia, ileus, known alcohol
intolerance, hypersensitivity to saccharin or parabens.
Side Effects: Constipation, N&V, fecal impaction, gastric irritation,
hypocalcemia, hypokalemia, sodium retention.
Precautions: Monitor ECG and electrolytes during therapy, use cautiously
in the elderly, CHF, hypertension, constipation.

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Lasix® (Furosemide) (Diuretic, Distal Loop)

Indications: CHF with acute pulmonary edema, hypertensive crisis,
increased ICP, nephrotic syndrome, hepatic cirrhosis.
Dose: 0.5–1 mg/kg slow IVP over 1–2 min, may repeat once at 2 mg/kg
slow IVP over 1–2 min.
Contraindications: Never use with ethacrinic acid, anuria, hypotension,
hepatic coma, dehydration, hypokalemia, hypersensitivity to sulfonamides.
Side Effects: Severe dehydration/hypovolemia, hypotension, hypokalemia,
hyponatremia, hypochloremia, azotemia, vertigo, dizziness.
Precautions: Monitor urine output and electrolytes during therapy and
injection site for thrombophlebitis, cardiac arrest following IV administration.
Lidocaine (Xylocaine®) (Antidysrhythmic, Anesthetic)
Indications: Pulseless VF/VT, wide-complex tachycardia of uncertain type.
Dose: 1–1.5 mg/kg IVP or ET tube (double dose if giving via ET tube), may
repeat q 5–10 min, maximum 3 mg/kg. If conversion successful, start an
infusion of 2–4 mg/min.
Contraindications: 2nd- or 3rd-degree HB, Stokes-Adams and WPW
syndromes, hypotension, hypersensitivity to amide-type local anesthetics.
Side Effects: Altered LOC, seizure, slurred speech, malignant hyperthermia,
hypotension, bradycardia, cardiovascular collapse, respiratory arrest.
Precautions: Reduce infusion dose by 50% if #70 yr, CHF, shock, liver
disease, marked hypoxia, digitalis toxicity, severe respiratory depression.
Magnesium Sulfate (Electrolyte, Anticonvulsant)
Indications: Seizures associated with toxemia of pregnancy, hypomagne-
semia or hypothyroidism, torsades de pointes, severe asthma, VF refractory
to lidocaine, digoxin-induced VT/VF.
Dose: Hypomagnesemia: 0.5–1 g/hr IV; cardiac arrest 1–2 g IVP; torsades de
pointes (noncardiac arrest): load with 1–2 g infused over 5–60 min, then
infuse 0.5–1 g /hr; digoxin-induced VT/VF: 1–2 g IVP; toxemia of pregnancy:
1–4 g slow IVP (4–5 g IV followed by an infusion of 1–2 g/hr) continuous
infusion not to exceed 40 g/24 hr.
Contraindications: Hypermagnesemia, hypocalcemia, renal disease, heart
block, toxemia of pregnancy 2 hr prior to delivery.
Side Effects: Hypotension, cardiac arrest, respiratory depression, altered
LOC, flushed skin, diaphoresis, hypocalcemia.
Precautions: Renal insufficiency.
Mannitol (Osmitrol®) (Diuretic [Osmotic])
Indications: Increased ICP, the oliguric phase of acute renal failure, severe
intraocular pressure, diuresis of toxic substances.
Dose: 1.5–2 g/kg IV over 30–60 min.
Contraindications: Intracranial bleeding, pulmonary edema, anuria,
dehydration.

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Side Effects: Altered LOC, HA, blurred vision, N&V, tachycardia, hypoten-
sion or HTN, chest pain, CHF, seizures.
Precautions: Elderly, cardiovascular and renal disease.
Milrinone (Primacor®) (Inotropic)
Indications: Short-term treatment of CHF in patients receiving digoxin and
diuretics.
Dose: Per order.
Contraindications: Obstructive pulmonic or aortic valvular disease,
hypersensitivity.
Side Effects: VT, SVT, hypotension, abnormal digoxin levels, angina, HA,
hypokalemia, tremors.
Precautions: Use cautiously in patients with a history of dysrhythmias,
electrolyte imbalances, renal impairment, pregnancy.
Morphine Sulfate (Opioid-Narcotic Analgesic [Agonist])
Indications: Moderate to severe pain, chest pain unrelieved with NTG,
CHF and dyspnea associated with pulmonary edema.
Dose: 4–15 mg IVP q 3–4 hr or as a loading dose titrated to respiratory
status followed by an infusion of 0.2–1 mg/mL.
Contraindications: Heart failure due to chronic lung disease, respiratory
depression, hypotension, undiagnosed acute abdominal pain, head injury,
altered LOC, acute alcoholism, DTs.
Side Effects: Respiratory depression, hypotension, N&V, bradycardia,
altered LOC, seizures.
Precautions: Reverse with Narcan, multiple drug interactions.
Narcan (Naloxone®) (Opioid-Narcotic Antagonist)
Indications: Narcotic-induced respiratory depression.
Dose: 0.4–2 mg IV, IM, SC, ET (double the dose when administered via ET
tube) q 2–3 min intervals, maximum 10 mg.
Contraindications: Known allergy to Narcan, narcotic addicts.
Side Effects: Acute withdrawal symptoms in addicted patients, VT, VF,
hypotension or hypertension, seizures.
Precautions: Avoid total narcotic reversal in addicted patients, half-life may
not be as long as narcotic half-life. May cause severe HTN in hypertensive
patient during labor.
Nipride® (Nitroprusside, Nitropress®) (Vasodilator)
Indications: Hypertensive crisis, acute CHF.
Dose: Per order.
Contraindications: Aortic coarctation or AV shunting, high output failure in
endotoxic sepsis.
Side Effects: Dizziness, restlessness, nausea, HA, palpitations, bradycardia,
tachycardia, flushing, seizures, increased ICP, thiocyanate toxicity.

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Precautions: Use with caution in hypothyroidism, liver or renal impairment,

increased ICP, and the elderly.
Nitroglycerin (Nitrostat®) (Antianginal, Nitrate)
Indications: Angina, CHF associated with acute MI, cardiac load-reducing
agent, hypertensive crisis.
Dose: 0.3–0.4 mg SL q 5 min, maximum 3 doses.
Contraindications: SBP !90 mm Hg, severe bradycardia, severe
tachycardia, Viagra® within 24 hr, RV infarction.
Side Effects: Hypotension with secondary tachycardia, syncope, HA,
flushed skin.
Precautions: Do not mix with other medications, titrate IV form to maintain
SBP "90 mm Hg.
Pitocin® (Oxytocin) (Hormone)
Indications: Postpartum hemorrhage.
Dose: 10 units IM or 10–40 units in 1000 mL saline, LR, or D5W, and infuse at
0.02–0.1 units/min (titrate to effect).
Contraindications: Known allergy, incomplete delivery.
Side Effects: Anaphylaxis, dysrhythmias, HTN, seizure, coma, hypotension,
postpartum hemorrhage, uterine rupture.
Precautions: Evaluate for multiple births.
Potassium Chloride (Mineral/Electrolyte)
Indications: Hypokalemia.
Dose: Hypokalemia ("2.5) up to 200 mEq/day as an infusion (not to exceed
20 mEq/hr or a concentration of 40 mEq/L via peripheral line) (up to 80
mEq/L has been used via central line [unlabeled]). Hypokalemia (!2) up to
400 mEq/day as an infusion (rate should generally not exceed 20 mEq/hr).
Contraindications: Hyperkalemia, severe renal impairment, untreated
Addison’s disease, severe tissue trauma.
Side Effects: Dysrhythmias including heart block, abdominal pain, N&V,
diarrhea, confusion, restlessness, weakness, respiratory paralysis, irritation
at IV site.
Precautions: Monitor HR, BP, RR, and ECG throughout infusion. Severe pain
and tissue necrosis with extravasation. Use with caution in the elderly with
cardiac or renal disease.
Procainamide (Pronestyl®) (Antidysrhythmic)
Indications: VT, PSVT refractory to adenosine and vagal stimulation, rapid
atrial fibrillation in WPW, paroxysmal atrial tachycardia, stable wide-complex
tachycardia of uncertain type, maintenance after conversion.
Dose: 20 mg/min, maximum 17 mg/kg; maintenance of 1–4 mg/min.
Contraindications: 2nd- or 3rd-degree HB, torsades de pointes, lupus,
myasthenia gravis, digoxin toxicity, hypersensitivity.

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Side Effects: Hypotension, widening QT, asystole, HA, N&V, flushed skin,
seizure, ventricular dysrhythmias, partial or complete HB.
Precautions: Stop administration for hypotension or when QT interval
begins to widen. Use cautiously in patients with CHF, cardiomyopathy, or
acute ischemic heart disease, and in patients with liver or renal disease.
Multiple drug interactions.
Propofol (Diprivan®) (Sedative, Anesthetic)
Indication: Sedation, anesthesia.
Dose: Initial dose 2–2.5 mg/kg; maintenance 100–200 #g/kg/min or may be
given in 25–50-mg increments; use half the dose for elderly and debilitated
patients.
Contraindications: Allergy to egg, soy, or glycerol products; labor and
delivery.
Side Effects: Apnea, HTN, bradycardia, dizziness, HA, N&V, flushed skin,
burning at the site.
Precautions: Lipid metabolism disorders, increased ICP, cardiovascular
disease, the elderly.
Proton Pump Inhibitors
Common Agents: Lansoprozole (Prevacid®), omprazole (Prilosec®),
pantroprazole (Protonix®), esomeprazole (Nexium®), rabeprazole (Aciphex®).
Indications: Duodenal and gastric ulcers; management of GERD; upper
GI bleed.
Dose: See individual order and drug for route and dosages.
Contraindications: Hypersensitivity.
Side Effects: Confusion, dizziness, drowsiness, HA, site pain, N&V,
hypotension or HTN, CVA, MI, shock.
Precautions: Assess elderly and severely ill patients for confusion routinely,
reduce dosage in impaired hepatic function.
Romazicon® (Flumazenil) (Antagonist [Benzodiazepines])
Indication: Antidote to benzodiazepines.
Dose: 0.2 mg IVP, may repeat 0.3 mg in 30 sec, followed with 0.5 mg q min,
maximum 3 mg/hr (0.2 mg given over 15 sec, followed by 0.2 mg if no
patient response after 45 sec). May be repeated at 60-sec intervals, up to a
maximum of 1 mg.
Contraindications: TCA OD, known history of seizures, increased ICP,
allergy to benzodiazepine.
Side Effects: Withdrawal symptoms, dizziness, seizures, N&V.
Precautions: Avoid using in multiple drug OD; use associated with high risk
of seizures in certain patients, especially those with head injury or alcoholism.
Sodium Bicarbonate (Alkalizing Agent, Buffer)
Indications: Hyperkalemia, tricyclic antidepressant OD, cocaine or
diphenhydramine or ASA OD, metabolic acidosis, shock associated with
severe diarrhea, dehydration, uncontrolled DM.

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Dose: 1 mEq/kg IVP, may repeat 0.5 mEq/kg q 10 min.

Contraindications: Metabolic or hypochloremic alkalosis, hypocalcemia,
renal failure, as an antidote to ingestion of strong mineral acid, HTN,
convulsions.
Side Effects: Hypokalemia, metabolic alkalosis, seizures, N&V, tetany.
Precautions: CHF, renal disease, concurrent use with glucocorticoids,
multiple drug interactions.
Succinylcholine chloride (Sucostrin®)
(Neuromuscular Blocking Agent [Depolarizing])
Indications: Paralysis to facilitate endotracheal intubation.
Dose: Initial dose: 1–2 mg/kg IVP (0.3–1.1 mg/kg IVP; maintenance: 0.5–10
mg/min continuous infusion).
Contraindications: Cannot use with lactated Ringer’s solution or in
patients with a family history of malignant hyperthermia, myopathies with
elevated CPK, acute narrow-angle glaucoma.
Side Effects: Hypotension, bradycardia, apnea, bronchospasm, hyper-
kalemia, malignant hyperthermia, severe persistent respiratory depres-
sion or apnea, anaphylaxis.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order. Use with caution in clients with CV, pulmonary, or
metabolic disorders. Patients with myasthenia gravis may show resistance.
Time Action Profile: Onset 0.5–1 min; peak 1–2 min; duration 4–10 min.
Thrombolytics
Common Agents: Activase® (Alteplase, recombinant; t-PA); Retavase®
(Reteplase), Streptase® (Streptokinase)
Indication: Acute MI !12 hr from onset of symptoms and acute ischemic
stroke.
Dose: See individual order and drug for route and dosages.
Contraindications: Active internal bleeding within 21 days (except
menses), history of neurovascular event within 3 months, major surgery or
trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN,
bleeding disorder, prolonged CPR, LP within 1 week.
Side Effects: Hypotension, reperfusion arrhythmias, HA, increased bleeding
time, hemorrhage, flushing, urticaria.
Precautions: Patients with severe renal or hepatic disease.
Toradol® (Ketorolac) (NSAID, Nonopioid Analgesic)
Indication: Short-term management of moderate acute pain.
Dose: 15–30 mg IV or 30–60 mg IM; use half the dose for patients over 65 yr,
!50 kg, or have renal impairment.
Contraindications: Allergy, prior to and during surgery, known alcohol
intolerance, active peptic ulcer disease or GI bleeding, renal impairment,
pregnancy, lactation.

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Side Effects: Drowsiness, GI bleed or perforation, nausea, HA, increased
bleeding time, anaphylaxis, bronchospasm.
Precautions: GI bleed; renal, hepatic, or CV disease.

Vasopressin (Pitressin®) (Vasopressor, Hormone)

Indication: Cardiac arrest as an alternative to epinephrine, GI hemorrhage,
neurogenic diabetes insipidus.
Dose: Cardiac arrest: 40 units IVP one-time dose; GI hemorrhage: 0.1–0.4
units/min; IV diabetes insipidus: 5–10 units IM/SC.
Contraindications: Pregnancy, epilepsy, heart failure, asthma, CAD,
migraine, allergy to beef or pork protein, renal failure with BUN.
Side Effects: Dizziness, HA, N&V, MI, chest pain, abdominal cramps,
diaphoresis, heartburn, diarrhea, bronchoconstriction, anaphylaxis, coma,
convulsions.
Precautions: Monitor ECG throughout therapy, never give the tannate IV,
multiple drug interactions.
Vecuronium (Norcuron®) (Neuromuscular
Blocking Agent [Nondepolarizing])
Indications: Paralysis to facilitate endotracheal intubation.
Dose: Initial dose: 80–100 #g/kg; maintenance 10–15 #g/kg 25–40 min after
initial dose, repeat every 12–15 min as needed or as a continuous infusion
at 1 #g/kg/min
Contraindications: Cannot use with lactated Ringer’s solution, sensitivity
to bromides.
Side Effects: Hypotension, tachycardia, bradycardia, dyspnea, flushed skin,
urticaria, malignant hyperthermia.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order; avoid use in patients with myasthenia gravis or Eaton-
Lambert syndrome.
Time Action Profile: Onset 1 min; peak 3–5 min; duration 15–25 min.

Verapamil (Calan®, Isoptin®) (Calcium Channel Blocker)

Indications: PSVT refractory to adenosine, atrial fibrillation, atrial flutter.
Dose: 2.5–5 mg (5–10 mg slow IVP over 2 min, may repeat 5–10 mg q
10 min, maximum 30 mg/min); may give prophylactic calcium chloride
(8–16 mg/kg IV) to counteract hypotension.
Contraindications: Atrial fibrillation/flutter with WPW, VT, or wide-complex
tachycardia of uncertain type, 2nd or 3rd degree heartburn, hypotension,
severe CHF.
Side Effects: Hypotension, exacerbation of CHF, asystole, bradycardia,
AV heart block, MI, CVA.
Precautions: Patients on oral beta blockers, hypertrophic cardiomyopathy,
impaired hepatic or renal function. Multiple drug interactions.

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Medications Compatible With IV KCl

acyclovir esmolol morphine
alatrovafloxacin conjugated neostigmine
aldesleukin estrogens norepinephrine
allopurinol ethacrynate sodium ondansetron
amifostine etoposide oxacillin
aminophylline famotidine oxytocin
amiodarone fentanyl paclitaxel
ampicillin filgrastim penicillin G potassium
amrinone fludarabine pentazocine
atropine fluorouracil phytonadione
aztreonam furosemide piperacillin/tazobactam
betamethasone gatifloxacin procainamide
calcium gluconate gemcitabine prochlorperazine edisylate
chlordiazepoxide granisetron propofol
chlorpromazine heparin propranolol
cimetidine hydralazine pyridostigmine
ciprofloxacin idarubicin potassium ranitidine
cisatracurium indomethacin remifentanil
cladribine insulin sargramostim
cyanocobalamin isoproterenol scopolamine
dexamethasone kanamycin sodium bicarbonate
digoxin labetalol succinylcholine
diltiazem lidocaine tacrolimus
diphenhydramine linezolid teniposide
dobutamine lorazepam theophylline
docetaxel magnesium sulfate thiotepa
dopamine melphalan tirofiban
doxorubicin liposome menadiol trimethaphan
droperidol meperidine trimethobenzamide
droperidol/fentanyl methoxamine vinorelbine
edrophonium methylergonovine warfarin
enalaprilat midazolam zidovudine
epinephrine minocycline

Medications Incompatible With IV KCl

adrenaline HCl chloramphenicol phenytoin
amphotericin B choles- sodium succinate phenytoin sodium
teryl sulfate complex chlorpromazine HCl sulphadiazine sodium
atropine sulfate diazepam suxamethonium chloride
cephalothin sodium ergotamine tartrate thiopentone sodium
methicillin sodium

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Reference Ranges for Common Laboratory Tests
Arterial Blood Gases (ABGs)

Normal ABG Results (U.S. System of Measurements)

pH PaO2 PaCO2 O2 sat HCO3 Base Excess

7.35–7.4580–100 35–45 95%–100% 21–28 $2 to %2 mEq/L
mm Hg mm Hg mEq/L
Normal ABG Results (SI Units)
pH PaO2 PaCO2 O2 sat HCO3 Base Excess
7.35–7.45 10.6–12.6 4.66–5.98 95%–100% 21–28 $2 to %2
kPa kPa mmol/L mmol/L
Critical Levels:
pH: !7.25 or "7.55
PaO2: !45
PaCO2: !20 or "60
HCO3: !15 or "40
Base Excess: & 3 mEq/L

Chemistries

Test Conventional SI Units

Albumin 3.9–5.0 g/dL 35–50 g/L
Alkaline phosphatase 44–147 units/L 40–120 U/L
ALT 6–59 units/L 20–65 U/L
AST 10–34 units/L 15–45 U/L
BUN 7–20 mg/dL 2.9–8.9 mmol/L
Bilirubin, direct 0.0–0.3 mg/dL 0–8 #mol/L
Bilirubin, total 0.2–1.9 mg/dL 0–20 #mol/L
Calcium 8.5–10.9 mg/dL 2.15–2.5 mmol/L
Chloride 101–111 mmol/L 98–106 mmol/L
Cholesterol, total 100–240 mg/dL 2–5.19 mmol/L
CO2 20–29 mEq/L 20–29 mmol/L
Creatinine 0.8–1.4 mg/dL 70–120 #mol/L
Gamma-GT 0–51 units/L 10–58 U/L
Glucose 64–128 mg/dL 3.3–11 mmol/L
Lactic acid 0.5–1.5 mEq/L or SI units: 0.5–1.5 mmol/L
8.1–15.3 mg/dL
(Continued on the following page)

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Chemistries (continued)

Test Conventional SI Units

LDH 105–333 units/L 300–600 mmol/L
Magnesium 1.5–2 mEq/L 0.7–1.05 mmol/L
Phosphorus 2.4–4.1 mg/dL 0.8–1.4 mmol/L
Potassium 3.5–5 mEq/L 3.5–5 mmol/L
Protein, total 6.3–7.9 g/dL 60–80 g/L
Sodium 136–144 mEq/L 136–144 mmol/L
Uric acid, serum Male: 4.0–8.5 mg/dL 0.24–0.51 mmol/L
Female: 2.8–7.3 mg/dL 0.16–0.43 mmol/L

Coagulation Profile

Test Conventional SI Units

INR 0.9–1.2 0.9–1.2
PT 10–14 sec 10–14 sec
PTT/aPTT 21–37 sec 21–37 sec
D-dimer !0.5 #g/mL
FDP (fibrin degrada- !5 #g/mL
tion products)
Fibrinogen 150–400 mg/dL 1.7–4.1 g/L

Cardiac Markers

Test Conventional SI Units

Albumin cobalt binding test !85 U/mL !85 U/mL
B-type natriuretic peptide 0–100 pg/mL Ø–100 ng/L
Creatinine phospho- Male: 55–170 U/L Male: 55–170 U/L
kinase, creatine kinase Female: 30–135 U/L Female: 30–135 U/L
CK isoenzymes CK-MB: 0%–3% 0–0.03
Troponins (TnI, TnT) Cardiac troponin Cardiac troponin
T: !0.2 ng/mL T: !0.2 ng/mL
Cardiac troponin Cardiac troponin
I: !0.03 ng/mL I: !0.03 ng/mL

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Cardiac Markers (continued)

Test Conventional SI Units

Myoglobin, serum !90 #g/L !90 #g/L
Lactate dehydrogenase 100–190 U/L 100–190 U/L
(LD, LDH), LDH isoenzymes
Aspartate aminotransferase 0–35 U/L 0-0.58 #kat/L

Hematology

Test Conventional SI Units

Blood volume 8.5–9.0% of body weight in kg 80–85 mL/kg
Male: 4.6–6.2 million/mm3 4.6–6.2 ' 1012/L
Red blood cell (RBC) Female: 4.2–5.9 million/mm3 4.2–5.9 ' 1012/L
Male: 13–18 g/100 mL 8.1–11.2 mmol/L
Hemoglobin (Hgb) Female: 12–16 g/100 mL 7.4–9.9 mmol/L
Hematocrit (Hct) Male: 45%–52% 0.45–0.52
Female: 37%–48% 0.37–0.48
Leukocytes (WBC) 4.300–10.800/mm3 4.3–10.8 ' 109/L
■ Bands 0%–5% 0.03–0.08
■ Basophils 0%–1% 0–0.01
■ Eosinophils 1%–4% 0.01–0.04
■ Lymphocytes 25%–40% 0.25–0.40
■ B lymphocytes 10%–20% 0.10–0.20
■ T lymphocytes 60%–80% 0.60–0.80
■ Monocytes 2%–8% 0.02–0.08
■ Neutrophils 54%–75% 0.54–0.75
Platelets 150,000–350,000/mm3 150–350 ' 109/L
Erythrocyte sedi- Male: 1–13 mm/hr 1–13 mm/hr
mentation rate Female: 1–20 mm/hr 1–20 mm/hr
Platelets 150,000–450,000 mm3 150–450 ' 109/L
Sedimentation rate Males under 50 yr: !15 mm/hr;
males over 50 yr: !20 mm/hr;
females under 50 yr: !20 mm/
hr; females over 50 yr: !30 mm/
hr (Westergren method)

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A & P Snapshot

IM injection sites.

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Two inches away

from the umbilicus

SC injection sites, technique, and variations.

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INDEX

Electrical Conduction of the Heart

SA node
Left bundle
Intra-atrial branch
pathways

AV Node
Purkinje
fibers
Bundle of His

Right bundle
branch
Electrical conduction of the heart.

Standard Placement: Lead-II & 7-Channel

and...
White's G
on the right Smoke
(negative) (Ground)
Over
Fire
Chest lead (positive)
and
Right leg lead +
Included for seven
channel monitoring

Standard placement: Lead II and 7-channel.

Normal Cardiac Rhythm Parameters

NSR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 60 and 100 bpm
SB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fewer than 60 bpm
ST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Over 100 bpm
QRS width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 0.08 and 0.12 sec
P-R interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 0.12 and 0.20 sec
Q-T interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0.30–0.40 sec
Atrial rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60–100 bpm
Junctional rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40–60 bpm
Ventricular rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20–40 bpm

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Lead Placement and Normal Deflection of PQRST Waves

Midclavicular
line
Anterior
axillary line
Midaxillary
line

V6
V5
V1 V2
V3
V4

Right Left
lung lung

V6

V5

V4
V1 V2 V3

Lead placement and normal deflection of PQRST waves.

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ECG Waveform of the Cardiac Cycle

PR
P T

Q
S
Atrial Ventricular Ventricular
depolarization depolarization repolarization

ECG waveform of the cardiac cycle.

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Heart Sounds

QRS QRS

P T P T

S1 S2 S1 S2

Aortic
valve
Pulmonic
valve

Mitral
S2 S1 valve
S2

S1

Tricuspid
valve

Heart sounds.

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INDEX

Figuring Rate and Measurement

To figure out rate (regular rhythms only), you can do one

of the following:

Count the number of QRS complexes Irregular

(regular rhythms only) in a 6-sec strip rhythms
and multiply by 10. should be
counted for
an entire
Divide the number of large boxes minute.
between two R waves into 300.

Remember the number sequence below and find an

R wave that falls on a heavy line. Starting from the
next heavy line, count 300, 150, 100, and so forth,
and whatever line the next R wave falls on is the
heart rate (see below for example).

1st R wave 300 150 100 75 60 50 43

Next R wave here Next R wave here

would be 150 bpm. would be 60 bpm.

Inherent rates of different cardiac regions:

SA Node ..................... 60–100 bpm
AV Node ....................... 40–60 bpm
Ventricles..................... 20–40 bpm

One small box

represents
One big box represents 0.04 sec and
0.20 sec and is 5 mm2. is 1 mm2.

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Normal Cardiac Cycle and Measurements

QRS T R
P P

Q S
P-R interval

Normal Rate → 60–100

Normal Rate bpm
60–100 bpm 0.04 sec
Normal P-RNormal
→ 0.12–0.20
P-R sec
0.12–0.20 sec 0.20 sec
Normal QRS → 0.08–0.12 sec
P wave → atrial depolarization; QRS → ventricular
depolarization; T wave → ventricular repolarization

Normal Sinus Rhythms

P waves before every QRS, P-R <0.20

Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 60–100

Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular
P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present
P-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal
QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal (0.08–0.12 sec)

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Analyzing the P-R Interval (PRI)

■ PRI is consistent and between 0.12 and 0.20 sec (3–5 small boxes). This is
considered a normal PRI.
■ PRI is !0.12 sec (3 small boxes): consider junctional rhythm.
■ PRI is longer than 0.20 sec (5 small boxes), it remains consistent in length
from PRI to PRI: consider 1" AV block.
■ PRI undergoes progressive lengthening until a QRS is dropped: consider
2" AV block, type I.
■ PRI is consistent; however, there are additional P waves that do not
precede a QRS complex: consider 2" AV block, type II.
■ PRI is not consistent, nor is there any correlation between the P wave and
the QRS: consider 3" AV block (CHB).

Analyzing the QRS Complex

■ QRS between 0.08 and 0.12 (2–3 small boxes): consider normal.
■ QRS #0.12 sec; “wide and bizarre”: consider ventricular ectopy.
■ QRS #0.12 sec (3 small boxes), with notched or “rabbit ears” appearance:
consider BBB.
■ QRS preceded by 1–2 very narrow “spikes”: think pacemaker.

Basic ECG Assessment

1. Determine ventricular rate.
2. Determine QRS duration and shape.
3. Identify P waves, and determine if a P wave precedes every QRS
complex.
4. If more than 1 P wave precedes a QRS complex, determine ratio of P
waves to QRS complex (ex., 4:1, 3:1, 2:1).
5. Is P wave shape consistent?
6. Determine atrial rate and rhythm.
7. Determine P-R intervals and if they are consistent.

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Sinus Tachycardia

Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fast (#100 bpm)

Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular
P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present
P-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal
QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Narrow (0.08–0.12 sec)

Sinus Bradycardia

Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Slow (!60 bpm)

Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular
P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present
P-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal
QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Narrow (0.08–0.12 sec)

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Atrial Fibrillation

Rate..............................................................................................................Variable
Rhythm ....................................................................................Irregularly-irregular
P waves ...............................................................................None (nondiscernible)
P-R....................................................................................................Nondiscernible
QRS.....................................................................................Narrow (0.08–0.12 sec)

Atrial Flutter

Flutter
waves

Rate .....................................Atrial → 250–350 bpm; ventricular → 125–175 bpm

Rhythm ...........................................................................................Usually regular
P waves ...........................................................Flutter waves → sawtooth pattern
P-R....................................................................................................Nondiscernible
QRS.....................................................................................Narrow (0.08–0.12 sec)

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Junctional Rhythm

No P waves

Rate .............................................................Normal junctional rate is 40–60 bpm

Rhythm ........................................................................................................Regular
P waves ................................If present: inverted, retrograde, buried in the QRS
P-R..................................................................................If present, it will be !0.12
QRS...............................................................................................................Narrow

Ventricular Tachycardia (Fast and Wide)

Rate.....................................................................................................100–220 bpm
Rhythm ...........................................................................................Usually regular
P waves.................................................................................................Not present
P-R .........................................................................................................Not present
QRS ..........................................................................Wide and bizarre (#0.12 sec)

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Ventricular Fibrillation

Rate ................................................................VF rate is 350–450 (no Ps or QRSs)

Rhythm.......................................................Completely chaotic and disorganized
P waves............................................................................................................None
P-R .......................................................................................................................N/A
QRS ..................................................................................................................None

Asystole

Rate...............................................................................................................No rate
Rhythm ...................................................................................................No rhythm
P waves............................................................................................................None
P-R .........................................................................................................Not present
QRS......................................................................None (occasional agonal beats)

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1" AV Block

Prolonged
P-R interval

Rate .........................................................................Usually between 60–100 bpm

Rhythm ........................................................................................................Regular
P waves ...................................................................Present, one P for every QRS
P-R .............................................................................................Remains #0.20 sec
QRS.....................................................................................Narrow (0.08–0.12 sec)

2" AV Block (Mobitz I—Wenckebach)

0.16
0.32 Dropped
0.20
QRS

Rate ......................................................................................................Slow (!100)

Rhythm ........................................................................................................Regular
P waves ........................................................................................................Present
P-R..........................................Gets progressively longer until a QRS is dropped
QRS.....................................................................................Narrow (0.08–0.12 sec)

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2" AV Block (Mobitz II)

Blocked
P waves

Rate .....................................................................................................Usually slow

Rhythm ........................................................................................................Regular
P waves....................................................................................More Ps than QRSs
P-R.........................................................Unblocked Ps usually have a normal P-R
QRS........................................................................Narrow, but may also be wide

3" AV Block (Complete Heart Block)

No correlation
between atria
P P P P
and ventricles

Rate ..................................................Atrial: 60–100 bpm; ventricular: 20–40 bpm

Rhythm ........................................Both ventricular and atrial are usually regular
P waves..........................................................More Ps than QRSs; no correlation
P-R .........................................................................................................Inconsistent
QRS ............................................................................Usually wider than 0.12 sec

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PVC (Premature Ventricular Complex)

Compensatory
Pause

Rate .....................................................................................................................N/A
Rhythm..................................Temporary delay caused by compensatory pause
P waves............................................................................................................None
P-R .......................................................................................................................N/A
QRS ..........................................................................Wide and bizarre (#0.12 sec)

Premature Atrial and Junctional Complex

P PAC No PJC
P

Rate..........................................................................................................Premature
Rhythm....................................................................................................Premature
P waves ..................................Present in PAC, but may be hidden in the T wave
P-R .......................................................................................Not present in the PJC
QRS ..............................................................................................................Normal

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Starting an IV
Prepare the patient: explain procedure, answer any questions, and give
reassurance.
Gather equipment: IV bag with primed tubing, sharps container, catheter,
tape, dressing, tourniquet, antiseptic swabs, gloves, IV catheter of appropri-
ate size.
Organize supplies: tear tape, hang IV solution with primed tubing close by,
sharps container within easy reach, 2 $ 2 or other dressing open.
Apply tourniquet: proximal to intended insertion site, either mid-forearm
or above the elbow; don gloves.
Locate vein: palpate with finger tips; to further enhance dilation, gently tap,
apply heat/warm soak, have patient make a fist, or dangle arm below heart.
Cleanse site: using moderate friction, cleanse in a circular motion, moving
outward from intended site.
Put on gloves: while waiting for cleansed area to dry, avoid touching site
once it has been prepared.
Apply traction (opposite the direction of the catheter).
Position needle: bevel side up, 15"–30" Note: hold the needle with the
thumb and pointer finger in a way that allows for visualization of the flash
chamber.
Insert needle, and observe for “flash back” in flash chamber. Lower catheter
almost parallel to the skin, and insert the needle 1–2 additional mL to ensure
catheter has also entered the vein.
Advance the catheter: thread catheter into vein while maintaining skin
traction and pulling back on needle.
Release the tourniquet, and apply digital pressure just above the end of
the catheter tip while gently stabilizing the hub of the catheter.
Remove needle, and discard into approved sharps container.
Connect IV tubing, open clamp, and observe for free flow of IV fluid.
Secure catheter, and apply sterile dressing per hospital policy/procedure.
Clean up, and document per hospital policy/procedure.

Peripheral and Central Line Care

General Care for All Vascular lines
■ Always use aseptic technique when caring for IV sites.
■ Assess for signs of infection every shift.
■ Remove peripheral line if site appears infected or phlebitic.
■ Call physician if IV access appears infected.
■ Change loose, soiled, or wet dressings immediately.

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Peripheral Access IV Lines
■ Change site every 72 hours.
■ Assess for signs of infiltration (swelling, tenderness, redness, burning
with infusion, decreased or no infusion rate, blanching of skin, site cool
to touch) or phlebitis (vein feels firm and appears red; warmth, swelling,
and tenderness); discontinue IV, and restart in a new site.
CVC: External Access Port(s) (Groshong)
■ Avoid touching the exit site with fingers.
■ Change the end cap(s) every 7 days or sooner if any blood, cracks, or
leaks are seen.
■ Change the dressing, and clean the exit site every day.
■ If using a transparent film, change and clean the exit site dressing once
a week.
■ Clean with alcohol. Never use iodine!
Tunneled CVC: External Access Ports (Hickman, Broviac, Leonard,
or Ventra Catheters)
■ Keep tubes clamped when not being used.
■ Change the end cap(s) every 7 days or sooner if any blood, cracks, or
leaks are seen.
■ Change the dressing, and clean the exit site every 2 days. If using an op-
site, change and clean the exit site dressing once a week.
Implanted Port Catheters: Groshong
■ Wash skin around area of port daily with soap and water. If recently
inserted, provide aseptic incision care until healed.

IV Solutions: Crystalloids and Colloids

IV solutions can be divided into two basic categories: crystalloids and colloids
(volume expanders). Crystalloids contain water, dextrose, and/or electrolytes
and are commonly used to treat different fluid and electrolyte imbalances.
Colloids (also referred to as plasma expanders or volume expanders) have an
increased osmotic pressure in comparison with crystalloids; they remain in
intravascular space longer and are used for volume expansion.

Comparison of Crystalloids

Type of Solution Components Indications

Saline solutions Na and Cl ■ Alkalosis
NS, 0.9% NaCl, sodium ■ Fluid loss
chloride, saline, 3% ■ Sodium depletion
and 5% saline
(Continued on the following page)

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Comparison of Crystalloids (continued)

Type of Solution Components Indications
Dextrose solutions Dextrose in ■ Replace calories as carbohydrates
D5W, D10W water ■ Prevent dehydration
■ Maintain water balance
■ Promote sodium diuresis
Dextrose and Dextrose in ■ Promote diuresis
saline mixtures saline ■ Correct moderate fluid loss
D5NS, D51/2NS, D10NS ■ Prevent alkalosis
■ Provide calories and sodium chloride
Multielectrolyte Combination ■ Replaces fluid lost due to vomiting
solutions of Na, Cl, or GI suctioning
Lactated Ringer’s, K, Ca, and ■ Treats dehydration
Ringer’s lactate lactate ■ Restores normal fluid balance

Volume Expanders (Colloids)

Volume expanders include colloids, dextran, and hetastarch. Colloids are protein
solutions such as albumin, plasma, and commercial plasmas (e.g., Plasmanate).
Dextran is a complex, synthetic sugar. Because Dextran is slowly metabolized, it
does not stay in the vascular space as long as a colloid. Hetastarch is a synthetic
colloid that works similarly to Dextran.

Comparison of Volume Expanders (Colloids)

Type of Solution Components Indications

Albumin Human plasma 5%: Rapid volume expansion
5% and 25% protein and mobilize interstitial edema
25%: Hypoproteinemia
Plasma plasmanate Contains human To increase serum colloid
Plasma protein plasma proteins osmotic pressure
fraction in NS
Dextran Synthetic colloid Volume expansion
40% and 70% made of glucose Mobilize interstitial edema
polysaccharides
Hetastarch: Synthetic colloid Volume expansion
Hespan made from corn Mobilize interstitial edema
Blood products: any of the components found in whole blood.

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Comparison of Blood Products

Blood Product Components Indications

Whole blood Contains all blood Rarely used; may be given to
products. an exsanguinating patient.
Packed red blood No clotting factors or Acute and chronic anemia;
cells (PRBCs) platelets, 80% blood loss.
Platelets plasma removed. Low platelet counts; coagu-
Usually given in lopathies; 1 unit may increase
pools of 6–10 units. platelet count by 6000 units.
Fresh frozen Plasma and clotting To replace clotting factors after
plasma factors. multiple transfusions (%6
PRBCs); Coumadin intoxica-
tion; replace clotting factors
Cryoprecipitate Clotting factors Hemophilia, fibrinogen
deficiency, DIC

Autologous Blood Donation/Transfusion

■ A procedure for collecting and storing a patient’s own blood several
weeks before its anticipated need by the patient.
■ Salvage of blood normally lost during a surgical procedure.
■ Used to prevent transmission of disease from donor blood. It is not
without risk—stored blood may still become contaminated.

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Reusable Assessment Flowsheet

Patient DX/S/P

Time Vital Signs Notes

↓ BP HR RR O2 sats Temp

on

on

on

224
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Labs/Diagnostics

Time General Chemistry

↓ Na& Cl' K& Ca& Mg&& Glu BUN Creat.

Hematology Cardiac Enzymes

Hct Hgb RBC WBC Platelets Troponin-I Troponin-T CPK-MB SGOT LDH Myoglobin
225

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Coagulation Blood Gases
Copyright © 2008 by F. A. Davis.

ACT PT INR PTT Thrombin pH PO2 PCO2 HCO3 BE CO2 SaO2

time

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Intake and Output Record

Intake Amount In Output Amount Out

IVF Urine

IVPB NG drainage/emesis

Blood/colloid

Oral intake Liquid stool

Other

Total In Total Out

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Selected References
Crimlisk JT, Grande MM. Neurologic assessment skills for the acute medical surgical
nurse. Orthop Nurs 2004 Jan-Feb; 23(1):3–9.
Deglin JH, Vallerand AH: Davis’s Drug Guide for Nurses, ed. 10. FA Davis, Philadelphia,
2006.
Gallimore D. Caring for patients after mechanical ventilation. Part 1: Physical and
psychological effects. Nurs Times 2007 Mar 13–19;103(11):28–29.
Gallimore D. Caring for patients after mechanical ventilation. Part 2: Nursing care to
prevent complications. Nurs Times 2007 Mar 20–26;103(12):28–29.
Garner JS. Hospital infection control practices advisory committee: Guideline for
isolation precautions in hospitals. Am J Infect Control 1996; 24:24–52.
Halvorsan L, et al. Building a rapid response team. Adv Crit Care Nurse 2007 Apr-
Jun;18(2):129–40.
Jackson, M. Critical thinking models and their application. In M Jackson, DD
Ignatavicius, B Case (eds.), Conversations in Critical Thinking and Clinical Judgment.
Pohl Publishing, Pensacola, FL, 2004, pp. 49–67.
Jaul E, Singer P, Calderon-Margalit R. Tube feeding in the demented elderly with severe
disabilities. Isr Med Assoc J 2006 Dec;8(12):870–74.
Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases
cardiac arrest outside of the intensive care unit. J Trauma 2007 May;62(5):1223–27;
discussion 1227–28.
Sagarin M, McAfee A. Hyperosmolar hyperglycemic, nonketotic coma
http://www.emedicine.com/emerg/topic264.htm. Accessed March 2007.
Scheffer BK, Rubenfeld MG. A consensus statement on critical thinking in nursing.
J Nurs Educ 2000 39(8):352–59.
Sole ML, et al. Introduction to Critical Care Nursing. Elsevier Saunders, Philadelphia,
2005.
Varughese S. Management of acute decompensated heart failure. Crit Care Nurs Q.
2007 Apr-Jun;30(2):94–103. Review.
Venes D, Thomas CL, Taber CW (eds): Taber’s Cyclopedic Medical Dictionary, ed. 19. FA
Davis, Philadelphia, 2001.
Wilkinson JM, Van Leuven K. Fundamentals of Nursing. FA Davis, Philadelphia, 2007.

Illustration Credits
Pages 17, 59, 167–168, 206 from Myers E: RNotes: Nurse’s Clinical Pocket Guide,
FA Davis, Philadelphia, 2003; pages 53, 55 from Williams L and Hopper
P: Understanding Medical Surgical Nursing, ed 2. FA Davis, Philadelphia, 2003;
pages 55–56 from Taber’s Cyclopedic Medical Dictionary, ed 19. FA Davis,
Philadelphia, 2001; pages 35, 36, 57, 77–79, 97–98, 115, 124, 144–145 from Scanlon VC
and Sanders T: Essentials of Anatomy and Physiology, ed 4. FA Davis, Philadelphia,
2003. Page 9 from Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of
Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright,
Mosby.

Adapted from Folstein et al, Mini Mental State, J Psych Res 12:196–198 (1975)
*Reference ranges vary according to brand of laboratory assay materials used; check
normal reference ranges from your facility’s laboratory when evaluating results.

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Index
Note: Page numbers followed by f refer to figures (illustrations).
A Angiotensin-converting enzyme (ACE) inhibitors,
Abdomen, assessment of, in emergency, 163 184
distention of, 100–101 Antibiotic-resistant staphylococcal infections,
pain in, 100–101 157–158
thrusts to, in Heimlich maneuver, 167f Antidysrhythmics, 185, 186, 188, 190, 191, 192, 194,
ABG (arterial blood gas) values, 201 196
assessment of, 37–38, 51–52 Antihypertensives, 184, 187
AC (assist-control) ventilation, 47 Arterial blood gas (ABG) values, 201
ACE (angiotensin-converting enzyme) inhibitors, assessment of, 37–38, 51–52
184 Arterial circulation, 36f
Acetylsalicylic acid (aspirin), 186 Arterial hematoma, 17–18
Acidosis, diabetic, 116–117 Arterial occlusion, 18–19
Activase (alteplase, t-PA), 185 Artificial airways, 55–56, 55f–56f
Activated charcoal, 184 Aspiration, 38–39
Acute hemolytic reaction, to transfusion, 175 Aspirin (acetylsalicylic acid), 186
Acute renal failure, 92 Assist-control (AC) ventilation, 47
Adenosine (Adenocard), 185 AST, reference range for, 201
Adrenalin (epinephrine), 190–191 Asystole, 216f
Adrenergic agonists, 185, 190 Ativan (lorazepam), 186
Adult, choking in, 170 Atracurium (Tracrium), 186–187
CPR in, 167f, 169 Atrial fibrillation, 214f
Heimlich maneuver in, 167f Atrial flutter, 214f
Advance directives, 164 Atrioventricular (AV) block, 217f–218f
AEDs (automated external defibrillators), 169, Atropine, 187
171 Autologous blood transfusion, 223
Airborne precautions, in infection prevention, 147 Automated external defibrillators (AEDs), 169,
Airway(s), artificial, 55–56, 55f–56f 171
assessment of, in emergency, 160 AV (atrioventricular) block, 217f–218f
methods of opening, 167f, 168f, 169, 170
Alarms, ventilator, 48–49 B
Albumin, reference range for, 201 Back, assessment of, in emergency, 163
Albumin solution, 222 blows to, in Heimlich maneuver, 168f
Albuterol (Ventolin), 185 Bacteremia, transfusion and, 175
Alginates, for pressure ulcer, 140 Bag delivery, of oxygen, 53, 53f, 54, 54f
Alkaline phosphatase, reference range for, 201 Balance, assessment of, 60
Allergic reaction, to transfusion, 175 Benadryl (diphenhydramine), 187
ALT, reference range for, 201 Beta blockers, 187, 191
Alteplase (Activase, t-PA), 185 Bilevel positive airway pressure (BiPAP), 47
Alupent (metaproterenol), 185 Bilirubin, reference range for, 201
Ambu bag, oxygen delivery via, 54, 54f BiPAP (bilevel positive airway pressure), 47
Aminophylline (Truphylline), 185–186 Bleeding/hemorrhage, 26–27
Amiodarone (Cordarone), 186 gastrointestinal, 109–112
Amyl nitrate, 186 wound, 26–27
Analgesics, 186, 189, 195, 198 Bloating, in patient with feeding tube, 108
routes for administration of, 11–12 Blood flow, 35f, 36f
Anaphylaxis, 173, 177 Blood gas values, 201
in reaction to transfusion, 175 assessment of, 37–38, 51–52
Angina, 23 Blood loss. See Bleeding/hemorrhage.

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Blood tests, reference ranges for, 203 Child/infant, choking in, 170
Blood transfusion, 223 CPR in, 167f, 168f, 169
adverse reactions to, 174–175 Heimlich maneuver in, 167f, 168f
Blood urea nitrogen (BUN) values, 201 Chin lift, head tilt and, to open airway, 167f, 168f,
assessment of, 80 169, 170
Braden scale, for pressure ulcer risk, 136 Chloride, reference range for, 201
Bradycardia, 20–21 Choking, management of, 170
sinus, 213f Cholesterol, reference range for, 201
Brain, functional areas of, 77f Circulation, arterial, 36f
vascular lesions of, and sudden neurological assessment of, 16
deficit, 75–77 in emergency, 162, 169
Breathing, assessment of, 37 Clostridium difficile–associated diarrhea (CDAD),
in emergency, 161, 169, 170 148–149
compromised, 16, 40–44, 45–46 CMV (continuous mandatory ventilation), 47
rescue, in CPR, 169 Coagulation tests, 202
Bretylium (Bretylol), 188 Code responses, 165–166
Brevibloc (esmolol), 191 COLDERRA mnemonic, in pain assessment, 11
Bronchodilators, 185 Colitis, pseudomembranous, 148–149
BUN (blood urea nitrogen) values, 201 Colloids, 222
assessment of, 80 Coma, 66
assessment scale for, 61
C hyperosmolar hyperglycemic nonketotic,
Calan (Isoptin, verapamil), 199 119–120
Calcium, reference range for, 201 myxedema, 121–122
Calcium channel blockers, 188, 199 Communication, of patient’s status, 1–2
Calcium chloride, 188 Compartment syndrome, 127–128
Calcium gluconate, 188 Complete heart block, 218f
Calcium imbalance, 82 Compressions (chest compressions), in CPR,
Cannula delivery, of oxygen, 53, 53f 169
Capillary refill, normal vs. delayed, 16 Confusion, 66
Carbon dioxide, delivery and pickup of, 59f Consciousness level, altered, 64–66
reference range for, 201 Consent, informed, 3–4
Cardiac cycle. See also Heart and Cardio- Constipation, 103–104
entries. Contact precautions, in infection prevention,
waveform of, 208f 148
studies of, 206, 206f–219f, 210, 212 Continuous mandatory ventilation (CMV), 47
Cardiac markers, 202–203 Continuous positive airway pressure (CPAP), 47
Cardiogenic shock, 178, 179f Coordination, assessment of, 60
Cardiopulmonary resuscitation (CPR), 167f, 168f, Cordarone (amiodarone), 186
169 Corvert (ibutilide fumarate), 192
Cardiovascular system, assessment of, 15–16 CPAP (continuous positive airway pressure), 47
Cardizem (diltiazem), 188–189 CPR (cardiopulmonary resuscitation), 167f, 168f,
CDAD (Clostridium difficile–associated diarrhea), 169
148–149 Cramps, in patient with feeding tube, 108
Central lines, care of, 220–221 Cranial nerves, 78f
Cervical spine, assessment of, in emergency, 163 assessment of, 62
Charcoal, activated, 184 Creatinine values, 201
Chemistries, reference ranges for, 201–202 assessment of, 80–81
Chest, assessment of, in emergency, 163 Critical thinking, in nursing, 6–8
compressions of, in CPR, 169 Cryoprecipitate, 223
pain in, 21–24 Crystalloids, 221–222
thrusts to, in Heimlich maneuver, 168f Cultural sensitivity, in nursing, 12–13
Chest tube, dislodgement of, 39–40 Cyanide poisoning, antidote to, 186

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D Electrocardiography (ECG), 206, 206f–219f, 210,

Dantrolene (Dantrium), 189 212
Data sheets, 224f–226f Electrolyte imbalances, 82–91
Débriding agents, for pressure ulcer, 140 Electrolyte solutions, 222
Decadron (dexamethasone), 189 Embolism, pulmonary, 44–45
Defibrillators, automated external, 169, 171 chest pain from, 23
Dehydration, 84–85 Emergency(ies), 172
Delegation, in nursing, 5–6 assessment in cases of, 160–164
Delirium, 67–68 documentation in cases of, 4–5
Deltoid site, for IM injection, 204f hypertensive, 27–28
Demerol (meperidine), 189 medications used in, 184–199
Dexamethasone (Decadron), 189 response to, when patient codes, 165–166
Dextran solution, 222 Endocrine system, 124f
Dextrose solutions, 189, 222 assessment of, 116
Diabetic ketoacidosis (DKA), 116–117 disorders of, 116–123
Diagnostic studies, in emergency, 164 Endotracheal tube, 56, 56f
Diarrhea, 104–105 Enzymatic débriding agents, for pressure ulcer,
Clostridium difficile–associated, 148–149 140
in patient with feeding tube, 108 Epigastric disorders, and chest pain, 24
Digestive tract, 115f Epinephrine (Adrenalin), 190–191
assessment of, 99–100 Esmolol (Brevibloc), 191
bleeding from, 109–112 Euvolemic hyponatremia, 91
Digoxin (Lanoxin), 190 External defibrillators, 169, 171
Digoxin immune fab (Digibind), 189–190 Extremities, assessment of, 15
Diltiazem (Cardizem), 188–189 in emergency, 163
Diphenhydramine (Benadryl), 187 Eye protection, in infection prevention, 146
Diprivan (propofol), 197
Disability, assessment for, 162 F
Distention, abdominal, 100–101 Face and head assessment, in emergency, 162
Diuretics, 194 Face shield, in infection prevention, 146
Dizziness, 68–69 Fall(s), 132–134
DKA (diabetic ketoacidosis), 116–117 Fasciitis, necrotizing, 130–131
Dobutamine (Dobutrex), 190 Feeding tube(s), problems with, 106–109
Documentation, in emergency situations, 4–5 Fever, 149–152
in management of pressure ulcer, 137 nonhemolytic transfusion reaction and, 175
Do Not Resuscitate orders, 164 sepsis and, 151
Dopamine (Intropin), 190 SIRS and, 151
Dorsogluteal site, for IM injection, 204f Fibrillation, atrial, 214f
Dressings, for pressure ulcers, 139–140 ventricular, 216f
Droplet precautions, in infection prevention, Film dressings, for pressure ulcer, 139
147 First-degree AV block, 217f
Dyspnea, 16, 40–42 ′′Five P’s,′′ in compartment syndrome, 127
Dysrhythmias, medications for, 185, 186, 188, 190, Flumazenil (Romazicon), 197
191, 192, 194, 196 Flutter, atrial, 214f
types of. See specific problems, e.g., Foam dressings, for pressure ulcer, 140
Tachycardia. Fracture(s), assessment for, 163
hip, 129–130
E pathological, 131–132
ECG (electrocardiography), 206, 206f–219f, 210, Fresh frozen plasma, 223
212 Furosemide (Lasix), 194
Edema, assessment of, 16
Education, of patients, regarding medications, G
182–183 Gait, assessment of, 125

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Gamma-GT, reference range for, 201 Hip, fracture of, 129–130
Gastric secretions, leakage of, in patient with Histamine blockers, 192
feeding tube, 107 Humidified systems, of oxygen delivery, 54,
Gastroesophageal reflux, in patient with feeding 54f
tube, 107 Hydrocolloid dressings, for pressure ulcer, 139
Gastrointestinal tract, 115f Hydrogels, for pressure ulcer, 139
assessment of, 99–100 Hypercalcemia, 82
bleeding from, 109–112 Hyperglycemia, 118
Genitourinary system, 97f–98f Hyperglycemic nonketotic coma, hyperosmolar,
assessment of, 80–82 119–120
Glasgow coma scale, 61 Hyperkalemia, 86–87
Gloves, in infection prevention, 146 Hypermagnesemia, 83
Glucagon, 191 Hypernatremia, 87–88
Glucose, reference range for, 201 Hyperosmolar hyperglycemic nonketotic coma
Glucose imbalance, 118–121 (HHNC), 119–120
Glycoprotein IIb/IIIa inhibitors, 191–192 Hyperphosphatemia, 84
Gowns, in infection prevention, 147 Hypertension, as emergency, 27–28
medications for, 184, 187
H Hypervolemic hyponatremia, 91
Hand placement, in CPR, 167f, 168f Hypocalcemia, 82
Hand washing, in infection prevention, 146 Hypoglycemia, 120–121
Head, assessment of, 15 Hypokalemia, 88–89
in emergency, 162 Hypomagnesemia, 83
support of, in Heimlich maneuver, 168f Hyponatremia, 89–91
tilting of, chin lift and, to open airway, 167f, Hypophosphatemia, 83
168f, 169, 170 Hypotension, 28–30
trauma to, 69–70 Hypotonic hyponatremia, 91
Heart. See also Cardiac and Cardio- entries. Hypoventilation, 43–44
anatomy of, 35f Hypovolemic hyponatremia, 91
conditions compromising, and chest pain, 23, Hypovolemic shock, 178, 179f
24
electrical conduction in, 206f I
studies of, 206, 206f–219f, 210, 212 Ibutilide fumarate (Corvert), 192
Heart block, 217f–218f ICP (intracranial pressure), increased,
Heart failure, 25–26 71–72
Heart sounds, 209f IM (intramuscular) injection sites, 204f
sites for assessment of, 17f IMV (intermittent mandatory ventilation), 47
Heimlich maneuver, 167f, 168f Inamrinone (Inocor), 193
Hematemesis, 109–111 Ineffective breathing, 43–44
Hematological tests, reference ranges for, 203 Infant/child, choking in, 170
Hematoma, arterial, 17–18 CPR in, 167f, 168f, 169
Hemolytic reaction, to transfusion, 175 Heimlich maneuver in, 167f, 168f
Hemorrhage/bleeding, 26–27 Infarction, myocardial, and chest pain, 23
gastrointestinal, 109–112 Infection prevention, 146–148
wound, 26–27 Inflammatory response syndrome, systemic,
Heparin, 192 151
Hepatitis, 153–154 Informed consent, 3–4
Hetastarch solution, 222 Injection sites, 204f, 205f
HHNC (hyperosmolar hyperglycemic nonketotic Inocor (inamrinone), 193
coma), 119–120 Inotropics, 190, 193
High-alert medications, 181 Intermittent mandatory ventilation (IMV), 47
High-pressure alarm, 49 Intracranial pressure (ICP), increased, 71–72
High respiratory rate alarm, 49 Intramuscular (IM) injection sites, 204f

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Intravenous infusion, 184, 220 Magnesium sulfate, 194

blood products used in, 223 Mannitol (Osmitrol), 194–195
adverse reactions to, 174–175 Mask(s), in infection prevention, 146
KCl in, medications incompatible with, 200 in oxygen delivery, 53, 53f, 54, 54f
solutions used in, 221–222 Mechanical ventilation, 47
Intropin (dopamine), 190 alarms used with, 48–49
Ipecac syrup, 193 problems with, 47–48
Ischemic attack, transient, 75–77 Medical-surgical nursing. See Nursing and see
Isoproterenol (Isuprel), 193 also Patient(s).
Isoptin (Calan, verapamil), 199 Medications, administration of, 2, 181–182. See
IV infusion. See Intravenous infusion. also Intravenous infusion.
(in)compatibility of IV potassium chloride in,
J 200
Jaw thrust, to open airway, 167f, 169, 170 sources of error in, 183
Junctional rhythm, 215f educating patients about, 182–183
emergency, 184–199
high-alert, 181
K Melena, 111–112
Kayexalate (sodium polystyrene sulfonate), 193 Meningitis, 155
Ketoacidosis, diabetic, 116–117 Mental status, assessment of, 15, 60, 63–64
Ketorolac (Toradol), 198–199 change in, 67–68
Kidney(s). See also Urinary tract; Urine. Meperidine (Demerol), 189
assessment of, 80–82 Metaproterenol (Alupent), 185
failure of, acute, 92 Methicillin-resistant Staphylococcus aureus
(MRSA) infection, 157–158
L MI (myocardial infarction), chest pain from, 23
Laboratory tests, reference ranges for, 201–203 Milrinone (Primacor), 195
Lactic acid, reference range for, 201 Mini–Mental Status Examination, 63–64
Lanoxin (digoxin), 190 Mnemonic aids, to pain assessment, 10–11
Lasix (furosemide), 194 Mobitz-type AV block(s), 217f–218f
LDH, reference range for, 202 Monitoring, of patient, 1
Lead placement, in electrocardiography, 206f, Morphine sulfate, 195
207f Motion, assessment of, 60, 125
Legal aspects, of nursing, 1–4 MRSA (methicillin-resistant Staphylococcus
Lethargy, 66 aureus) infection, 157–158
Level of consciousness, altered, 64–66 Multielectrolyte solutions, 222
Lidocaine (Xylocaine), 194 Multiple organ dysfunction syndrome, 151
Linens, prevention of infection from, 146 Musculoskeletal system, assessment of, 125–126
Liver, viral infection of, 153 disorders of, and chest pain, 24
Lorazepam (Ativan), 186 Mycobacterium tuberculosis infection, 158–159
Lower gastrointestinal tract, bleeding from, Myocardial infarction (MI), chest pain from, 23
111–112 Myxedema coma, 121–122
Low exhaled volume alarm, 49
Low-pressure alarm, 48 N
Lung(s), embolism in, 44–45 Naloxone (Narcan), 195
chest pain from, 23 Narcan (naloxone), 195
infection of, 156, 158 Nasal prongs, oxygen delivery via, 53, 53f
chest pain from, 23 Nasogastric tube (NGT), insertion of, 102–103
Lung sounds, assessment of, 37 Nasopharyngeal airway, 55, 55f
Nausea, 112–113
M in patient with feeding tube, 108
Magnesium, reference range for, 202 Neck, assessment of, 15
Magnesium imbalance, 83 in emergency, 163

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Necrotizing fasciitis (NF), 130–131 education for, regarding medications, 182–183
Needles/sharps, prevention of injury from, 147 equipment used in care of, prevention of
Neurogenic shock, 178, 180f infection from, 146
Neurological assessment, 60–61 falls by, 132–134
in emergency, 163 monitoring of, 1
Neurological deficit, sudden, 75–77 safety of, 2–3
Neuromuscular blocking agents, 186, 198 medication administration and, 181–182
Neurovascular status, assessment of, 125–126 PE (pulmonary embolism), 44–45
NF (necrotizing fasciitis), 130–131 chest pain from, 23
NGT (nasogastric tube), insertion of, 102–103 PEEP (positive end-expiratory pressure), 47
Nitroglycerin (Nitrostat), 196 Pericarditis, chest pain from, 24
Nitroprusside (Nipride, Nitropress), 195 Perineum, assessment of, in emergency,
Nonhemolytic reaction, febrile, transfusion and, 163
175 Peripheral lines, care of, 220–221
Nonketotic coma, hyperosmolar hyperglycemic, Phosphate imbalance, 83–84
119–120 Phosphorus, reference range for, 202
Nonrebreather delivery, of oxygen, 53, 53f Physician orders, 3
Norcuron (vecuronium), 199 Pitocin (oxytocin), 196
Numeric rating scale, in pain assessment, 9 Pitressin (vasopressin), 199
Nursing, 1–14. See also Patient(s). Plasma infusions, 222, 223
critical thinking in, 6–8 Platelets, in transfusion, 223
cultural sensitivity in, 12–13 reference range for, 203
delegation in, 5–6 Pneumonia, 156
documentation in, 4–5 chest pain from, 23
legal aspects of, 1–4 Positive end-expiratory pressure (PEEP), 47
pain management in, 8–12. See also Pain. Potassium, reference range for, 202
spiritual care in, 14 Potassium chloride solutions, 196
IV, medications incompatible with, 200
O Potassium imbalance, 86, 88–89
Obtundation, 66 PQRST mnemonic, in pain assessment, 10
Oliguria, 92 PQRST waves, normal deflection of, 207f
Organ dysfunction syndrome, multiple, 151 Premature atrial complex, 219f
Oropharyngeal airway, 55, 55f Premature junctional complex, 219f
Osmitrol (mannitol), 194–195 Premature ventricular complex, 219f
Oxygen delivery systems, 53–55, 53f–55f Pressure support ventilation (PSV), 47
Oxygen transport, in respiratory system, 58f Pressure ulcer, 127, 135–140
Oxytocin (Pitocin), 196 Primacor (milrinone), 195
P-R interval, analysis of, 212
P Procainamide (Pronestyl), 196–197
Pacing, transcutaneous, 171 Propofol (Diprivan), 197
Packed red blood cells, 223 Protein, reference range for, 202
Pain, 8–12 Proton pump inhibitors, 197
abdominal, 100–101 Pseudomembranous colitis, 148–149
assessment of, 9–11 PSV (pressure support ventilation), 47
mnemonics aiding, 10–11 Pulmonary embolism (PE), 44–45
rating scales in, 9–10 chest pain from, 23
chest, 21–24 Pulmonary infection(s), 156, 158
management of, 8–12 chest pain from, 23
Palpitations, 30–31 Pulse, assessment of, 16
Pathological fracture, 131–132 in emergency, 169
Patient(s). See also Nursing.
code responses for, 165–166 Q
communication of status of, 1–2 QRS complex, analysis of, 212

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R Sodium imbalance, 87, 89–91

Rapid response teams, 164–165 Sodium polystyrene sulfonate (Kayexalate),
Recovery position, 167f 193
Reference ranges, for laboratory tests, 201–203 Sore, pressure, 127, 135–140
Reflexes, assessment of, 60–61 Spinal cord, 79f
Reflux, in patient with feeding tube, 107 trauma to, 74–75
Renal assessment, 80–82 Spine, assessment of, in emergency, 163
Renal failure, acute, 92 Spiritual care, in nursing, 14
Rescue breathing, in CPR, 169 Standard infection-prevention precautions,
Respiratory distress/failure, 45–46 146–147
Respiratory system, 57f Standard of care, in nursing, 4
assessment of, 37–38 Staphylococcal infection, antibiotic-resistant,
oxygen and carbon dioxide transport in, 157–158
58f–59f State practice laws, for nurses, 1
Responsiveness, assessment of, 65 Stomal infection, in patient with feeding tube,
management of choking victim based on, 170 107
Resuscitation, cardiopulmonary, 167f, 168f, 169 Strength, assessment of, 60
orders against, 164 Stroke, 75–77
Romazicon (flumazenil), 197 Stupor, 66
Subcutaneous (SC) injection sites, 205f
S Succinylcholine chloride (Sucostrin), 198
Safety, of patient, 2–3 Sudden neurological deficit, 75–77
medication administration and, 181–182 Surgical site, problems involving, 141–142
Saline solutions, 221, 222 Synchronized intermittent mandatory ventilation
SC (subcutaneous) injection sites, 205f (SIMV), 47
Second-degree AV block, 217f–218f Syncope, 32–33
Seizure(s), 72–73 Systemic inflammatory response syndrome
Self-harm, protection of patient from, 2–3 (SIRS), 151
Sensation, assessment of, 60
Sepsis, 151 T
Septic shock, 151, 178 Tachycardia, 33–35
Sharps/needles, prevention of injury from, 147 sinus, 213f
Shock, 176–178, 179f–180f ventricular, 215f
anaphylactic, 177 TCP (transcutaneous pacing), 171
cardiogenic, 178, 179f Tendon reflexes, grading of, 60
hypovolemic, 178, 179f Third-degree AV block, 218f
neurogenic, 178, 180f Thrombolytics, 185, 198
septic, 151, 178 Thyroid disorders, 121–123
Shortness of breath (SOB), 16, 40–42 Toradol (ketorolac), 198–199
SIMV (synchronized intermittent mandatory t-PA (Activase, alteplase), 185
ventilation), 47 Tracheostomy tube, dislodgement of, 49–51
Sinus bradycardia, 213f Tracrium (atracurium), 186–187
Sinus rhythm, 211f Transcutaneous pacing (TCP), 171
Sinus tachycardia, 213f Transfusion, 223
SIRS (systemic inflammatory response adverse reactions to, 174–175
syndrome), 151 Transient ischemic attack, 75–77
Skeletal system, 144f Transparent films, for pressure ulcer, 139
Skin, assessment of, 126–127 Transtracheal oxygenation, 55, 55f
structures of, 145f Trauma, head, 69–70
SOB (shortness of breath), 16, 40–42 spinal cord, 74–75
Sodium, reference range for, 202 Truphylline (aminophylline), 185–186
Sodium bicarbonate, 197–198 Tuberculosis, 158–159

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U Ventilation rate, in CPR, 169
Ulcer, pressure, 127, 135–140 Ventilator(s), 47
Unresponsiveness, assessment for, 169 alarms on, 48–49
management of choking in presence of, problems with, 47–48
170 Ventolin (albuterol), 185
Upper gastrointestinal tract, bleeding from, Ventricular fibrillation, 216f
109–111 Ventricular tachycardia, 215f
Urgent situations. See Emergency(ies). Ventrogluteal site, for IM injection, 204f
Uric acid, reference range for, 202 Venturi mask, oxygen delivery via, 54, 54f
Urinary tract, 97f–98f Verapamil (Calan, Isoptin), 199
assessment of, 80–82 Viral hepatitis, 153–154
catheterization of, 94–95 Visual analog scale, for rating pain, 9
infection of, 95–96 Volume expanders, 222
Urine, low output of, 92 Vomiting, 113–114
retention of, 93–94 in patient with feeding tube, 108
UTI (urinary tract infection), 95–96
W
V Wenckebach AV block, 217f
Vacuum-assisted closure (VAC) units, for Whole blood, for transfusion, 223
wounds, 142, 143f Wound(s), hemorrhage from, 26–27
Vancomycin-resistant staphylococcal infection, pressure-ulcer, 127, 135–140
157–158 vacuum-assisted closure units for, 142, 143f
Vasopressin (Pitressin), 199
Vastus lateralis site, for IM injection, 204f X
Vecuronium (Norcuron), 199 Xylocaine (lidocaine), 194

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Notes

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Notes

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